OBJECTIVES: To analyse the attitudes of medical personnel towards terminally ill patients and their right to be fully informed. DESIGN: Self-administered questionnaire composed of 56 closed questions. SETTING: Three general hospitals and eleven health centres in Granada (Spain). The sample comprised 168 doctors and 207 nurses. RESULTS: A high percentage of medical personnel (24.1%) do not think that informing the terminally ill would help them face their illness with greater serenity. Eighty-four per cent think the patient's own home is the best place to die: 8.9% of the subjects questioned state that the would not like to be informed of an incurable illness. CONCLUSION: In our opinion any information given should depend on the patient's personality, the stage of the illness and family circumstances. Our study confirms that a hospital is not the ideal environment for attending to the needs of the terminally ill and their families.
Osuna, E; Perez-Carceles, M D; Esteban, M A; Luna, A
Where there are clear clinical indications that a patient suffering from a terminal illness would not benefit from cardiopulmonary resuscitation, there is no legal or ethical requirement that CPR be discussed with the patient as a treatment option or that CPR be administered if the patient stops breathing or suffers cardiac arrest.
Ginn, D.; Zitner, D.
One clinical psychologist who worked with terminally ill, end-stage Acquired Immune Deficiency Syndrome (AIDS) patients in a hospice type setting experienced more than 150 deaths over an 18-month time period. Many of the patients denied that they had AIDS; some distinguished between having AIDS and testing positive for Human Immunodeficiency Virus…
Fraenkel, William A.
Proposals have been developed to clarify physician responsibility in withholding treatment to terminally ill patients. 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,…
Jarrett, William H.
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 terminally ill 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 terminal illness. This article describes a series of studies focused on the exploration, development, and analysis of a measure of hopelessness specifically intended for use with terminally ill cancer patients. The 1st stage of measure development involved interviews with 13 palliative care experts and 30 terminally ill patients. Qualitative analysis of the patient interviews culminated in the development of a set of potential questionnaire items. In the 2nd study phase, we evaluated these preliminary items with a sample of 314 participants, using item response theory and classical test theory to identify optimal items and response format. These analyses generated an 8-item measure that we tested in a final study phase, using a 3rd sample (n = 228) to assess reliability and concurrent validity. These analyses demonstrated strong support for the Hopelessness Assessment in Illness Questionnaire providing greater explanatory power than existing measures of hopelessness and found little evidence that this assessment was confounded by illness-related variables (e.g., prognosis). In summary, these 3 studies suggest that this brief measure of hopelessness is particularly useful for palliative care settings. Further research is needed to assess the applicability of the measure to other populations and contexts.
Rosenfeld, Barry; Pessin, Hayley; Lewis, Charles; Abbey, Jennifer; Olden, Megan; Sachs, Emily; Amakawa, Lia; Kolva, Elissa; Brescia, Robert; Breitbart, William
Hopelessness has become an increasingly important construct in palliative care research, yet concerns exist regarding the utility of existing measures when applied to patients with a terminal illness. This article describes a series of studies focused on the exploration, development, and analysis of a measure of hopelessness specifically intended…
Rosenfeld, Barry; Pessin, Hayley; Lewis, Charles; Abbey, Jennifer; Olden, Megan; Sachs, Emily; Amakawa, Lia; Kolva, Elissa; Brescia, Robert; Breitbart, William
This exploratory study investigated factors associated with the wish to hasten death among a sample of terminally ill cancer patients. Semi-structured interviews conducted on a total of 72 hospice and home palliative care patients were subjected to qualitative analysis using QSR-NUDIST. The main themes to emerge suggested that patients with a high wish to hasten death had greater concerns with physical symptoms and psychological suffering, perceived themselves to be more of a burden to others, and experienced higher levels of demoralization, while also reporting less confidence in symptom control, fewer social supports, less satisfaction with life experiences and fewer religious beliefs when compared with patients who had a moderate or no wish to hasten death. The implications of these findings will be discussed. PMID:12132547
Kelly, B; Burnett, P; Pelusi, D; Badger, S; Varghese, F; Robertson, M
Background: To explore the association between hydration volume and symptoms during the last 3 weeks of life in terminally ill cancer patients. Patients and methods: This was a multicenter, prospective, observational study of 226 consecutive terminally ill patients 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
The objective of this study was to investigate which terminally ill cancer patients receive in-patient care in hospices and other specialist palliative care in-patient units. An interview survey was made of family or others who knew about the last year of life of a random sample of people who died in 1990. Twenty district health authorities from a range of
Julia Addington-Hall; Dan Altmann; Mark McCarthy
Suicide prevention efforts are a major focus of psychiatry residency training. Residents are taught to identify suicide risk factors, monitor for suicidal ideation, and develop crisis stabilization plans for patients at risk for self harm. In contrast, training and support for dealing with suicide completion is often lacking. Although suicide remains a predictable outcome for many patients with severe mental illness, this topic may be avoided or reviewed only with residents who are directly affected by patient suicide. The purpose of this paper is to present a psychiatry resident's experience of dealing with a patient suicide and identify obstacles to developing this aspect of training. Options for "preventative" training in helping trainees deal with this unfortunate outcome of mental illness will be reviewed. PMID:14535611
Although Wernicke encephalopathy has been reported in the oncological literature, only one terminally ill cancer patient with Wernicke encephalopathy has been reported. Wernicke encephalopathy, a potentially reversible condition, may be unrecognized in terminally ill cancer patients. In this communication, we report three terminally ill cancer patients who developed Wernicke encephalopathy. Early recognition and subsequent treatment resulted in successful palliation of
Hideki Onishi; Chiaki Kawanishi; Masanari Onose; Tomoki Yamada; Hideyuki Saito; Akira Yoshida; Kazumasa Noda
Nutrition and hydration have long been considered to be life-sustaining therapies that are associated with comfort and relief of suffering. This belief is largely based on our own experiences with the sensations of thirst and hunger, which have led physicians to question whether withdrawing or withholding nutritional support from a dying patient can be morally or ethically justified. When considered in light of the available evidence, the underlying premise of this question must be reevaluated. The evidence suggests an alternative formulation, namely, that unrequested nutritional support provided by either the enteral or parenteral route to a terminally ill patient may be both medically and ethically indefensible because it may increase suffering without improving outcome. PMID:11137488
Winter, S M
We present a novel knowledge discovery methodology that relies on Rough Set Theory to predict the life expectancy of terminally ill patients in an effort to improve the hospice referral process. Life expectancy prognostication is particularly valuable for terminally ill patients since it enables them and their families to initiate end-of-life discussions and choose the most desired management strategy for the remainder of their lives. We utilize retrospective data from 9105 patients to demonstrate the design and implementation details of a series of classifiers developed to identify potential hospice candidates. Preliminary results confirm the efficacy of the proposed methodology. We envision our work as a part of a comprehensive decision support system designed to assist terminally ill patients in making end-of-life care decisions. PMID:22255812
Gil-Herrera, Eleazar; Yalcin, Ali; Tsalatsanis, Athanasios; Barnes, Laura E; Djulbegovic, Benjamin
Understanding the relationship between cognitive impairment and desire for hastened death has important implications for palliative care practice and the debate over the legalization of physician-assisted suicide. The presence of cognitive impairment may significantly influence terminally ill patient's attitudes towards hastened death. As cognitive abilities become compromised, patients may have more difficulty making decisions and finding alternative solutions besides death
Hayley Ann Pessin
Goals of work The goal of this study was to develop a new, objective prognostic score (OPS) for terminally ill 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 terminally ill cancer patients from six training hospitals in Korea were prospectively followed\\u000a until death. The Cox proportional hazard model was
Sang-Yeon Suh; Youn Seon Choi; Jae Yong Shim; Young Sung Kim; Chang Hwan Yeom; Daeyoung Kim; Shin Ae Park; Sooa Kim; Ji Yeon Seo; Su Hyun Kim; Daegyeun Kim; Sung-Eun Choi; Hong-Yup Ahn
Withholding and withdrawing artificial nutrition and hydration from terminally ill patients 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 terminally ill patient because of complications such as aspiration pneumonia, dyspnea, nausea, diarrhea, and hypervolemia. From the perspective of Islam, rules governing the care of terminally ill patients 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 terminally ill 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
The Functional Assessment of Cancer Therapy-End of Life (FACT-EOL) was developed to assess the quality of life of cancer patients with a life expectancy of six months or less. Phase I of the study identified the major concerns of 74-terminally ill cancer ...
A. J. Grisinger
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 aim of this work was to carry out a cost evaluation of the home care programme for terminally ill cancer patients run\\u000a by the Istituto Oncologico Romagnolo (I.O.R.) in the areas of Forlì, Cesena, Ravenna and Rimini (Romagna, Italy). To determine\\u000a effective home care direct costs, we first selected 1 week of care as an observation unit. We then
Marco Maltoni; Claudio Travaglini; Matteo Santi; Oriana Nanni; Emanuela Scarpi; Simonetta Benvenuti; Livia Albertazzi; Laura Amaducci; Stefania Derni; Laura Fabbri; Angelo Masi; Luigi Montanari; Giuseppe Pasini; Antonio Polselli; Umberto Tonelli; Paola Turci; Dino Amadori
Background While cancer patients have higher oxidative stress (OS) and lower antioxidant activity, evidence for the association of these parameters with survival in patients with terminally ill cancer is lacking. Methods We followed 65 terminal cancer patients prospectively. We assessed their performance status, some symptoms, and serum levels of vitamin C and OS level. The Gehan’s generalized Wilcoxon test was used to examine the association between survival times and variables. Results Subjects’ performance status was very poor and they had a high level of OS and a low level of vitamin C. No significant association of these two parameters with survival time was noted (p-value, 0.637 for high OS and 0.240 for low vitamin C). Poor performance status was independently related to high OS status after adjusting for potential confounders (adjusted OR, 4.45; p-value, 0.031). Conclusions In this study, OS was not associated with survival of terminally ill cancer patients and its prognostic role requires further study.
This paper presents a Rough Set Theory (RST) based classification model to identify hospice candidates within a group of terminally ill patients. Hospice care considerations are particularly valuable for terminally ill patients since they enable patients and their families to initiate end-of-life discussions and choose the most desired management strategy for the remainder of their lives. Unlike traditional data mining methodologies, our approach seeks to identify subgroups of patients possessing common characteristics that distinguish them from other subgroups in the dataset. Thus, heterogeneity in the data set is captured before the classification model is built. Object related reducts are used to obtain the minimum set of attributes that describe each subgroup existing in the dataset. As a result, a collection of decision rules is derived for classifying new patients based on the subgroup to which they belong. Results show improvements in the classification accuracy compared to a traditional RST methodology, in which patient diversity is not considered. We envision our work as a part of a comprehensive decision support system designed to facilitate end-of-life care decisions. Retrospective data from 9105 patients is used to demonstrate the design and implementation details of the classification model. PMID:23366132
Gil-Herrera, Eleazar; Yalcin, Ali; Tsalatsanis, Athanasios; Barnes, Laura E; Djulbegovic, Benjamin
In the debate on euthanasia and physician-assisted suicide, we have to exclude terminally ill patients 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 terminally ill cancer patients.\\u000a Six cancer
Akira Kugaya; Tatsuo Akechi; Tomohito Nakano; Hitoshi Okamura; Yasuo Shima; Yosuke Uchitomi
Background: Nursing homes (NHs) are less well stud- ied than hospices or hospitals as a setting for terminal care. For more targeted palliative care, more informa- tion is needed about the patient characteristics, symp- toms, direct causes and underlying diseases, and inci- dence of terminally ill NH patients. These aspects are examined in this study. Methods: Prospective observational cohort study
Hella E. Brandt; Luc Deliens; Marcel E. Ooms; Jenny T. van der Steen; Gerrit van der Wal; Miel W. Ribbe
Understanding why some terminally ill patients may seek a hastened death (a construct referred to as "desire for hastened death" or DHD) is critical to understanding how to optimize quality of life during an individual's final weeks, months or even years of life. Although a number of predictor variables have emerged in past DHD research, there is a dearth of longitudinal research on how DHD changes over time and what factors might explain such changes. This study examined DHD over time in a sample of terminally ill cancer patients admitted to a palliative care hospital. A random sample of 128 patients completed the Schedule of Attitudes toward Hastened Death (SAHD) at two time points approximately 2-4 weeks apart participated. Patients were categorized into one of four trajectories based on their SAHD scores at both time points: low (low DHD at T1 and T2), rising (low DHD at T1 and high DHD at T2), falling (high DHD at T1 and low DHD at T2) and high (high DHD at T1 and T2). Among patients who were low at T1, several variables distinguished between those who developed DHD and those who did not: physical symptom distress, depression symptom severity, hopelessness, spiritual well-being, baseline DHD, and a history of mental health treatment. However, these same medical and clinical variables did not distinguish between the falling and high trajectories. Overall, there appears to be a relatively high frequency of change in DHD, even in the last weeks of life. Interventions designed to target patients who are exhibiting subthreshold DHD and feelings of hopelessness may reduce the occurrence of DHD emerging in this population. PMID:24747154
Rosenfeld, Barry; Pessin, Hayley; Marziliano, Allison; Jacobson, Colleen; Sorger, Brooke; Abbey, Jennifer; Olden, Megan; Brescia, Robert; Breitbart, William
The basic principles dealing with euthanasia (1998) as expressed by the German Association of Doctors states that in advance written directives are of "substantial help for the doctor in his or her actions". This requires, however, wide proliferation of patient directives. Hence it was important to ascertain the prevalence of such directives in the German population, as well as the relationship to the wish for enlightenment in terminal illness and diseases in their final stages. This was accomplished in December 1998 using 2050 people obtained with the Random-Route-Procedure (1024 from the new German states, 1013 from the old German states). The sample was obtained from the opinion research institute USUMA with ages ranging between 14 - 92. The main results from this representative survey represent an important record of the status quo with respect to opinion shaping of patient autonomy. 16 % of this survey expressed the wish not to be fully enlightened in the case of a terminal illness or they wished for a clarification to be given to the family only. This result shows that part of the population still holds on to their right of no knowledge. 59.1 % expressed the wish for a complete and immediate enlightenment. The other 24.9 % desired a careful step-by-step presentation of information. The high percentage of those who desired information and enlightenment is in contradiction to the small 2.5 % of patients who have actually written advance directives. These empirical results are consistent with the clinical experience of many doctors and represents the decision of the "representational" doctors for the current ethical regulation of patient directives as an ideal idea. Since 71.9 % of those surveyed had never before thought about this issue conclusions are drawn regarding patient consultations. Gender and East/West differences are also shown. PMID:12012266
Schröder, Christina; Schmutzer, Gabriele; Brähler, Elmar
We conducted a retrospective study by reviewing the medical records of 104 patients to assess the usefulness of the objective prognostic score (OPS) in an independent population of Korea. The median survival time (±standard error) of the high OPS group (?3) was 9.0 ± 1.31 days and that of the low OPS group (<3) was 26.0 ± 3.3 days. The former was significantly shorter than the latter (P < .001). Only delirium (hazard ratio 1.751, P = .032) was related to shorter survival time independent of the OPS. This study demonstrates that the OPS is a valid and useful prognostic tool for predicting survival in terminally ill Korean patients with cancer, and that inclusion of delirium into the OPS may improve its prognostic value. PMID:23744975
Yoon, Seok-Joon; Jung, Jin-Gyu; Kim, Jong-Sung; Kim, Sung-Soo; Kim, Samyong
The purpose of this article is to explore the attitudes of lay people and physicians regarding euthanasia and physician-assisted suicide in terminally ill 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 = .002) reported that in the case of a cardiac and/or respiratory arrest, there would not be an effort to revive a terminally ill cancer patient. Only 8.1% of lay people and 2.1% of physicians agreed on physician-assisted suicide (P = .023). Many of the respondents, especially physicians, supported sedation but not euthanasia or physician-assisted suicide. However, many of the respondents would prefer the legalization of a terminally ill patient's hastened death. PMID:17060293
Parpa, Efi; Mystakidou, Kyriaki; Tsilika, Eleni; Sakkas, Pavlos; Patiraki, Elisabeth; Pistevou-Gombaki, Kyriaki; Galanos, Antonis; Vlahos, Lambros
The aim of this study was to determine the opinions of private medical practitioners in Bloemfontein, South Africa, regarding euthanasia of terminally ill patients. 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 completed the questionnaire. Only three refused participation because they were opposed to euthanasia. Respondents were mainly male (74.2%), married (91.9%) and Afrikaans-speaking (91.9%). More were specialists (53.2%) than general practitioners (46.8%). A smaller percentage (35.5%) would never consider euthanasia for themselves compared to for their patients (46.8%). The decision should be made by the patient (50%), the patient's doctor with two colleagues (46.8%), close family (45.2%) or a special committee of specialists in ethics and medicine (37.1%). The majority (46.9%) indicated that euthanasia should be performed by an independent doctor trained in euthanasia, followed by the patient's doctor (30.7%). Notification should mainly be given to a special committee (49.9%). Only 9.8% felt that no notification was necessary. There was strong opposition to prescribing of medication to let the patient die. Withdrawal of essential medical treatment to speed up death was the most acceptable method. Although the responding group was fairly homogeneous, responses varied widely, indicating the complexity of opinions. PMID:19251970
Brits, L; Human, L; Pieterse, L; Sonnekus, P; Joubert, G
Cancer cachexia is mediated by cytokines affecting intermediate metabolism of energy, proteins, carbohydrate and lipid. It is aggravated by common therapeutic measures: surgery, chemotherapy and radiotherapy that reduce oral intake as well as increase catabolism. Enteral or parenteral nutrition support decreases the catabolic rate of the patient, helping the patient withstand the side effects of the therapeutic measures, but do not reverse to anabolism. Terminally ill cancer patients who are refractory to the different therapeutic measures need palliative care. Nutrition is a basic human right and is conceived by the patient and his family, as well as by the medical community and human society, to be vital for survival. We obviously make every effort to feed our cancer patients as long as they can tolerate food via the alimentary system. However, we are reluctant to administer parenteral feeding, due to fear of accelerated tumor growth, complications, cost and futility, thereby leading to unnecessary prolongation of suffering. However, there is a group of patients who, although they are not candidates for any antineoplastic therapy, are still in good physical and mental condition, with expected life spans of three months or more, suffering from conditions such as intestinal obstruction, fistulas or any condition which makes the preferred route of enteral nutrition impossible. In these specific patients, palliative parenteral nutrition should be considered. The functional status of the patient has to be reasonable (Karnofsky status > 50, ECOG< 3). The decision should be taken after careful multidisciplinary discussion. The patient and caregivers should be aware that this is not a cancer-specific treatment and probably will not prolong the patient's life. Total parenteral nutrition (TPN) in this situation is best if provided at the patient's home. PMID:18488864
Gutman, Mordechai; Singer, Pierre; Gimmon, Zvi
Several themes emerged when interviews were conducted with clinician-researchers regarding their attitudes and concerns when recruiting terminally ill cancer patients into non-therapeutic research. The prominent themes were ethical considerations, patient-centered issues, and health professional issues. Promoting communication and autonomy and fostering familial support are important elements for overcoming patient-centered issues. Facilitating the doctor-patient relationship, using teamwork, and implementing educational programs were seen as key factors for dealing with health professional issues.
OBJECTIVES: To study the opinions of nationals (Emiratis) and doctors practising in the United Arab Emirates (UAE) with regard to informing terminally ill patients. DESIGN: Structured questionnaires administered during January 1995. SETTING: The UAE, a federation of small, rich, developing Arabian Gulf states. PARTICIPANTS: Convenience samples of 100 Emiratis (minimum age 15 years) and of 50 doctors practising in government
A Harrison; A M al-Saadi; A S al-Kaabi; M R al-Kaabi; S S al-Bedwawi; S O al-Kaabi; S B al-Neaimi
Our research on the texts of the Byzantine historians and chroniclers revealed an apparently curious phenomenon, namely, the abandonment of terminally ill emperors by their physicians when the latter realised that they could not offer any further treatment. This attitude tallies with the mentality of the ancient Greek physicians, who even in Hippocratic times thought the treatment and care of the terminally ill to be a challenge to nature and hubris to the gods. Nevertheless, it is a very curious attitude in the light of the concepts of the Christian Byzantine physicians who, according to the doctrines of the Christian religion, should have been imbued with the spirit of philanthropy and love for their fellowmen. The meticulous analysis of three examples of abandonment of Byzantine emperors, and especially that of Alexius I Comnenus, by their physicians reveals that this custom, following ancient pagan ethics, in those times took on a ritualised form without any significant or real content.
Lascaratos, J; Poulakou-Rebelakou, E; Marketos, S
This article is concerned to describe the significance of the Moreno approach in caring for the incurably ill. The anthropology of Moreno, his therapeutic philosophy and the main attitudes in the encounter with a patient are outlined and discussed with reference to central aspects of the situation of the incurably ill (fear of losing their own autonomy, social death). The possibilities offered by the Moreno approach to therapy in attending these patients are illustrated with examples of the main techniques in psychodrama-therapy: doubling and role-reversal. Above all two functions of doubling appear to be especially important in caring for the incurably ill: that of comprehensive attendance and vicarious action. Possible variations in which the role-reversal can be carried out are specified and discussed as means of helping a patient to have confidence in himself and of helping him to perceive and to develop the intrinsic strength within himself in dealing with his situation. Doubling and role-reversal surely cannot be universal rules in attending the incurably ill, but they are good possibilities to respect and to support the autonomy of the human being and to convert into concrete action the conviction of his right to self-determination which is equally characterized for the therapeutic philosophy of Moreno as well as for attending the incurably ill. PMID:1946905
Loneliness is a universal phenomenon, and its pain is intensified by a diagnosis of a terminal illness. The present study is an investigation of the strategies used by patients with Multiple sclerosis (MS), by individuals diagnosed with cancer, and by the general population to cope with loneliness. Three hundred and twenty nine MS patients, 315…
Studies of patients who are terminally ill consistently identify strong associations between “sense of burden to others” and marked end-of-life distress. However, little research has addressed the issue of burden to others among patients nearing death. The aim of this study was to carefully examine “burden to others” and clarify its relationship with various psychosocial, physical, and existential issues arising
Harvey Max Chochinov; Linda J. Kristjanson; Thomas F. Hack; Thomas Hassard; Susan McClement; Mike Harlos
Studies of patients who are terminally ill consistently identify strong associations between ''sense of burden to others'' and marked end-of-life distress. However, little research has addressed the issue of burden to others among patients nearing death. The aim of this study was to carefully examine ''burden to others'' and clarify its relationship with various psychosocial, physical, and existential issues arising
Harvey Max Chochinov; Linda J. Kristjanson; Thomas F. Hack; Thomas Hassard; Susan McClement; Mike Harlos
Background Oncologists often overestimate survival of advanced cancer patients. This study aimed to validate a score for survival prediction\\u000a in terminally ill cancer patients.\\u000a \\u000a \\u000a \\u000a \\u000a Methods Between 2004 and 2008, a prospective study was performed in 500 consecutive advanced cancer patients referred to a palliative\\u000a care unit. Evaluation at admission included physical examination and routine blood tests. On a randomly selected training\\u000a set,
Jean-Philippe Durand; Olivier Mir; Romain Coriat; Anatole Cessot; Sylvain Pourchet; François Goldwasser
Analyzed attitudes of 614 Protestant and Catholic Cleveland clergy toward terminal illness and euthanasia. Clergy responses revealed that, although eager to prolong life, terminally ill patients feared prolonged illness more than death. The controversial nature of euthanasia became more apparent with clergy who had more training in death…
Nagi, Mostafa H.; Lazerine, Neil G.
Death and dying are often surrounded by a conspiracy of silence. Usually it is an unconsciously organised silence, leaving those whose lives are threatened by terminal illness or an accelerated death with a physiological insult and without much-needed communication. The silence seems self-protecting for relatives, medical and nursing staff. Silence is a false reassurance and offers no emotional growth or understanding of the events which surround death in its finality. People who fear death of a close family member often begin the process of grieving their loss before actual loss occurs, and can remain locked in grief for years unless helped by the right communication. According to Hampe (1975) this phenomenon is known as 'anticipating grief' or grieving. If medical staff and nurses are to feel confident in anything to do with death and dying, or to feel comfortable in dealing with terminal illness, they should have some understanding of death itself. They should also feel confident in opening up and maintaining an effective dialogue. This requires training in the relevant interviewing, assessment and counselling skills (Maguire, 1985). A systematic approach is necessary to provide good care for the spouses of critically ill patients, who may suffer anticipatory grief. Excerpts from a very helpful paper by Breu (1982) and an adapted care plan are included (with permission) at the end of this paper. PMID:2754230
Youll, J W
"Patient awareness of prognosis patient-family caregiver congruence on referred place of death caregiving burden of family contribute to the quality of life for terminally ill cancer patients in Taiwan."
Did you mean: "Patient awareness of prognosis patient-family caregiver congruence on referred place of death caregiving burden of family contribute to the quality of life for terminally ill cancer patients in Taiwan." ?
Although the place of death of patients with terminal cancer is influenced by multiple factors, few studies have systematically investigated its determinants. The purpose of this study was to examine the influence of the patients' sociodemographic, clinical and support network variables on the place of death of terminally ill cancer patients under the care of home care agencies in Japan. Among 528 patients from 259 home care agencies, 342 (65%) died at home and 186 (35%) died at a hospital. From the multivariate logistic regression model, patients who expressed the desire for receiving home care at referral [odds ratio (OR), 95% confidence interval (CI): 2.19, 1.09-4.40] in addition to the family caregiver's desire for the same (OR, 95%CI: 3.19, 1.75-5.81), who had more than one family caregiver (OR, 95%CI: 2.28, 1.05-4.94), who had the support of their family physician (OR, 95%CI: 2.23, 1.21-4.08), who were never rehospitalized (OR, 95%CI: 0.04, 0.02-0.07), who received more home visits by the home hospice nurse during the stable phase under home hospice care (OR, 95%CI: 1.25, 1.02-1.53), and who were in the greatest functionally dependent status during the last week prior to death (OR, 95%CI: 8.60, 4.97-14.89) were more likely to die at home. Overall, this model could accurately classify 95% of the places of death, which is higher than other published studies. A clearer understanding of factors that might influence the place of death of terminally ill cancer patients would allow healthcare professionals to modify healthcare systems and tailor effective interventions to help patients die at their place of preference. PMID:12882263
Fukui, Sakiko; Kawagoe, Hiromi; Masako, Sakai; Noriko, Nishikido; Hiroko, Nagae; Toshie, Miyazaki
Behavior of a number of Quality of Life measures gathered from two samples of terminal cancer patients over the last weeks of their lives are reported. Samples represent patients in the 26 hospices participating in a nationwide U.S. demonstration project and patients in the palliative care units of two Montreal hospitals. The U.S. data reported are quality of life measures made by a lay principal care person (PCP) or trained interviewer; the Montreal measures were made by both an attending doctor and an attending nurse. The general finding, as expected, is one of increasing deterioration in quality of life, with accelerated deterioration between 3 and 1 week of death. Pain follows a somewhat different pattern than other measures. More patients are in either of the extreme categories at an earlier point in time than found for other measures, and there are fewer changes as death is approached. Finally, about 20% of the patients do not fall into extremely low quality of life categories, even in the week prior to death. PMID:2418050
Morris, J N; Suissa, S; Sherwood, S; Wright, S M; Greer, D
Objective: To determine patient characteristics associated with the desire for life-sustaining treatments in the event of terminal illness.\\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
Terminally ill cancer patients who have an early talk with their physician about care at the end-of-life are less likely to receive aggressive therapy – and more likely to enter hospice care – than patients who delay such discussions until the days and weeks before death, a new study by Dana-Farber Cancer Institute researchers suggests.
Abstract Background: Dignity therapy is a brief psychotherapy developed for patients living with a life-limiting illness. Objective: To determine the influence of dignity therapy on depression and anxiety in inpatients with a terminal illness and experiencing a high level of distress in a palliative care unit. Methods: A nonblinded phase II randomized controlled trial of 80 patients who were randomly assigned to one of two groups: intervention group (dignity therapy+standard palliative care [SPC]) or control group (SPC alone). The main outcomes were depression and anxiety scores, as measured with the Hospital Anxiety and Depression Scale, and assessed at baseline (T1), day 4 (T2), day 15 (T3), and day 30 (T4) of follow-up. This study is registered with www.controlled-trials.com/ISRCTN34354086 . Results: Of the final 80 participants, 41 were randomly assigned to SPC and 39 to dignity therapy. Baseline characteristics were similar between the two groups. Dignity therapy was associated with a decrease in depression scores (median, 95% confidence interval [CI]: -4.00, -6.00 to -2.00, p<0.0001; -4.00, -7.00 to -1.00, p=0.010; -5.00, -8.00 to -1.00, p=0.043, for T2, T3, and T4, respectively). Dignity therapy was similarly associated with a decrease in anxiety scores (median, 95% CI: -3.00, -5.00 to -1.00, p<0.0001; -4.00, -7.00 to -2.00, p=0.001; -4.00, -7.00 to -1.00, p=0.013, for T2, T3, and T4, respectively). Conclusion: Dignity therapy resulted in a beneficial effect on depression and anxiety symptoms in end-of-life care. The therapeutic benefit of dignity therapy was sustained over a 30-day period. Having established its efficacy, future trials of dignity therapy may now begin, comparing it with other psychotherapeutic approaches within the context of terminal illness. PMID:24735024
Julião, Miguel; Oliveira, Fátima; Nunes, Baltazar; Vaz Carneiro, António; Barbosa, António
The present study is a qualitative and phenomenological research aimed to understand the phenomenon Nurses working in the FHP (Family Health Program) and home care provided to the family living in a home where terminality of one of its members is being experienced. The study was carried out with healthcare providers who work in the Southeastern Region of the city of Sao Paulo/SP, Brazil. Existential phenomenology was used as the theoretical background. This study made possible the comprehension of what this experience meant to healthcare providers in a moment of being with the family in an existential situation of loss and death, creating a home protection network in order to make this process of terminality of one of the family members as smooth as possible. Even though permeated by care giving filled with humane feelings, thus representing a unique and remarkable experience, it was also a weary and difficult event that triggered labor health problems. PMID:19842599
Valente, Silvia Helena; Teixeira, Marina Borges
Undertreatment of cancer pain with analgesic drugs is still a frequent problem in French hospitals. In the absence of good analgesic practices, the use of a so-called lytic cocktail, which combines a neuroleptic (chlorpromazine), an opioid (meperidine), and an antihistamine (promethazine) has become common during the terminal phase of the disease. The lytic cocktail (LC) has been subsequently denounced as a type of disguised euthanasia. The aim of our study was to examine the prescription of morphine and lytic cocktail for terminally ill patients in a 427-bed French general hospital during a 3-year period (1989-1991) that coincided with the beginning of a pain relief service. The study was performed in two steps: a chart review of the 841 deceased patients during the observation period and an examination of morphine and parenteral promethazine consumption from the hospital pharmacy. Data from both the charts and the pharmacy showed an inverse relationship between these treatments. Morphine consumption increased while LC consumption decreased. The number of deceased patients who received LC were 24.4% in 1989, 19.9% in 1990, and 6.6% in 1991 (P < 0.001 between 1990 and 1991). The number of deceased who received morphine were 13.6% in 1989, 20.6% in 1990, and 23.9% in 1991 (P < 0.01 between 1989 and 1990). During the same period, the annual hospital morphine consumption increased by 191%, and the annual hospital parenteral promethazine consumption decreased by 62.5%. Our results suggest that, when pain is more correctly treated, the use of an inappropriate method of symptom control decreases.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:7541434
Meunier-Cartal, J; Souberbielle, J C; Boureau, F
Palliative care rests on the three pillars of symptom control, communication, and family support. As our patient population ages, we family doctors will be increasingly involved in the care of the terminally ill elderly at home. Terminal illnesses are much more common in the elderly, and often death can be predicted. Family doctors have a most important role in co-ordinating the home-support services, in providing comfort care, and in supporting the family members who are caring for the terminally ill elderly at home.
The need for new special care programs to care for nursing home patients who are dying and know it is discussed. Four different types of dying patients are identified according to their special needs. The hospice concept is described and conclusions are made about its application to the nursing home. In particular, it is concluded that: (1) nursing home administration need to form joint efforts with hospitals and home health services in deciding how to meet needs of dying patients; (2) a team concept is a good way to provide hospice care; and (3) current staff of nursing homes need to be educated in managing the patient who is dying and knows it. PMID:10243211
Breindel, C L
Notes that, in survey of 50 cancer patients offered living wills, 6 individuals declined to sign advance directives. Contains detailed evaluation of each of six cases. Discusses potential value of living wills in context of other, newer forms of advance directives, such as durable power of attorney for health care, and more detailed living will…
Stephens, Ronald L.; Grady, Rosemary
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
Barbara Gomes; Irene J Higginson
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.
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 to the patient with Alzheimer's disease and the patient's family. PMID:17347512
Wolf-Klein, Gisele; Pekmezaris, Renee; Chin, Lisa; Weiner, Joseph
Studies of patients who are terminally ill consistently identify strong associations between "sense of burden to others" and marked end-of-life distress. However, little research has addressed the issue of burden to others among patients nearing death. The aim of this study was to carefully examine "burden to others" and clarify its relationship with various psychosocial, physical, and existential issues arising in patients who are terminally ill. A cohort of 211 patients with end-stage cancer was assessed, using an assortment of validated psychometrics to document psychosocial, physical, and existential aspects of their end-of-life experience. This included an assessment of their sense of "burden to others." Forty percent of participants indicated a negligible sense of burden to others, scoring within the lowest quarter on an ordinal measure of "burden to others;" 25% scored within the second lowest quarter; 12% within the third quarter; and 23% within the highest or most severe range. The most highly correlated variables with "sense of burden to others" included depression (r=0.460; df=201, P<0.0001), hopelessness (r=0.420; df=199, P<0.0001), and outlook (r=0.362; df=200, P<0.0001). Four variables emerged in a multiple regression analysis predicting burden to others, including hopelessness, current quality of life, depression, and level of fatigue [R(2) adj=0.32, F(6,174)=13.76, P<0.0001]. There was no association between sense of burden to others and actual degree of physical dependency. Feeling a sense of burden to others is common among dying patients. Although 40% of the sample reported little in the way of sense of burden to others, the remainder endorsed higher degrees of burden-related distress, with 23% scoring within the most severe range. The lack of association between "sense of burden to others" and the degree of physical dependency suggests this perception is largely mediated through psychological and existential considerations. Strategies that target meaning and purpose, depression, and level of fatigue could lessen this source of distress and enhance quality, dignity-conserving care. PMID:17616329
Chochinov, Harvey Max; Kristjanson, Linda J; Hack, Thomas F; Hassard, Thomas; McClement, Susan; Harlos, Mike
Family caregivers are integral to the care of patients with physical or mental impairments. Unfortunately, providing this care is often detrimental to the caregivers' health. As a result, in the last decade, there has been a proliferation of interventions designed to improve caregivers' well-being. Interventions for caregivers of persons at end-of-life, however, are relatively few in number and are often underdeveloped. They also are typically designed to help reduce the work of caregiving or to help caregivers cope with the physical and emotional demands of providing care. While useful, these interventions generally ignore a primary stressor for family caregivers—a loved one's suffering. Patient suffering, whether physical, psychosocial, or spiritual, has a major impact on family caregivers. However, interventions that focus on the relief of patient suffering as a way to improve caregiver well-being have rarely been tested. It is our view that more research in this area could lead to new and more effective interventions for family caregivers of seriously or terminally ill patients. In support of our view, we will define suffering and review the relationships between patient suffering and caregiver well-being. We will then discuss a conceptual framework for intervention design. Finally, we conclude with a discussion of implications and future directions for intervention research.
Hebert, Randy S.; Arnold, Robert M.; Schulz, Richard
Objective: This study examined the impact of spirituality and religiosity on depressive symptom severity in a sample of terminally ill patients 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
In August 1985 the National Conference of Commissioners on Uniform State Laws drafted a document entitled The Uniform Rights of the Terminally Ill Act, which it recommended for enactment by all U.S. states. The act attempts to set uniform, clear guidelines for advance directives, or living wills--written declarations made by a patient that are used to guide treatment decisions should the patient become incompetent and terminally ill. The act limits the scope of an advance directive to the withdrawal or withholding of "life-sustaining treatment," which is "any medical procedure or intervention that when administered to a qualified patient will serve only to prolong the process of dying." Qualified patients are those with a terminal condition, which is "an incurable or irreversible condition that without the administration of life-sustaining treatment will, in the opinion of the attending physician, result in death within a relatively short time." The National Conference of Catholic Bishops (NCCB) Committee for Pro-Life Activities responded to the act in July 1986. The NCCB wishes to narrow the act's scope to apply only to patients in the "final stage of a terminal condition." Other specific concerns are the withdrawal of artificial nutrition and hydration, the need for communication with the family in making decisions, and the protection of an unborn child's life when the mother fulfills the conditions of the act and her living will stipulates a desire for withdrawal of life-sustaining treatment.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:10280352
Goal of the project is to develop an Evidence-based Clinical Decision Support (CDSS-EBM) system and make it available at the point of care to improve prognostication of the life expectancy of terminally ill patients to improve referral of patients to hosp...
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
C F Bolton; J J Gilbert; A F Hahn; W J Sibbald
Background The clinical prediction of survival is among the most challenging tasks because it refers to the process whereby the medical team assimilates clinical data using subjective methods. The purpose of this prospective observational study was to develop a model for evaluating survival time using objective laboratory parameters. Methods Albumin (ALB), creatinine (CRE), C-reactive protein (CRP) and the neutrophilic leukocyte count (NEU) were measured using automated analysers. A total of 177 subjects with any one positive item of 4 items were included in the study. Age on the observation date and date of death were recorded. Results ALB, CRE, CRP and the NEU were all significant predictors of survival time (p?0.05). The median survival time of patients with anyone of the 4 items positive would be over 1 year; if any 2 items were positive, the median survival time was approximately 1 year; if any 3 items were positive, the median survival time was approximately 4 months and if 4 items were positive, the median survival time was approximately 20 days. Conclusions This study suggests that a model using ALB, CRE, CRP and the NEU is potentially useful in the objective evaluation of survival time in terminally ill patients.
Abstract Introduction: We devised a comfort care kit (CCK) consisting of nonoral and nonparenteral rescue medications for caregivers to use at home for symptom control in imminently dying patients who have lost their ability to swallow. The aim of this study was to evaluate the feasibility of the CCK from the perspective of bereaved caregivers. Methods: CCKs were handed out to caregivers for patients who were entered into the care for the dying pathway (CDP). Each CCK includes morphine and haloperidol ampoules, lorazepam tablets, atropine drops, and paracetamol suppositories given either through sublingual or rectal route. We conducted a telephone survey of bereaved caregivers to assess CCK's feasibility (proportion of use), pattern of use, perceived benefits and challenges, and need to transfer to emergency department at the end of life. Results: Forty-nine caregivers completed the survey. Thirty-three (67%) reported that they used the CCK. A majority (76%) only used one medication from the kit. Atropine drops were the most commonly used, followed by morphine and paracetamol. All family members reported that the CCK was easy to use and 98% found it to be effective for symptom management. All except one patient died at home. Conclusion: The CCK was feasible and perceived to be effective for symptom control and easy to use. Further research is necessary to optimize the use of this kit and to document related outcomes. PMID:24708221
Yap, Richard; Akhileswaran, R; Heng, Chong Poh; Tan, Angela; Hui, David
Family units with a terminally ill child have a tendency to withdraw and this isolation may lead to problems in their mental health. A tendency with psychologists, clergy and helpers from other professions is to act as ideal experts on the lives of saddened people. From painful personal experience, this does not seem to enable acquiescence. Therefore, the aim of research on families with terminally ill children, was to explore and describe their lives and to develop an approach to facilitate their families to obtain acquiescence. In this article however, attention will be given to the life-world of families with terminally ill children. The research consists of two phases. In phase one the experiences of four families with terminally ill children are explored and described by means of phenomenological, unstructured, in-depth interviews. In phase two an acquiescence approach, which was designed for educational psychologists to facilitate families with terminally ill children to achieve acquiscence, is described. This approach is based on results from phase one. This article focuses on phase one. In this phase four families were interviewed individually, in the privacy of their homes. The interviews were audiotaped, and were transcribed for the purpose of data gathering. The data was analysed according to Tesch's method and a literature control was performed to verify the results. Guba's model for the validity of qualitative research was used. Five recurrent themes were identified: 1. Families are able to choose their reactions to the crises of having a terminally ill child. 2. When there is a terminally ill child in the family, the family's values change. 3. Acceptance of the circumstances with a terminally ill child, makes life easier. 4. As families with a terminally ill child learn to live every moment to the full, their quality of life improves. 5. As people learn to accept support, their quality of life with a terminally ill child improves. The research indicated that families with terminally ill children move through a lonely and painful process, which is characterised by growth at the end. This growth implies that the life skills mentioned above, were obtained after years of unimaginable suffering. In order to reduce this period of suffering, an acquiescence approach was designed for educational psychologists to facilitate discovery and acceptance regarding the above life skills with family units and thus allow them to achieve acquiescence. PMID:11885477
Hechter, S; Poggenpoel, M; Myburgh, C
In Australia and Oregon, USA, legislation to permit statutory sanctioned physician-assisted dying was enacted. However, opponents, many of whom held strong religious views, were successful with repeal in Australia. Similar opposition in Oregon was formidable, but ultimately lost in a 60-40% vote reaffirming physician-assisted dying. This paper examines the human dilemma which arises when technological advances in end-of-life medicine conflict with traditional and religious sanctity-of-life values. Society places high value on personal autonomy, particularly in the United States. We compare the potential for inherent contradictions and arbitrary decisions where patient autonomy is either permitted or forbidden. The broader implications for human experience resulting from new legislation in both Australia and Oregon are discussed. We conclude that allowing autonomy for the terminally ill, within circumscribed options, results in fewer ethical contradictions and greater preservation of dignity. Key Words: Physician-assisted suicide • voluntary euthanasia • patient autonomy • religious belief
Fraser, S.; Walters, J.
Objective: To study the perception of doctors and nurses on the care and bereavement support for relatives of critically ill and dying patients in an acute medical care setting. Participants and Methods: A self-administered questionnaire survey was completed by 169 nurses and 20 doctors at the Department of Medicine and Geriatrics, Caritas Medical Centre, Hong Kong. Results: When handling the
DM Tse; KK Wu; MH Suen; FY Ko; GL Yung
Rapid response to methylphenidate as an add-on therapy to mirtazapine in the treatment of major depressive disorder in terminally ill cancer patients: a four-week, randomized, double-blinded, placebo-controlled study.
This is a 4 week, randomized, double-blind, placebo-controlled study to examine the effects of methylphenidate as add-on therapy to mirtazapine compared to placebo for treatment of depression in terminally ill cancer patients. It involved 88 terminally ill cancer patients from University of Malaya Medical Centre, Kuala Lumpur, Malaysia. They were randomized and treated with either methylphenidate or placebo as add on to mirtazapine. The change in Montgomery-Åsberg Depression Rating Scale (MADRS) score from baseline to day 3 was analyzed by linear regression. Changes of MADRS and Clinical Global Impression-Severity Scale (CGI-S) over 28 days were analyzed using mixed model repeated measures (MMRM). Secondary analysis of MADRS response rates, defined as 50% or more reduction from baseline score. A significantly larger reduction of Montgomery-Åsberg Depression Rating Scale (MADRS) score in the methylphenidate group was observed from day 3 (B=4.14; 95% CI=1.83-6.45). Response rate (defined as 50% or more reduction from baseline MADRS score) in the methylphenidate treated group was superior from day 14. Improvement in Clinical Global Impression-Severity Scale (CGI-S) was greater in the methylphenidate treated group from day 3 until day 28. The drop-out rates were 52.3% in the methylphenidate group and 59.1% in the placebo group (relative risk=0.86, 95%CI=0.54-1.37) due to cancer progression. Nervous system adverse events were more common in methylphenidate treated subjects (20.5% vs 9.1%, p=0.13). In conclusions, methylphenidate as add on therapy to mirtazapine demonstrated an earlier antidepressant response in terminally ill cancer patients, although at an increased risk of the nervous system side effects. PMID:24503279
Ng, Chong Guan; Boks, Marco P M; Roes, Kit C B; Zainal, Nor Zuraida; Sulaiman, Ahmad Hatim; Tan, Seng Beng; de Wit, Niek J
This paper explores ethical issues relating to the management of patients who are terminally ill and unable to maintain their own nutrition and hydration. A policy of sedation without hydration or nutrition is used in palliative medicine under certain circumstances. The author argues that this policy is dangerous, medically, ethically and legally, and can be disturbing for relatives. The role
G M Craig
End-of-life decisions for terminally-ill newborn infants are usually made with the consent of parents as well as physicians, but may occasionally involve disagreement about which decision is in the best interest of the child. Paediatricians, while acting in accordance with the principle of respecting the autonomy of the parents, may collide with their own motive of avoiding pointless suffering of the infant. Based on their religious beliefs Islamic parents may not consent to an end-of-life decision. Three newborn girls who eventually died had been suffering from a skeletal dysplasia and a serious bronchopulmonary dysplasia, serious intractable deterioration after surgery for necrotising enterocolitis, and trisomy 18 respectively. In the first two cases there was no preceding consensus between parents and physicians and the girls died after more suffering than the paediatrician found acceptable. The physicians should aspire to prevent conflict situations by paying sufficient attention to the differences in beliefs. This demands that physicians understand and respect different beliefs and that they are able to communicate on the subject of these differences. It is important to Islamic parents that the natural course allows Allah to exercise his authority over life and death, and human dignity. Doing the best for the child is often more important than respect for patient or parent autonomy. PMID:17378297
Westra, A E; Smit, B J; Willems, D L
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 ill patients 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.
The question of whether terminally ill patients should artificially be given fluids has been debated since before palliative care became a recognised specialty. Arguments have been adduced from physiological, comfort, legal psychological, and emotional perspectives. Palliative care specialists agree that the priority is preventing the symptoms associated with dehydration, rather than the dehydration itself. However, the majority of terminally ill patients are cared for in settings outside hospices, and those admitted to hospital will tend to be exposed to a more technical approach. There are no randomised controlled trials in this area, and although an ethical minefield, we should not be afraid to manage individual patients according to the principles of palliative care where control of symptoms, not normalising of physiological variables, is the primary objective. PMID:9307738
Chadfield-Mohr, S M; Byatt, C M
This research explored the ethical issues that nurses reported in the process of elaboration and further disclosure after an initial diagnosis of a terminal illness had been given. One hundred and six hospice nurses in Norway and Denmark completed a questionnaire containing 45 items of forced-choice and open-ended questions. This questionnaire was tested and used in three countries prior to this study; for this research it was tested on Danish and Norwegian nurses. All respondents supported the ethics of ongoing disclosure to terminally ill patients based on ethical principles embedded in their country's Patients' Rights Acts. Truth, as an intrinsic value, proved foundational to patient autonomy, the most frequent ethical principle these nurses reported to justify their ethical position on information disclosure to terminally ill people. Telling the truth about a diagnosis was not the end of ethics in hospice care, but rather the beginning because what occurs ethically in dealing with prognosis issues became central to these hospice nurses, the patients and their families. Coupled with truth-telling, compassionate interaction and care become extensions of patients' rights. PMID:12659488
Lorensen, Margarethe; Davis, Anne J; Konishi, Emiko; Bunch, Eli H
In medically ill patients, 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
Rackley, Sandra; Bostwick, J Michael
ObjectiveFormer studies in chronic diseases showed the importance of patients’ beliefs and perceptions. The Revised Illness Perception Questionnaire was developed to assess these illness perceptions. Our goal was to investigate psychometric properties of the IPQ-R for Fibromyalgia Dutch language version (IPQ-R FM-Dlv) and to describe illness perceptions of participants with FM.
M. W. van Ittersum; C. P. van Wilgen; W. K. H. A. Hilberdink; J. W. Groothoff; C. P. van der Schans
End-of-Life Care for Children With Terminal Illness KidsHealth > Parents > Doctors & Hospitals > Caring for a Seriously or Chronically Ill Child > End-of- ... families cope with terminal illness. What Is Hospice Care? Hospice care, sometimes called end-of-life palliative ...
Patients with psychiatric illnesses may be at higher risk for the development of certain medical problems. Those with more\\u000a severe psychiatric illnesses may encounter barriers to promoting good health and to obtaining good health care when comorbid\\u000a illnesses do occur. This paper reviews some of the recent literature on health care practices and health system access for\\u000a the mentally ill;
Larry S. Goldman
Data from interviews with 100 social workers who treat the terminally ill 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
Joan K. Parry
Facing a terminal illness is an unimaginably difficult experience, yet many individuals intend to work despite their prognosis. However, research has not systematically examined the potential antecedents underlying such intentions. Using behavioral intention theory as an underlying framework, this study hypothesized that reasons for working (intrinsic and extrinsic), the will to live, disability severity, accessibility of travel, and age would predict intentions to work during terminal illness. A representative sample of medically diagnosed amyotrophic lateral sclerosis (a.k.a. Lou Gehrig's disease) patients with a mean life expectancy of approximately 3 years participated (mean age=57.8 years). Controlling for length of diagnosis, employment status, and demographic variables, results indicated that intrinsic reasons were particularly strong predictors of intentions, followed by age, disability severity, and accessibility of travel. Exploratory findings also indicated that behavioral intentions were positively related to future employment status, consistent with past theory. ((c) 2005 APA, all rights reserved). PMID:16316283
Westaby, James D; Versenyi, Andrea; Hausmann, Robert C
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.
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 concerning medical end-of-life decisions to be made at a later date. Hopeless suffering, loss of dignity, and no prospect of recovery were the most prevalent reasons for explicitly requesting EAS. According to the relative, in 92% of patients EAS had contributed favourably to the quality of the end of life, mainly by preventing or ending suffering. PMID:17131559
Georges, Jean-Jacques; Onwuteaka-Philipsen, Bregje D; Muller, Martien T; Van Der Wal, Gerrit; Van Der Heide, Agnes; Van Der Maas, Paul J
The global euthanasia debate by health care professionals has raised important ethical issues concerning the professional duties and responsibilities of nurses caring for terminal patients. The purpose of this study was to examine the attitudes of acutely ill patients towards the practice of euthanasia in Hong Kong. A modified form of the 23-item Questionnaire for General Household Survey scale was used. This cross-sectional survey study was conducted with a stratified sample of in-patients recruited from a wide variety of departments in a regional, acute general hospital. Seventy-seven out of 129 patients responded (59.7%) and a high proportion of patients agreed with the use of euthanasia in the following circumstances: ‘where they were a third party’, if ‘someone they loved’ was affected, or if ‘they themselves were the patient’. Of the 77 patients, 54 agreed with active euthanasia (70.1%) and 65 with passive (84.4%). The results also indicated that a few socio-demographic characteristics (such as age, gender and household income) statistically significantly correlated with patients’ attitudes towards euthanasia. These findings highlight that Chinese patients with acute illness generally accept the use of euthanasia. Further research on the attitudes and perceptions of patients towards the use of euthanasia is recommended, particularly in diverse groups of Chinese and Asian patients with acute or terminal illness.
Lam, R.C.S; Chien, Wai-Tong
This study examined the ethical issues experienced by nurses working in a small group of elderly persons' care settings in the UK, using a survey questionnaire previously used in other countries for examining the cultural aspects of ethical issues. However 'culture' relates not only to ethnicity but also the organizational culture in which care is delivered. Nurses working in elderly persons' care settings described a range of issues faced when caring for elderly terminally ill people, which illustrated the different needs of patients, relatives, professionals and society. These issues related to the unique needs of elderly people (such as dementia sufferers) and could have an impact on patients' quality of death. PMID:15030023
Enes, S Patricia D; de Vries, Kay
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 number of terminally ill prison inmates rises each year. Mental health professionals are uniquely prepared to provide therapy during the end-of-life process with their assessment, training, empathy, and communication skills. This case study examines the six-month therapy of one terminally ill inmate, using a client-centered approach. Drawing…
Antiphospholipid antibodies are responsible for a wide spectrum of clinical manifestations. Venous, arterial and microvascular thrombosis and severe catastrophic cases account for a large morbidly/mortality. Through the connection between the immune, inflammatory and hemostatic systems, it is possible that these antibodies may contribute to the development of organ dysfunction and are associated with poor short and long-term prognoses in critically ill patients. We performed a search of the PubMed/MedLine database for articles written during the period from January 2000 to February 2013 to evaluate the frequency of antiphospholipid antibodies in critically ill patients and their impact on the outcomes of these patients. Only eight original studies involving critically ill patients were found. However, the development of antiphospholipid antibodies in critically ill patients seems to be frequent, but more studies are necessary to clarify their pathogenic role and implications for clinical practice.
Vassalo, Juliana; Spector, Nelson; de Meis, Ernesto; Soares, Marcio; Salluh, Jorge Ibrain Figueira
Addressing spiritual needs is acknowledged as an essential component of holistic nursing care. Findings are emerging that suggest that chronic illness demands significant changes in patients' lifestyle. In such circumstances it is claimed that spiritual care can be therapeutic to patients (Cohen et al, 2000; Sherwood, 2000). This study was carried out in order to understand further the spiritual coping mechanisms of patients suffering from chronic illness. A qualitative methodology based on descriptive phenomenology was used to capture participants' lived experience. The main themes emerging from this study suggest that chronic illness led participants to use the following spiritual coping mechanisms: faith, prayer, and related sources of support. Patients coping with chronic illness were engaged in both a personal and private struggle. Patients may benefit from nursing interventions that are sensitive, supportive, and responsive to their spiritual needs. PMID:12514485
Involvement of the family in decisions to withhold or withdraw intensive care and parental involvement in care planning for terminally ill infants does not aggravate or prolong parents' grief responses, their feelings of guilt, or the incidence of pathological grief responses. Effective physical pain and symptom management is critically important. Compassionate care plans, however, need to implement a number of other and equally important components. Parents are not uniform in their perceived needs to make various kinds of contacts with their dying infant. They should be allowed to make their individual choices regarding contact with their baby during that time. The perinatal loss of a twin infant appears to evoke no less serious stress and risks to parents' compared to the loss of a singleton. The disruption of family life during a perinatal loss affects siblings of the baby, and their specific needs should be acknowledged. Post-death or post-autopsy meetings with the family should routinely be scheduled a few weeks after death, and bereavement support should actively be offered. Parents need to be informed about differences to be expected between maternal and paternal grief responses. The risk of pathological grief variants and chronic grief should be mentioned to parents because professional help is required in such occurrence. PMID:17486525
Schulze, A; Wermuth, I
Gastroesophageal reflux (GER) is a common occurrence in critically ill, mechanically ventilated patients. Reflux can lead to pulmonary aspiration of gastric contents and subsequent pneumonia. Several characteristics of patients, interventions provided in the intensive care unit setting, and factors associated with feeding increase a patient's risk for reflux. Critical care nurses and clinical nurse specialists can identify patients at highest risk for GER by utilizing the patient's history, reviewing the medications, and assessing the current status to provide interventions to reduce the risk of GER and its sequelae of aspiration pneumonia. This article reviews the physiology of GER, risk factors, and interventions to decrease GER in the critically ill patient. PMID:23388865
Schallom, Marilyn; Orr, James; Metheny, Norma; Pierce, Janet
In a palliative care setting, there is evidence from the practice of spiritual care delivery to suggest that some terminally ill patients may seek, with varying degrees of openness and articulation, to connect with a higher power, or God, despite having expressed no previous interest in religion or belief. Developing a better understanding of the thoughts and feelings of such patients requires insight into the initial triggers of their search. In this small qualitative study involving six patients, fear, hope, and a natural connection are posited as possible prompts. The results highlight the complexity of ambivalent feelings toward a transcendent being that can be the focus of anger and blame while simultaneously offering a source of comfort and hope for an afterlife. Moreover, the study revealed something of the extent to which health professionals may feel limited in facilitating necessary discussion by a need to protect patients and themselves from entering an unfamiliar and complex area. PMID:23123983
Critically ill patients were observed during routine movement inside the hospital to and from the intensive therapy unit. One patient a month suffered major cardiorespiratory collapse or death as a direct result of movement. Renewed bleeding of a pelvic fracture, cardiac arrhythmia, cardiac embarrassment due to a haemothorax, and cardiovascular decompensation were seen. It was difficult to continue treatment during movement, especially maintaining an airway or providing adequate intermittent positive pressure ventilation. Seventy postoperative patients suffered few ill effects on being moved. Greater awareness of the dangers of moving critically ill patients within hospital is needed. Thorough preparation for the move and adequate maintenance of treatment during movement requires the skill of experienced medical staff.
This paper responds to the Expert Patient initiative by questioning its over-reliance on instrumental forms of reasoning. It will be suggested that expertise of the patient suffering from chronic illness should not be exclusively seen in terms of a model of technical knowledge derived from the natural sciences, but should rather include an awareness of the hermeneutic skills that the patient needs in order to make sense of their illness and the impact that the illness has upon their sense of self-identity. By appealing to MacIntyre's concepts of "virtue" and "practice", as well as Frank's notion of the "wounded story-teller", it will be argued that chronic illness can be constituted as a practice, by building a culture of honest and courageous story-telling about the experience of chronic suffering. The building of such a practice will renew the cultural resources available to the patient, the physician and the rest of the community in understanding illness and patient-hood. PMID:16215796
The United Network for Organ Sharing recently changed its policies for liver allocation to give patients with severe hepatic failure priority due to their greater risk of morbidity and mortality. This case illustrates the benefit of transplant in critically ill patients. PMID:24853154
Jacobson, Katherine; Cameron, Andrew; Essary, Alison C
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 ill patient because of the unavailability of a reli- able history, delay in reporting of diagnostic laboratory results, and the comorbidities that
YORAM SHENKER; JAMES B. SKATRUD
According to the guidelines of WHO [WHO, 1999. Cancer Pain and Palliative Care Program. Cancer Pain Release, vol. 13], the term terminally ill patient refers to oncological patients whose life expectancy is lower than 90 days, and the index of their physical state (defined as the Karnofsky Index) is below 50. The terminally ill oncological patients are treatable with the palliative cures, representing a treatment system aimed at improving the quality of life (QOL) of both the patient and the family members, decreasing the physical and psychical sufferance of the patient. The present study followed 35 terminally ill oncological patients with bone metastases, at their homes, for the University of Catania. These patients had previously been followed by the Local Sanitary Unit (ASL 3) of Catania, and established a life expectancy not longer than 3 months. Independently from the basic neoplastic disease resulting in the bone metastases, all the patients were treated with sodium clodronate (SC) intravenously, 300 mg every second day, in order to decrease the bone pains. The visual analogue scale (VAS) for pain relief, the autonomy (IADL) and autosufficiency (ADL, Barthel Index) were evaluated after 1, 3, and 6 months of treatment. The results indicate an overall significant improvement both in the pain symptoms and the QOL. Also the compromised autonomy and autosufficiency of this population seemed to be improved, at least as compared to the predicted and expected results at the start of this trial, and also compared to the relevant literature. One can conclude that the i.v. application of 300 mg of SC every other day produced a significant pain reduction and improved the QOL, and helped in maintaining the actual autonomy and autosufficiency. On this basis we suggest the use of this compound in the given type of terminally ill patients. PMID:16325938
Santangelo, Antonino; Testai, Manuela; Barbagallo, Patrizia; Manuele, Sara; Di Stefano, Alessandra; Tomarchio, Marcello; Trizzino, Giorgio; Musumeci, Giovanni; Panebianco, Pietra; Maugeri, Domenico
Hyperglycemia frequently occurs with acute medical illness, especially among patients with cardiovascular disease, and has been linked to increased morbidity and mortality in critically ill patients. Even patients who are normoglycemic can develop hyperglycemia in response to acute metabolic stress. An expanding body of literature describes the benefits of normalizing hyperglycemia with insulin therapy in hospitalized patients. As a result, both the American Diabetes Association and the American College of Endocrinology have developed guidelines for optimal control of hyperglycemia, specifically targeting critically ill, hospitalized patients. Conventional blood glucose values of 140–180 mg/dL are considered desirable and safely achievable in most patients. More aggressive control to <110 mg/dL remains controversial, but has shown benefits in certain patients, such as those in surgical intensive care. Intravenous infusion is often used for initial insulin administration, which can then be transitioned to subcutaneous insulin therapy in those patients who require continued insulin maintenance. This article reviews the data establishing the link between hyperglycemia and its risks of morbidity and mortality, and describes strategies that have proven effective in maintaining glycemic control in high-risk hospitalized patients.
Tracheostomy is a common critical care procedure in patients with acute respiratory failure who require prolonged mechanical ventilatory support. Tracheostomy usually is considered if weaning from mechanical ventilation has been unsuccessful for 14 to 21 days. A recent clinical trial suggested that early tracheostomy may benefit patients who are not improving and who are expected to require prolonged respiratory support. In this study, early tracheostomy improved survival and shortened duration of mechanical ventilation. Minimally invasive bedside percutaneous tracheostomy was introduced recently as an alternative to the traditional surgical technique. In expert hands, the 2 techniques are equivalent in complications and safety; however, the bedside percutaneous approach may be more cost-effective. Tracheostomy should be considered early (within the first week of mechanical ventilation) in patients with a high likelihood of prolonged mechanical ventilation. Depending on local medical expertise and costs, either the percutaneous or the surgical technique may be used. PMID:16342657
Rana, Sameer; Pendem, Shanthan; Pogodzinski, Matthew S; Hubmayr, Rolf D; Gajic, Ognjen
By taking care of cancer patients in their process of end of life, nursing experience situations of suffering before the anguish of others. This study aimed to understand the meaning and significance attributed by the nurses from the palliative care cancer hospital. This is a phenomenological research, grounded in Heidegger's thinking, performed with 13 nurses, who work at Oncology hospitalward, through semi-structured interviews, which were analyzed according to the steps recommended by Josgrilberg. From understanding the statementsof the subjects, two ontological themesemerged: Feeling satisfaction and love in the care offered and Feeling anger and inabilitytowards terminally ill patients.We inferred that working in Oncology Ward is something rewarding for these professionals, but it entails physical and mental suffering, from feeling helpless before the death-dying process. Thus, we showedthat nursing professionals need to be recognized as human beings and as such, also deserving of care. PMID:24676106
de Almeida, Carla Simone Leite; Sales, Catarina Aparecida; Marcon, Sônia Silva
The perormance of two groups of hospitalized mentally ill patients (schizophrenia and major depression) and two groups of non-mentally-ill patients (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
Thomas Grisso; Paul S. Appelbaum
While dysglycemia (hyperglycemia, hypoglycemia and glucose variability) is clearly associated with increased mortality in critically ill patients, target range of blood glucose control remains controversial. Standardized insulin infusion protocols constitute the basis of treatment of these patients. The choice of protocol and its implementation is a great challenge. In this article, we review the published data to help define the essential elements that compose a good protocol and apply the right conditions to make it safe and effective. PMID:24690510
Boutin, Jean-Marie; Gauthier, Lyne
Pneumothorax in critically ill patients remains a common problem in the ICU, occurring in 4% to 15% of patients. Pneumothorax should be considered a medical emergency and requires a high index of suspicion, prompt recognition, and intervention. The diagnosis of pneumothorax in the critically ill patient can be made by physical examination findings or radiographic studies including chest radiographs, ultrasonography, or CT scanning. Ultrasonography is emerging as the diagnostic procedure of choice for the diagnosis and management guidance and management of pneumothoraces, if expertise is available. Pneumothoraces in unstable, critically ill patients or in those on mechanical ventilation should be managed with tube thoracostomy. If there is suspicion for tension pneumothorax, immediate decompression and drainage should be performed. With widespread use of CT scanning, there have been more occult pneumothoraces diagnosed, and the most recent literature suggests that drainage is preferred. In patients with a persistent air leak or failure of the lung to expand, current guidelines suggest that an early thoracic surgical consultation be requested within 3 to 5 days. PMID:22474153
Yarmus, Lonny; Feller-Kopman, David
Critically ill patients in intensive care units (ICU) for more than a few days have a mortality of approximately 20% world-wide. These critically ill patients, in the absence of a previous diagnosis of diabetes, commonly exhibit stress hyperglycemia and insulin resistance (1). Many of these critically ill patients die of multiorgan dysfunction (MOD) and sepsis. Since stress hyper- glycemia has
Robert W. Schrier
Background Depressive symptoms, apathy, and fatigue are common symptoms among medically ill older adults and patients with advanced disease, and are associated with morbidity and mortality. Methylphenidate has been used to treat these symptoms because of its rapid effect. Objective To review the literature regarding the efficacy and safety of methylphenidate to treat depressive symptoms, apathy, and fatigue in medically ill older adults and in palliative care. Methods English-language articles presenting systematic reviews, clinical trials, or case series describing use of methylphenidate to treat depressive symptoms, fatigue, or apathy in medically ill older adults or in palliative care were identified. The keywords “methylphenidate” and either “depressive”, “depression”, “fatigue”, or “apathy” were used to search the Cochrane Database, MEDLINE, PsycINFO, and International Pharmaceutical Abstracts. Included articles addressed depressive symptoms, apathy, or fatigue in 1) older adults (generally age 65 years or older), particularly those with comorbid medical illness; 2) adult patients receiving palliative care; and 3) adults with other chronic illnesses. We excluded articles regarding 1) treatment of depression in healthy young adults; 2) treatment of bipolar disorder or attention-deficit hyperactivity disorder; and 3) treatment of narcolepsy, chronic fatigue syndrome and related disorders. Results 19 controlled trials of methylphenidate in medically ill older adults or in palliative care were identified. Unfortunately, their conflicting results, small size, and poor methodologic quality limit our ability to draw inferences regarding the efficacy of methylphenidate, although the evidence of its safety is stronger. The available evidence suggests possible effectiveness of methylphenidate for depressive symptoms, fatigue, apathy, and cognitive slowing in various medically ill populations. Conclusions In the absence of definitive evidence of effectiveness, trials of low-dose methylphenidate in medically ill adults suffering from depression, apathy, or fatigue with monitoring for response and adverse effects are appropriate.
Hardy, Susan E.
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 terminally ill 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 terminally ill frogs recovered rapidly to normal activity levels and appetite within 5 days of commencing treatment. In contrast, five untreated terminally ill 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 terminally ill Bd-infected frogs. PMID:22779237
Young, Sam; Speare, Rick; Berger, Lee; Skerratt, Lee F
This article is a review of the literature on the subject of how nurses who provide palliative care are affected by ethical issues. Few publications focus directly on the moral experience of palliative care nurses, so the review was expanded to include the moral problems experienced by nurses in the care of the terminally ill patients. The concepts are first defined, and then the moral attitudes of nurses, the threats to their moral integrity, the moral problems that are perceived by nurses, and the emotional consequences of these moral problems are considered in turn. The results show that the moral behaviour of nurses, which is theoretically grounded in commitment to care and to the patient, appears to be shaped by specific processes that lead to engagement or to mental and behavioural disengagement in morally difficult situations. Nurses often appear to fail to recognize the moral dimensions of the problems they experience and also to lack the skills they need to resolve moral problems adequately. Although the findings show that several elements that are beyond the control of nurses, owing to their lack of autonomy and authority, influence their moral experience, intrinsic factors such as feelings of insecurity and powerlessness have a profound effect on nurses' perceptions and attitudes in the face of moral problems. The moral problems perceived by these nurses are related to end-of-life issues, communication with patients, the suffering of patients, and the appropriateness of the medical treatment. PMID:11944206
Georges, Jean-Jacques; Grypdonck, Mieke
One of the most perplexing problems in the medicolegal field concerns the criteria on which decisions not to treat terminally ill 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 terminally ill incompetent patient on the real issues regarding criteria and the decision-making process that remain to be resolved. PMID:507056
Annas, G J
Facing a terminal illness is an unimaginably difficult experience, yet many individuals intend to work despite their prognosis. However, research has not systematically examined the potential antecedents underlying such intentions. Using behavioral intention theory as an underlying framework, this study hypothesized that reasons for working (intrinsic and extrinsic), the will to live, disability severity, accessibility of travel, and age would
James D. Westaby; Andrea Versenyi; Robert C. Hausmann
This article discusses students with terminal illnesses and the challenges teachers face in dealing with the issue of death. Classroom strategies for dealing with death are described and include using children's literature that explores death, using deaths of pets as teachable moments, and using children's films. (Contains references.) (CR)
Rice, Craig J.; Gourley, Junean Krajewski
In 2005, the American Counseling Association (ACA) introduced a new ethical standard for counselors working with clients with terminal illness who are considering hastened death options. The authors' purpose is to inform counselors of the Death With Dignity Act and explore relevant ethical guidelines in the "ACA Code of Ethics" (ACA, 2005).
Kurt, Layla J.; Piazza, Nick J.
This article examines the use of lobotomy as a treatment for chronic intractable pain and reconstructs then-common perceptions of pain and of the patients who suffered from it. It delineates the social expectations and judgments implicit in physicians' descriptions of the patients, analyzing what was expected from such patients and how the medical establishment responded to non-normative expressions of suffering. I argue that the medicalized response to an expectation for normativity demonstrates the convergence between psychiatric and palliative interventions. Based on a historically informed perspective of psychiatric interventions in the field of pain medicine, I examine the use of psychiatric medications for pain syndromes today and evaluate the interface between depression, chronic pain, and terminal illness. While not detracting from the medical imperative to alleviate pain, I question the usage of social criteria and normative judgments in the clinical decision of how to treat pain. What normalizing social function does the use of psychiatric interventions in pain treatment fulfill? This approach leads to a reexamination of perceptions of dualism in pain medicine. PMID:19855124
Studies on tight glycemic control by intensive insulin therapy abruptly changed the climate of limited interest in the problem of hyperglycemia in critically ill patients and reopened the discussion on accuracy and reliability of glucose sensor devices. This article describes important components of blood glucose measurements and their interferences with the focus on the intensive care unit setting. Typical methodologies, organized from analytical accuracy to clinical accuracy, to assess imprecision and bias of a glucose sensor are also discussed. Finally, a list of recommendations and requirements to be considered when evaluating (time-discrete) glucose sensor devices is given.
Van Herpe, Tom; Mesotten, Dieter
The prevalence of smoking is higher in patients with psychiatric illness compared with the general population. Smoking causes chronic illnesses, which lead to premature mortality in those with psychiatric illness, is associated with greater burden of psychiatric symptoms, and contributes to the social isolation experienced by individuals with psychiatric disorders. Most patients with a psychiatric illness present initially to primary care rather than specialty care settings, and some patients receive care exclusively in the primary care setting. Therefore, family physicians and other primary care clinicians have an important role in the recognition and treatment of tobacco use disorders in patients with psychiatric illnesses. In this article we review common myths associated with smoking and psychiatric illness, techniques for implementing evidence-based tobacco use treatments, the evidence base for tobacco use treatment for patients with specific psychiatric diagnoses, and factors to consider when treating tobacco use disorders in patients with psychiatric illness. PMID:24808119
Cerimele, Joseph M; Halperin, Abigail C; Saxon, Andrew J
Critically ill surgical patients account for approximately half the patients in an active multidisciplinary critical care unit. Hypovolemia and sepsis are common in such patients and affect a number of organ systems. Monitoring these systems provides therapeutically relevant information that may decrease morbidity and improve patient survival. Circulatory hemodynamics may be assessed by direct measurement of the arterial blood pressure, central venous and pulmonary artery pressure monitoring and cardiac output determination; the data thus obtained are valuable in guiding fluid replacement in the hypovolemic individual. The respiratory status may be assessed by bedside spirometry and measurement of arterial blood gas tensions to gauge pulmonary function and the need for assisted ventilation. Renal dysfunction is common in such patients; careful analysis of both urine and blood may identify prerenal as opposed to renal and postrenal factors. Monitoring of the gastrointestinal tract, especially for hemorrhage, is important. Finally, careful attention to nutritional status and provision of adequate protein and energy intake by mouth or by vein is a vital component of the optimal care of these patients.
Holliday, R L; Doris, P J
The aim of the study was to illuminate the experiences of surviving relatives in connection with their care at home of terminally ill, dying spouses, followed by an outline of the need for palliative assistance by the district nurse. Qualitative interviews with eight surviving relatives have been analysed on the basis of the phenomenological method. The essence of these phenomena was the loving promise to the terminally ill and dying spouse in which the shared grief, structural disintegration and powerlessness, lifelines and supporters and viable grief appeared. This promise consisted of that dying spouse will be able to stay at home during the illness and his or her desire to die at home. It was given during uncomfortable hospitalization and springing from the spouse's desire for autonomy and integrity at the end of his or her life. In keeping the promise, the surviving spouse became altruistic, neglecting his or her own primary needs in the unselfish fulfilment of the needs of the terminally ill spouse. The surviving spouse grieved in lonely isolation characterized by stress and an ethical dilemma in connection with breaching the promise. Light was shed on the professional palliative care with the surviving spouse's lacking verbalization of grief and powerlessness, regardless of whether expert professional palliation or insufficient professional palliation was provided. In that way the findings of the study showed the necessity for professional involvement in the decision concerning palliation at home, including identification of the resources of the primary caregiver. PMID:17559447
Fisker, Tove; Strandmark, Margaretha
A caregiver is an unpaid person, typically a family member or friend, who helps an ill person with the physical care and management of a disease. The task of caregiving results in additional responsibilities on the caregiver's daily life, and occupies the caregiver's time, energy, and attention, which is demanding and complex. The burden from caregiving, when prolonged, might affect the physical health of caregivers, causing symptoms, such as anxiety and depression, leading to a negative impact on their capacity for social engagement. This information sheet focuses on the best available evidence on factors that influence caregiver burden of the terminally-ill person, and provides some recommendations for practice. PMID:23186519
OBJECTIVE To examine the feasibility and efficacy of integrating home health monitoring into a primary care setting. DESIGN A mixed method was used for this pilot study. It included in-depth interviews, focus groups, and surveys. SETTING A semirural family health network in eastern Ontario comprising 8 physicians and 5 nurses caring for approximately 10 000 patients. PARTICIPANTS Purposeful sample of 22 patients chosen from the experimental group of 120 patients 50 years old or older in a larger randomized controlled trial (N = 240). These patients had chronic illnesses and were identified as being at risk based on objective criteria and physician assessment. INTERVENTIONS Between November 2004 and March 2006, 3 nurse practitioners and a pharmacist installed telehomecare units with 1 or more peripheral devices (eg, blood-pressure monitor, weight scale, glucometer) in patients’ homes. The nurse practitioners incorporated individualized instructions for using the unit into each patient’s care plan. Patients used the units every morning for collecting data, entering values into the system either manually or directly through supplied peripherals. The information was transferred to a secure server and was then uploaded to a secure Web-based application that allowed care providers to access and review it from any location with Internet access. The devices were monitored in the office on weekdays by the nurse practitioners. MAIN OUTCOME MEASURES Acceptance and use of the units, patients’ and care providers’ satisfaction with the system, and patients’ demographic and health characteristics. RESULTS All 22 patients, 12 men and 10 women with an average age of 73 years (range 60 to 88 years), agreed to participate. Most were retired, and a few were receiving community services. Common diagnoses included hypertension, diabetes, cardiovascular disease, and chronic obstructive pulmonary disease. All patients had blood pressure monitors installed, 11 had wired weight scales, 5 had glucometers, and 5 had pulse oximeters. The units were in place for 9 to 339 days. Three patients asked to have the systems removed early because they did not use them or found them inconvenient. The other patients and their informal caregivers found the technology user-friendly and useful. Health care providers were satisfied with the technology and found the equipment useful. They thought it might reduce the number of office visits patients made and help track long-term trends. CONCLUSION These pilot results demonstrate that telehomecare monitoring in a collaborative care community family practice is feasible and well used, and might improve access to and quality of care.
Liddy, Clare; Dusseault, Joanne J.; Dahrouge, Simone; Hogg, William; Lemelin, Jacques; Humber, Jennie
Effectiveness of palliative home-care services in reducing hospital admissions and determinants of hospitalization for terminally ill patients followed up by a palliative home-care team: A retrospective cohort study.
Background: It has been demonstrated that most patients in the terminal stages of cancer would benefit from palliative home-care services. Aim: The aim of this study was to assess the effectiveness of appropriate palliative home-care services in reducing hospital admissions, and to identify factors predicting the likelihood of patients treated at home being hospitalized. Design: Retrospective cohort study. Setting/participants: We enrolled all 402 patients listed by the Local Health Authority No. 5, Veneto Region (North-East Italy), as dying of cancer in 2011. Results: Of the cohort considered, 39.9% patients had been taken into care by a palliative home-care team. Irrespective of age, gender, and type of tumor, patients taken into care by the palliative home-care team were more likely to die at home, less likely to be hospitalized, and spent fewer days in hospital in the last 2 months of their life. Among the patients taken into care by the palliative home-care team, those with hematological cancers and hepatocellular carcinoma were more likely to be hospitalized, and certain symptoms (such as dyspnea and delirium) were predictive of hospitalization. Conclusions: Our study confirms the effectiveness of palliative home care in enabling patients to spend the final period of their lives at home. The services of a palliative home-care team reduced the consumption of hospital resources. This study also provided evidence of some types of cancer (e.g. hematological cancers and hepatocellular carcinoma) being more likely to require hospitalization, suggesting the need to reconsider the pathways of care for these diseases. PMID:24367058
Riolfi, Mirko; Buja, Alessandra; Zanardo, Chiara; Marangon, Chiara Francesca; Manno, Pietro; Baldo, Vincenzo
The number of terminally ill prison inmates rises each year. Mental health professionals are uniquely prepared to provide therapy during the end-of-life process with their assessment, training, empathy, and communication skills. This case study examines the six-month therapy of one terminally ill inmate, using a client-centered approach. Drawing from existential therapy, the review of meaningful life events in the client's life clarifies current goals and the value of the current final stage of life. Ethical issues that arose are discussed, including pain management and compassionate release. Creative solutions to these ethical dilemmas were implemented through consideration of the overt and underlying goals of the inmate, the necessary rules and protocols of the prison, and in conjunction with professional codes of ethics. PMID:14969279
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
Jen-Huoy Tsay; Cheng-Hua Lee; Yea-Jen Hsu; Pen-Jen Wang; Ya-Mei Bai; Yiing-Jenq Chou; Nicole Huang
Previous research suggests that caregivers and terminally ill patients face substantial difficulties discussing illness and death. Existing research, however, has focused primarily on the experience of patients. The current study compared responses as well as the relative strength of association between mortality communication, fear of death, and…
Bachner, Yaacov G.; O'Rourke, Norm; Carmel, Sara
Apart from the rather rare ictal psychotic events, such as non-convulsive status epilepticus, modern epileptic psychoses have been categorized into three main types; chronic and acute interictal psychoses (IIPs) and postictal psychosis (PIP). Together, they comprise 95% of psychoses in patients with epilepsy (PWE). Four major questions, that is, “Is psychosis in PWE a direct consequence of epilepsy or schizophrenia induced by epilepsy?”, “Is psychosis in PWE homogeneous or heterogeneous?”, “Does psychosis in PWE have symptomatological differences from schizophrenia and related disorders?”, “Is psychosis in PWE uniquely associated with temporal lobe epilepsy (TLE)?” are tried to be answered in this review with relevant case presentations. In the final section, we propose a tentative classification of psychotic illness in PWE, with special attention to those who have undergone epilepsy surgery. Psychotic disorders in PWE are often overlooked, mistreated, and consequently lingering on needlessly. While early diagnosis is unanimously supported as a first step to avoid this delay, necessity of switching from antiepileptic drugs with supposedly adverse psychotopic effects. to others is more controversial. To elucidate the riddle of alternative psychosis, we need badly further reliable data.
Tadokoro, Yukari; Oshima, Tomohiro
Patients suffering from factitious illness present complex problems for themselves and hospital personnel. This article describes a multidisciplinary intervention through confrontation approach that has proved to be successful with such patients. (Author)
Wedel, Kenneth R.
The authors of this study are interested in listening to the experiences professional doctors and nurses who work face to face with patients in terminal phase of their illnesses have. For this reason, the authors carried out a series of in-depth interviews with these professionals in order to know the real difficulties and obstacles which these professionals experience in real cases, as well as the procedure methods followed with these patients. The authors publish the results obtained in eight of these interviews, four with doctors and four with nurses; given the length of these interviews, the authors have decided to publish them in two consecutive articles which form one complete study This study is qualitative and the analysis of data obtained has been structured around the proposed research questions, keeping the diversity and variability how to deal with patients, plus the experiences shown by those interviewed, by citing their words textually. PMID:18564789
Caro, García M P; Rio-Valle, Schmidt J; Quintana, Cruz F; Peña, Prados D; Vinuesa, Muñoz A; Pappous, Athanasios
Objective: To assess the effect of metoclopramide on gastric motility in critically ill patients. Design: Prospective, controlled, single-blind cross-over trial. Setting: A 10-bed general intensive care unit. Patients: Ten critically ill, enterally fed adult patients without renal failure. Interventions: Each patient received enteral feeding with Enrich via a nasogastric tube at 50 ml\\/h throughout the 5-h study period on two
C. A. Jooste; J. Mustoe; G. Collee
Neuromuscular complications of critical illness are common, and can be severe and persistent, with substantial impairment in physical function and long-term quality of life. While the etiology of ICU-acquired weakness (ICUAW) is multifactorial, both direct (ie, critical illness neuromyopathy) and indirect (ie, immobility/disuse atrophy) complications of critical illness contribute to it. ICUAW is often difficult to diagnose clinically during the acute phase of critical illness, due to the frequent use of deep sedation, encephalopathy, and delirium, which impair physical examination for patient strength. Despite its limitations, physical examination is the starting point for identification of ICUAW in the cooperative patient. Given the relative cost, invasiveness, and need for expertise, electrophysiological testing and/or muscle biopsy may be reserved for weak patients with slower than expected improvement on serial clinical examination. Currently there are limited interventions to prevent or treat ICUAW, with tight glycemic control having the greatest supporting evidence. There is a paucity of clinical trials evaluating the specific role of early rehabilitation in the chronic critically ill. However, a number of studies support the benefit of intensive rehabilitation in patients receiving chronic mechanical ventilation. Furthermore, emerging data demonstrate the safety, feasibility, and potential benefit of early mobility in critically ill patients, with the need for multicenter randomized trials to evaluate potential short- and long-term benefits of early mobility, including the potential to prevent the need for prolonged mechanical ventilation and/or the development of chronic critical illness, and other novel treatments on patients' muscle strength, physical function, quality of life, and resource utilization. Finally, the barriers, feasibility, and efficacy of early mobility in both medical and other ICUs (eg, surgical, neurological, pediatric), as well as in the chronic critically ill, have not been formally evaluated and require exploration in future clinical trials. PMID:22663968
Thrombo-prophylaxis has been shown to reduce the incidence of pulmonary embolism (PE) and mortality in surgical patients. The purpose of this review is to find out the evidence-based clinical practice criteria of deep vein thrombosis (DVT) prophylaxis in acutely ill medical and critically ill patients. English-language randomized controlled trials, systematic reviews, and meta-analysis were included if they provided clinical outcomes and evaluated therapy with low-dose heparin or related agents compared with placebo, no treatment, or other active prophylaxis in the critically ill and medically ill population. For the same, we searched MEDLINE, PUBMED, Cochrane Library, and Google Scholar. In acutely ill medical patients on the basis of meta-analysis by Lederle et al. (40 trials) and LIFENOX study, heparin prophylaxis had no significant effect on mortality. The prophylaxis may have reduced PE in acutely ill medical patients, but led to more bleeding events, thus resulting in no net benefit. In critically ill patients, results of meta-analysis by Alhazzani et al. and PROTECT Trial indicate that any heparin prophylaxis compared with placebo reduces the rate of DVT and PE, but not symptomatic DVT. Major bleeding risk and mortality rates were similar. On the basis of MAGELLAN trial and EINSTEIN program, rivaroxaban offers a single-drug approach to the short-term and continued treatment of venous thrombosis. Aspirin has been used as antiplatelet agent, but when the data from two trials the ASPIRE and WARFASA study were pooled, there was a 32% reduction in the rate of recurrence of venous thrombo-embolism and a 34% reduction in the rate of major vascular events.
Saigal, Saurabh; Sharma, Jai Prakash; Joshi, Rajnish; Singh, Dinesh Kumar
Thrombo-prophylaxis has been shown to reduce the incidence of pulmonary embolism (PE) and mortality in surgical patients. The purpose of this review is to find out the evidence-based clinical practice criteria of deep vein thrombosis (DVT) prophylaxis in acutely ill medical and critically ill patients. English-language randomized controlled trials, systematic reviews, and meta-analysis were included if they provided clinical outcomes and evaluated therapy with low-dose heparin or related agents compared with placebo, no treatment, or other active prophylaxis in the critically ill and medically ill population. For the same, we searched MEDLINE, PUBMED, Cochrane Library, and Google Scholar. In acutely ill medical patients on the basis of meta-analysis by Lederle et al. (40 trials) and LIFENOX study, heparin prophylaxis had no significant effect on mortality. The prophylaxis may have reduced PE in acutely ill medical patients, but led to more bleeding events, thus resulting in no net benefit. In critically ill patients, results of meta-analysis by Alhazzani et al. and PROTECT Trial indicate that any heparin prophylaxis compared with placebo reduces the rate of DVT and PE, but not symptomatic DVT. Major bleeding risk and mortality rates were similar. On the basis of MAGELLAN trial and EINSTEIN program, rivaroxaban offers a single-drug approach to the short-term and continued treatment of venous thrombosis. Aspirin has been used as antiplatelet agent, but when the data from two trials the ASPIRE and WARFASA study were pooled, there was a 32% reduction in the rate of recurrence of venous thrombo-embolism and a 34% reduction in the rate of major vascular events. PMID:24987238
Saigal, Saurabh; Sharma, Jai Prakash; Joshi, Rajnish; Singh, Dinesh Kumar
In a prospective study the criteria and characteristics associated with the admission of acutely ill psychiatric patients to in-patient or day hospital care were examined. Over a four-month period, 54 patients were admitted to hospital and 43 to a day hospital. There was significantly more schizophrenics in the hospital. Day hospital patients were significantly younger, had shorter psychiatric histories, were considered less severely ill and had more insight into their illness. Hospital patients had poorer employment histories, and perceived their families as less supportive; admission had more often been requested by them or their families. PMID:6882981
Bowman, E P; Shelley, R K; Sheehy-Skeffington, A; Sinanan, K
This study was designed to compare the abilities of hospitalized, medically ill patients with non-ill comparison subjects to engage in an informed consent process. Eighty-two inpatients under the age of 70 were recruited from patients admitted for evaluation or treatment of ischemic heart disease (N = 675). The comparison subjects (n = 82) were matched person-to-person on age, gender, race,
Paul S. Appelbaum; Thomas Grisso
Background Previous research has shown that symptom severity often implies an increased family burden. Few other illness-related variables\\u000a have, however, been investigated in this context. This study investigates how family burden is affected by symptom, function,\\u000a and cognition, as well as how the patient perceives his\\/her illness and quality of life.\\u000a \\u000a \\u000a \\u000a Method A total of 99 relatives, to as many patients diagnosed
Fredrik Hjärthag; Lars Helldin; Ulla Karilampi; Torsten Norlander
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.
Hospital physicians care for most seriously ill patients in the United States. We employed dimensional analysis to describe communication about death and dying in audio-recorded admission encounters between seriously ill patients and hospitalists. Acknowledging or not acknowledging the possibility of dying emerged as a key process. Acknowledgment was rare, and depended on synergistic communication behaviors between patient and physician. Facilitators included patients cuing for information and disclosing emotional distress, and physicians exploring the patient’s understanding of his or her illness and emotional distress. When hospitalists focused on acute issues, stated that they were awaiting test results, and deferred to other physicians, discussion moved away from acknowledgment. Meaningful discussion of end-of-life issues, including goals and values, fears about death and dying, prognosis, and options for palliative care followed open acknowledgment. This acknowledgment process can serve as a guide for providers to sensitively and honestly discuss essential end-of-life issues.
Anderson, Wendy G.; Kools, Susan; Lyndon, Audrey
Fluid overload may occur in critically ill patients as a result of aggressive resuscitation therapies. In such circumstances, persistent fluid overload must be avoided since it does not benefit the patient while it may be harmful. In the septic patient, early volume expansion seems to be beneficial. Beyond that threshold, when organ failure develops, fluid overload has been shown to
Jorge Cerda; Geoffrey Sheinfeld; Claudio Ronco
Gentamicin intrapatient pharmacokinetics variations were studied in 40 critically ill medical patients, suffering gram-negative sepsis. These patients were studied in two phases throughout gentamicin treatment: firstly, on the second day of treatment, when aggressive fluid therapy was required, and secondly, five days later, when patients had achieved a more stable clinical condition. Pharmacokinetic parameters were determined using least squares linear
C. Triginer; I. Izquierdo; R. Fernfindez; J. Rello; J. Torrent; S. Benito; A. Net
Hyperglycemia is a commonly encountered issue in critically ill patients in the intensive care setting. The presence of hyperglycemia is associated with increased morbidity and mortality, regardless of the reason for admission (e.g., acute myocardial infarction, status post-cardiovascular surgery, stroke, sepsis). However, the pathophysiology and, in particular, the treatment of hyperglycemia in the critically ill patient remain controversial. In clinical practice, several aspects must be taken into account in the management of these patients, including blood glucose targets, history of diabetes mellitus, the route of nutrition (enteral or parenteral), and available monitoring equipment, which substantially increases the workload of providers involved in the patients' care. This review describes the epidemiology, pathophysiology, management, and monitoring of hyperglycemia in the critically ill adult patient.
Viana, Marina Vercoza; Moraes, Rafael Barberena; Fabbrin, Amanda Rodrigues; Santos, Manoella Freitas; Gerchman, Fernando
Introduction Regional citrate anticoagulation (RCA) is gaining popularity in continous renal replacement therapy (CRRT) for critically ill patients. The risk of citrate toxicity is a primary concern during the prolonged process. The aim of this study was to assess the pharmacokinetics of citrate in critically ill patients with AKI, and used the kinetic parameters to predict the risk of citrate accumulation in this population group undergoing continuous veno-venous hemofiltration (CVVH) with RCA. Methods Critically ill patients with AKI (n?=?12) and healthy volunteers (n?=?12) were investigated during infusing comparative dosage of citrate. Serial blood samples were taken before, during 120 min and up to 120 min after infusion. Citrate pharmacokinetics were calculated and compared between groups. Then the estimated kinetic parameters were applied to the citrate kinetic equation for validation in other ten patients’ CVVH sessions with citrate anticoagulation. Results Total body clearance of citrate was similar in critically ill patients with AKI and healthy volunteers (648.04±347.00 L/min versus 686.64±353.60 L/min; P?=?0.624). Basal and peak citrate concentrations were similar in both groups (p?=?0.423 and 0.247, respectively). The predicted citrate curve showed excellent fit to the measurements. Conclusions Citrate clearance is not impaired in critically ill patients with AKI in the absence of severe liver dysfunction. Citrate pharmacokinetic data can provide a basis for the clinical use of predicting the risk of citrate accumulation. Trial Registration ClinicalTrials.gov Identifier NCT00948558
Zhu, Qiuyu; Liu, Junfeng; Qian, Jing; You, Huaizhou; Gu, Yong; Hao, Chuanming; Jiao, Zheng; Ding, Feng
Pain, agitation, and delirium (PAD) are common in critically ill patients. Consequently, analgesic and sedative medications are frequently administered to critically ill patients to treat PAD, to improve synchrony with mechanical ventilation, and to decrease the physiological stress response. However, prolonged, continuous deep sedation of intensive care unit (ICU) patients is associated with numerous adverse outcomes, including longer durations of mechanical ventilation, prolonged ICU stays, acute brain dysfunction, and an increased risk of death. The 2013 ICU PAD Guidelines were developed to provide a clear, evidence-based road map for clinicians to better manage PAD in critically ill patients. Significant knowledge gaps in these areas still remain, but if widely adopted, the PAD Guidelines can help bridge these gaps and will be transformative in terms of their impact on ICU care. Strong evidence indicates that linking PAD management strategies with ventilator weaning, early mobility, and sleep hygiene in ICU patients will result in significant synergistic benefits to patient care and reductions in costs. An interdisciplinary team-based approach, using proven process improvement strategies, and ICU patient and family activation and engagement, will help ensure successful implementation of the ICU PAD Care Bundle in ICUs. This paper highlights the major recommendations of the 2013 ICU PAD Guidelines. We hope this review will help ICU physicians and other health care providers advance the management of PAD in critically ill patients, and improve patients' clinical outcomes. PMID:24424616
Pandharipande, Pratik P; Patel, Mayur B; Barr, Juliana
Psychiatric consultation to the critically ill cardiac patient focuses on several common problems: anxiety, delirium, depression, personality reactions, and behavioral disturbances. A review of the causes and treatment of anxiety in the coronary care unit is followed by a discussion of delirium in the critically ill cardiac patient. A description of delirium associated with the use of the intraaortic balloon pump and its treatment with high doses of intravenous haloperidol is also included. After the initial crisis has been stabilized in the critical care unit, the premorbid personality traits of the patient may emerge as behavioral disturbances--particularly as the duration of stay increases. The use of psychiatric consultation completes the discussion.
Sanders, K M; Cassem, E H
Ethical dilemma: offering short-term extracorporeal membrane oxygenation support for terminally ill children who are not candidates for long-term mechanical circulatory support or heart transplantation.
The use of extracorporeal membrane oxygenation (ECMO) in terminally ill pediatric patients who are not candidates for long-term mechanical circulatory support or heart transplantation requires careful deliberation. We present the case of a 16-year-old female with a relapse of acute lymphoid leukemia and acute-on-chronic cardiomyopathy who received short-term ECMO therapy. In addition, we highlight several ethical considerations that were crucial to this patient's family-centered care and demonstrate that this therapy can be accomplished in a manner that respects patient autonomy and family wishes. PMID:24668981
Shankar, Venkat; Costello, John P; Peer, Syed M; Klugman, Darren; Nath, Dilip S
SummaryBackground According to a recent hypothesis, the profound loss of body protein that occurs in critically ill patients is triggered and maintained by cell shrinkage secondary to cellular dehydration. We tested this hypothesis by studying sequential changes in intracellular water, total body protein, total body potassium, and intracellular potassium in patients receiving intensive care for blunt trauma or sepsis.Methods Nine
P. J Finn; L. D Plank; M. A Clark; A. B Connolly; G. L Hill
Examines the difficulties experienced by diabetic patients in learning about their illness. Diabetic people (N=138) were questioned by means of a closed answer questionnaire. Results reveal that patients easily acquired manual skills, yet numerous learning difficulties were associated with the skills required to solve problems and make decisions,…
Bonnet, Caroline; Gagnayre, Remi; d'Ivernois, Jean Francois
The clinical features of Celiac Disease (CD) are heterogeneous and both severity and extent of villous atrophy do not correlate with clinical presentation. This study aims to evaluate the psychological wellbeing of CD patients with a similar clinical pattern and to explore whether patients with different levels of wellbeing differed in illness perception and coping strategies. CD outpatients with proven diagnosis filled in validated questionnaires to investigate wellbeing (PGWBI), illness perception (IPQ-R) and coping style (COPE). One hundred and four patients underwent data analysis. Compared to Italian reference sample, CD patients reported a significantly reduced PGWBI total score (p<0.001), self-control (p<0.001), general health (p=0.002) and vitality (p<0.001) and increased anxiety (p=0.009). 7.7% of patients reported a positive wellbeing, 40.4% distress absence, 28.8% a moderate distress and 23.1% a severe distress. Patients with distress showed a different illness perception and reported more frequently two dysfunctional strategies: focus on and venting emotions (p= 0.009) and substance abuse (p= 0.01) compared to those having a positive wellbeing. A high percentage of CD patients experience distress and differ from those who reach wellbeing in illness perception and use of coping strategies. Assessing subjective viewpoint with standardized methods can provide useful information for a better management of CD patients. PMID:23298509
Baiardini, I; Braido, F; Menoni, S; Bellandi, G; Savi, E; Canonica, G W; Macchia, D
Background: Patients with chronic insomnia are more likely to develop affective disorders, cardiac morbidity, and other adverse health outcomes, yet many clinicians tend to trivialize the complaint of insomnia or to at- tribute it only to psychiatric causes. Objectives: To estimate the prevalence and longitudi- nal course of insomnia in patients with documented chronic medical illness and\\/or depression and to
David A. Katz; Colleen A. McHorney
Sir, “Is your journey really necessary?” asked a railway poster during the privations of the Second World War. A similar question should be asked of clinicians committing sick patients to a transfer between, or within, hospitals, with the additional question, “Is this transfer really safe?” There are many potential risks associated with transporting the critically ill patient, including their greater
Peter J. Shirley; Julian F. Bion
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 ill patients 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
Objective Illness behaviors (cognitive, affective, and behavioral reactions) among individuals with systemic sclerosis (SSc) are of clinical concern due to relationships between these behaviors and physical and mental-health quality of life such as pain and symptoms of depression. Self-report measures with good psychometric properties can aid in the accurate assessment of illness behavior. The Illness Behavior Questionnaire (IBQ) was designed to measure abnormal illness behaviors; however, despite its long-standing use, there is disagreement regarding its subscales. The goal of the present study was to evaluate the validity of the IBQ in a cohort of patients with SSc. Methods Patients with SSc (N = 278) completed the IBQ at enrollment to the Genetics versus ENvironment In Scleroderma Outcome Study (GENISOS). Structural validity of previously derived factor solutions was investigated using confirmatory factor analysis. Exploratory factor analysis was utilized to derive SSc-specific subscales. Results None of the previously derived structural models were supported for SSc patients. Exploratory factor analysis supported a SSc-specific factor structure with 5 subscales. Validity analyses suggested that the subscales were generally independent of disease severity, but were correlated with other health outcomes (i.e., fatigue, pain, disability, social support, mental health). Conclusion The proposed subscales are recommended for use in SSc, and can be utilized to capture illness behavior that may be of clinical concern.
Merz, Erin L.; Malcarne, Vanessa L.; Roesch, Scott C.; Sharif, Roozbeh; Harper, Brock E.; Draeger, Hilda T.; Gonzalez, Emilio B.; Nair, Deepthi K.; McNearney, Terry A.; Assassi, Shervin; Mayes, Maureen D.
The efficacy of selective decontamination of the oral cavity and GI-tract in the treatment of established gram-negative pneumonia in critically ill patients was evaluated in a prospective open trial. 25 patients with pneumonia caused by Enterobacteriaceae or Pseudomonadaceae were studied. All patients were mechanically ventilated (range 2–60 days). Non-absorbable antibiotics (polymyxin E 100 mg, tobramycin 80 mg, amphotericin B 500
C. P. Stoutenbeek; H. K. F. van Saene; D. R. Miranda; D. F. Zandstra; D. Langrehr
This article is meant as a review for critical care nurses caring for patients with chest tubes. The types of chest tubes, equipment needed, types of chest drainage systems, chest tube placement and setup, nursing care, chest tube removal, and complications will be discussed. PMID:23571188
Kane, Christy J; York, Nancy L; Minton, Lori A
Legal standards for informed consent are discussed in the context of dental care for the elderly and severely ill. Variations in state common law and legislation are analyzed, focusing on differences between practitioner-oriented and patient-oriented approaches to informed consent. Implications for educators and practitioners are examined.…
Litch, C. Scott; Liggett, Martha L.
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
This paper examines conceptions of trust among three groups of respondents diagnosed with either breast cancer, Lyme disease or mental illness. Interviews were carried out using an open-ended interview guide to explore how patients made assessments of trust in their doctors and health care plans. The guide followed a conceptual approach that asked questions about competence, agency\\/fiduciary responsibility, control, disclosure
David Mechanic; Sharon Meyer
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
Andrew J. Slack; Julia Wendon
Hyperglycemia and insulin resistance develop in the majority of severe acute illness and/or injury. One of the main causes of hyperglycemia in critically ill patients 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 ill patients 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 ill patients 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 ill patients, which is currently the subject of further study. Continued streamlining, achieving optimal blood glucose ranges in critically ill patients 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 ill patients 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
Microaspiration of contaminated oropharyngeal secretions and gastric contents frequently occurs in intubated critically ill patients, and plays a major role in the pathogenesis of ventilator-associated pneumonia. Risk factors for microaspiration include impossible closure of vocal cords, longitudinal folds in high-volume low-pressure polyvinyl chloride cuffs, and underinflation of tracheal cuff. Zero positive end expiratory pressure, low peak inspiratory pressure, tracheal suctioning, nasogastric tube and enteral nutrition increase the risk for microaspiration. Other patient related factors include supine position, coma, sedation, and hyperglycemia. Technetium 99 labelled enteral feeding is probably the most accurate marker of microaspiration in critically ill patients. However, use of this radioactive marker is restricted to nuclear medicine departments. Blue methylene is a reliable qualitative marker of microaspiration. However, fiberoptic bronchoscopy is required to diagnose microaspiration of blue dye in ICU patients. Quantitative pepsin measurement in tracheal aspirates is accurate in diagnosing microaspiration of gastric contents in critically ill patients. In addition, this marker is easy to use in routine practice. However, pepsin should be detected rapidly after aspiration. In vitro, and clinical studies suggested that semirecumbent position, polyurethane cuffs, positive end expiratory pressure, low-volume low-pressure cuff, and continuous control of cuff pressure were efficient in reducing microaspiration in ICU patients. Other preventive measures such as subglottic aspiration, tapered shape cuff, guayule latex cuff, lateral horizontal patient position, gastrostomy tube, and postpyloric feeding require further investingation. PMID:21679139
Nseir, Saad; Zerimech, Farid; Jaillette, Emmanuelle; Artru, Florent; Balduyck, Malika
Introduction Levetiracetam (LEV) is used in the setting of acute brain injury for seizure treatment or prophylaxis but its safety and efficacy\\u000a in this setting is unknown.\\u000a \\u000a \\u000a \\u000a Method We retrospectively analyzed the patterns of use and safety\\/efficacy of LEV in 379 patients treated in the neuroscience intensive\\u000a care unit (NSICU). We extracted from the charts clinical data including diagnosis, AED therapy before
Jerzy P. Szaflarski; Jason M. Meckler; Magdalena Szaflarski; Lori A. Shutter; Michael D. Privitera; Stephen L. Yates
Introduction Intensive insulin therapy (IIT) with tight glycemic control may reduce mortality and morbidity in critically ill patients\\u000a and has been widely adopted in practice throughout the world. However, there is only one randomized controlled trial showing\\u000a unequivocal benefit to this approach and that study population was dominated by post-cardiac surgery patients. We aimed to\\u000a determine the association between IIT and
Miriam M Treggiari; Veena Karir; N David Yanez; Noel S Weiss; Stephen Daniel; Steven A Deem
Abstract 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.
Introduction Delirium is a common occurrence in critically ill patients and is associated with an increase in morbidity and mortality. Septic patients with delirium may differ from a general critically ill population. The aim of this investigation was to study the relationship between systemic inflammation and the development of delirium in septic and non-septic critically ill patients. Methods We performed a prospective cohort study in a 20-bed mixed intensive care unit (ICU) including 78 (delirium?=?31; non-delirium?=?47) consecutive patients admitted for more than 24 hours. At enrollment, patients were allocated to septic or non-septic groups according to internationally agreed criteria. Delirium was diagnosed using the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) during the first 72 hours of ICU admission. Blood samples were collected within 12 hours of enrollment for determination of tumor necrosis factor (TNF)-?, soluble TNF Receptor (STNFR)-1 and -2, interleukin (IL)-1?, IL-6, IL-10 and adiponectin. Results Out of all analyzed biomarkers, only STNFR1 (P?=?0.003), STNFR2 (P?=?0.005), adiponectin (P?=?0.005) and IL-1? (P?0.001) levels were higher in delirium patients. Adjusting for sepsis and sedation, these biomarkers were also independently associated with delirium occurrence. However, none of them were significant influenced by sepsis. Conclusions STNFR1, STNFR2, adiponectin and IL-1? were associated with delirium. Sepsis did not modify the relationship between the biomarkers and delirium occurrence.
Objective: Alteration in thyroid hormones are seen in critically ill patients admitted to intensive care units. Our objective was to study the thyroid hormone profile, prolactin and, glycosylated hemoglobin (HbA1c) at admission and analyze their correlation with mortality. Materials and Methods: In this single centre, prospective, observational study, 100 consecutive patients (52M; 48F) admitted to medical ICU irrespective of diagnosis were included. Patients with previous thyroid disorders and drugs affecting thyroid function were excluded. All participants underwent complete physical examination and a single fasting blood sample obtained at admission was analyzed for total triiodothyronine (T3), total thyroxine (T4), thyroid stimulating hormone (TSH), HbA1c, and prolactin. The patients were divided into two groups: Group 1 – survivors (discharged from the hospital) and Group 2 – nonsurvivors (patients succumbed to their illness inside the hospital). The data were analyzed by appropriate statistical methods and a P-value of <0.05 was considered significant. Results: The mean age of the participants was 58.7 ± 16.9 years and the mean duration of ICU stay was 3.3 ± 3.1 days. A total of 64 patients survived, whereas remaining 36 succumbed to their illness. The baseline demographic profile was comparable between survivors and nonsurvivors. Nonsurvivors had low T3 when compared with survivors (49.1 ± 32.7 vs. 66.2 ± 30.1, P = 0.0044). There was no significant difference observed between survivors and nonsurvivors with respect to T4, TSH, HbA1c, and prolactin. Conclusion: Our study showed that low T3 is an important marker of mortality in critically ill patients. Admission HbA1c, prolactin, T4, and TSH did not vary between survivors and nonsurvivors.
Kumar, K. V. S. Hari; Kapoor, Umesh; Kalia, Richa; Chandra, N. S. Ajai; Singh, Parikshit; Nangia, R.
Increased blood lactate levels (hyperlactataemia) are common in critically ill patients. Although frequently used to diagnose inadequate tissue oxygenation, other processes not related to tissue oxygenation may increase lactate levels. Especially in critically ill patients, 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.
Critically ill patients often have distressful episodes of severe thirst, but the underlying complex biochemical, neurohormonal regulatory controls that regulate this primal sensation have rarely been addressed by clinicians. Subtle changes in plasma osmolality are the most potent stimulus for thirst. In response to increases in osmolality, osmoreceptors activate release of the neurohormone vasopressin (also known as antidiuretic hormone). The released vasopressin acts on the kidneys to conserve water to correct the hyperosmolar state. If this compensatory mechanism is unsuccessful, thirst arises to promote drinking. Thirst induced by marked volume loss, in contrast, is more closely related to the volemic and pressure changes regulated by the renin-angiotensin aldosterone system. Understanding the physiological mechanisms of thirst will help in understanding the pathophysiological consequences of underlying thirst-related disease and treatments in critically ill patients. Further clinical research is needed to elucidate the multiple inhibitory and excitatory neurohormonal stimuli that motivate patients’ intense desire for water.
Arai, Shoshana; Stotts, Nancy; Puntillo, Kathleen
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 patient illness 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
Quality controls of autologous blood collections in critically ill patients comprise the control of blood products, blood collection, and of the patients themselves. The control of products is defined in European guidelines, the AMG (law governing the manufacture and prescription of medicine) and GMP regulations. The products are described in the monograph of the Federal Health Office. The quality control of blood collection in patients with a critical vascular disease is important since vagotonic or hypertensive crises may occur frequently (in 10-15% of cardiosurgical patients). The quality control of the critically ill patients themselves is important in order to be able to balance benefits against risks. A phlebotomy of 500 ml may lead to a considerable deterioration of the clinical condition. The clinical condition can be controlled by simple exercise tests prior to and after the blood collection (bicycle ergometer, treadmill or climbing stairs). In our own investigations only about 25% of cardiosurgical patients (40% of patients with aortocoronary venous bypass) received autohemotherapy, and 20% of them showed a clinical deterioration during the phase of blood collection. Other problematic patients are those suffering from a tumor. A clear clinical benefit of autohemotherapy in these patients has not been demonstrated up to now; nevertheless, when a curative therapy is possible, they should be treated with autohemotherapy. PMID:7693254
Kiesewetter, H; Jung, F; Koscielny, J; Pindur, G; Wenzel, E
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 ill patients. 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 ill patients 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 ill patients.
The Housing First approach used by Pathways to Housing, Inc., was used to enhance residential independence and treatment retention of homeless, seriously mentally ill methadone patients. The Keeping Home project first secured scattered-site apartments and assertive community treatment services and then addressed patients' service needs. Three years post-implementation, methadone treatment retention for 31 Keeping Home patients versus 30 comparison participants (drawn from an administrative database) was 51.6% vs. 20% (p < .02); apartment/independent housing retention was 67.7% vs. 3% or 13% (both p's < .01). Although results firmly support Keeping Home, future research needs to address study's possible database limitations. PMID:22873188
Appel, Philip W; Tsemberis, Sam; Joseph, Herman; Stefancic, Ana; Lambert-Wacey, Dawn
Paraoxonase 1 is believed to play a role in preventing lipid oxidation and, thus, limiting production of proinflammatory mediators.\\u000a Systemic inflammatory response in sepsis increases oxidative stress and decreases high-density lipoprotein (HDL) concentrations.\\u000a The objective of this study was to investigate serum paraoxonase 1 activities in critically ill patients with sepsis and after\\u000a recovery. Serum paraoxonase 1 arylesterase\\/paraoxonase activities, concentration
Frantisek Novak; Lucie Vavrova; Jana Kodydkova; Frantisek Novak Sr; Magdalena Hynkova; Ales Zak; Olga Novakova
The chronic care model is a guide to higher-quality chronic illness manage- ment within primary care. The model predicts that improvement in its 6 in- terrelated components—self-management support, clinical information sys- tems, delivery system redesign, decision support, health care organization, and community resources—can produce system reform in which informed, activated patients interact with prepared, proactive practice teams. Case stud- ies
Thomas Bodenheimer; Edward H. Wagner; Kevin Grumbach
This paper examines conceptions of trust among three groups of respondents diagnosed with either breast cancer, Lyme disease or mental illness. Interviews were carried out using an open-ended interview guide to explore how patients made assessments of trust in their doctors and health care plans. The guide followed a conceptual approach that asked questions about competence, agency/fiduciary responsibility, control, disclosure and confidentiality. Respondents were given ample opportunity to raise other areas of concern. The data were organized using the NUDIST software package for the analysis of non-numerical and unstructured qualitative data. Patients viewed trust as an iterative process and commonly tested their physicians against their knowledge and expectations. Interpersonal competence, involving caring, concern and compassion, was the most common aspect of trust reported, with listening as a central focus. Most patient comments referred to learnable skills and not simply to personality characteristics. Technical competence also received high priority but was often assessed by reputation or interpersonal cues. Patients were much concerned that doctors be their agents and fight for their interests with health care plans. Disclosure and confidentiality were less common concerns; most patients anticipated that doctors would be honest with them and respect their confidences. Patients' responses also appeared to vary by their disease, their socio-demographic characteristics, their involvement with self-help groups, and how their illness conditions unfolded. PMID:10975226
Mechanic, D; Meyer, S
The purpose of this study was to investigate the frequency of enteral feeding intolerance in critically ill septic burn patients, the effect of enteral feeding intolerance on the efficacy of feeding, the correlation between the infection marker (procalcitonin [PCT]) and the nutrition status marker (prealbumin) and the impact of feeding intolerance on the outcome of septic burn patients. From January 2009 to December 2012 the data of all burn patients with the diagnosis of sepsis who were placed on enteral nutrition were analyzed. Septic patients were divided into two groups: group A, septic patients who developed feeding intolerance; group B, septic patients who did not develop feeding intolerance. Demographic and clinical characteristics of patients were analyzed and compared. The diagnosis of sepsis was applied to 29% of all patients. Of these patients 35% developed intolerance to enteral feeding throughout the septic period. A statistically significant increase in mean PCT level and a decrease in prealbumin level was observed during the sepsis period. Group A patients had statistically significant lower mean caloric intake, higher PCT:prealbumin ratio, higher pneumonia incidence, higher Sequential Organ Failure Assessment Maximum Score, a longer duration of mechanical ventilation, and a higher mortality rate in comparison with the septic patients without gastric feeding intolerance. The authors concluded that a high percentage of septic burn patients developed enteral feeding intolerance. Enteral feeding intolerance seems to have a negative impact on the patients' nutritional status, morbidity, and mortality. PMID:24879397
Lavrentieva, Athina; Kontakiotis, Theodore; Bitzani, Militsa
BACKGROUND: This review on the current literature of the intrahospital\\u0009\\u0009\\u0009\\u0009transport of critically ill patients addresses type and incidence of adverse\\u0009\\u0009\\u0009\\u0009effects, risk factors and risk assessment, and the available information on\\u0009\\u0009\\u0009\\u0009efficiency and cost-effectiveness of transferring such patients for diagnostic\\u0009\\u0009\\u0009\\u0009or therapeutic interventions within hospital. Methods and guidelines to prevent\\u0009\\u0009\\u0009\\u0009or reduce potential hazards and complications are provided. METHODS:
Tooth brushing in critically ill patients 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 ill patients are suggested. With increased emphasis being placed on oral care, the evidence that supports this intervention must be evaluated carefully.
Ames, Nancy J.
The essential mandate of medicine is the relief of suffering. However, the quest for an integrated model towards a conceptualization of suffering is still ongoing and empirical studies are few. Qualitative inquiry using 31 in-depth interviews and content analysis was carried out between 1999 and 2001 in 26 patients diagnosed with terminal cancer. The suffering experience was described through a multiplicity of heterogenous elements from the physical, psychological, and social spheres. Systematic synthesis of interview material yielded three apparently irreducible core dimensions. Respondents defined their suffering in terms of 1) being subjected to violence, 2) being deprived and/or overwhelmed, and 3) living in apprehension. Cassell wrote, in 1991, that to know the suffering of others demands an exhaustive understanding of what makes them the individuals they are (1). Our model can be of use in structuring and eliciting this necessary information. Understanding how a particular patient feels harmed, deprived or overburdened, and overtaken by fear, provides a lever for action tailored to the specifics of that person's experience. PMID:15132070
Daneault, Serge; Lussier, Véronique; Mongeau, Suzanne; Paillé, Pierre; Hudon, Eveline; Dion, Dominique; Yelle, Louise
Glomerular filtration rate (GFR) is an accepted measure for assessment of kidney function. For the critically ill patient, 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 ill patient. 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. PMID:23862059
Seller-Pérez, Gemma; Herrera-Gutiérrez, Manuel E; Maynar-Moliner, Javier; Sánchez-Izquierdo-Riera, José A; Marinho, Anibal; do Pico, José Luis
Subjective feeling of schizophrenic patients has been underestimated in the study of this illness. Subjective experience associated with the onset of the disease is of interest in a clinical point of view but also in the study of the underlying mechanisms. The fields of cognitive psychology, but also neuroscientific inputs, provide new paradigms to understand schizophrenia. In a more global perspective, subjective experience has an important impact on quality of life and is highly related to symptomatology and treatments. Identification of these subjective dimensions is needed to develop more efficacious strategies. PMID:24084429
Background This review on the current literature of the intrahospital transport of critically ill patients addresses type and incidence of adverse effects, risk factors and risk assessment, and the available information on efficiency and cost-effectiveness of transferring such patients for diagnostic or therapeutic interventions within hospital. Methods and guidelines to prevent or reduce potential hazards and complications are provided. Methods A Medline search was performed using the terms 'critical illness', 'transport of patients', 'patient transfer', 'critical care', 'monitoring' and 'intrahospital transport', and all information concerning the intrahospital transport of patients was considered. Results Adverse effects may occur in up to 70% of transports. They include a change in heart rate, arterial hypotension and hypertension, increased intracranial pressure, arrhythmias, cardiac arrest and a change in respiratory rate, hypocapnia and hypercapnia, and significant hypoxaemia. No transport-related deaths have been reported. In up to one-third of cases mishaps during transport were equipment related. A long-term deterioration of respiratory function was observed in 12% of cases. Patient-related risk indicators were found to be a high Therapeutic Intervention Severity Score, mechanical ventilation, ventilation with positive end-expiratory pressure and high injury severity score. Patients' age, duration of transport, destination of transport, Acute Physiology and Chronic Health Evaluation II score, personnel accompanying the patient and other factors were not found to correlate with an increased rate of complications. Transports for diagnostic procedures resulted in a change in patient management in 40-50% of cases, indicating a good risk:benefit ratio. Conclusions To prevent adverse effects of intrahospital transports, guidelines concerning the organization of transports, the personnel, equipment and monitoring should be followed. In particular, the presence of a critical care physician during transport, proper equipment to monitor vital functions and to treat such disturbances immediately, and close control of the patient's ventilation appear to be of major importance. It appears useful to use specifically constructed carts including standard intensive care unit ventilators in a selected group of patients. To further reduce the rate of inadvertent mishaps resulting from transports, alternative diagnostic modalities or techniques and performing surgical procedures in the intensive care unit should be considered.
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.
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 terminally ill cancer patients in the hospice ward or who received\\u000a shared-care consultation.
Yu-Wen Chiu; Chia-Tsuan Huang; Shao-Min Yin; Yung-Cheng Huang; Ching-hsin Chien; Hung-Yi Chuang
Introduction Liver dysfunction associated with artificial nutrition in critically ill patients is a complication that seems to be frequent, but it has not been assessed previously in a large cohort of critically ill patients. Methods We conducted a prospective cohort study of incidence in 40 intensive care units. Different liver dysfunction patterns were defined: (a) cholestasis: alkaline phosphatase of more than 280 IU/l, gamma-glutamyl-transferase of more than 50 IU/l, or bilirubin of more than 1.2 mg/dl; (b) liver necrosis: aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l, plus bilirubin of more than 1.2 mg/dl or international normalized ratio of more than 1.4; and (c) mixed pattern: alkaline phosphatase of more than 280 IU/l or gamma-glutamyl-transferase of more than 50 IU/l, plus aspartate aminotransferase of more than 40 IU/l or alanine aminotransferase of more than 42 IU/l. Results Seven hundred and twenty-five of 3,409 patients received artificial nutrition: 303 received total parenteral nutrition (TPN) and 422 received enteral nutrition (EN). Twenty-three percent of patients developed liver dysfunction: 30% in the TPN group and 18% in the EN group. The univariate analysis showed an association between liver dysfunction and TPN (p < 0.001), Multiple Organ Dysfunction Score on admission (p < 0.001), sepsis (p < 0.001), early use of artificial nutrition (p < 0.03), and malnutrition (p < 0.01). In the multivariate analysis, liver dysfunction was associated with TPN (p < 0.001), sepsis (p < 0.02), early use of artificial nutrition (p < 0.03), and calculated energy requirements of more than 25 kcal/kg per day (p < 0.05). Conclusion TPN, sepsis, and excessive calculated energy requirements appear as risk factors for developing liver dysfunction. Septic critically ill patients should not be fed with excessive caloric amounts, particularly when TPN is employed. Administering artificial nutrition in the first 24 hours after admission seems to have a protective effect.
Grau, Teodoro; Bonet, Alfonso; Rubio, Mercedes; Mateo, Dolores; Farre, Merce; Acosta, Jose Antonio; Blesa, Antonio; Montejo, Juan Carlos; de Lorenzo, Abelardo Garcia; Mesejo, Alfonso
The objective of this study was to examine venous thromboembolism (VTE) prophylaxis use, risk reduction, and readmission in medically ill patients during hospitalization and after discharge. This 5-year retrospective study linked outpatient files from MarketScan Commercial and Medicare Supplemental databases. Patients were categorized into prophylaxis and non-prophylaxis groups based on guideline-recommended anticoagulant use from the index date to 180 days posthospital discharge and before the first VTE event date. Outcome variables were VTE events and rehospitalization. Risk adjustment was conducted within the prophylaxis group and between the prophylaxis and non-prophylaxis groups using propensity score matching. Among 4467 patients, 28.99% of the patients (n = 1295) were admitted with cancer, 18.03% (n = 805) with pneumonia, 14.06% (n = 628) with heart failure, 11.06% (n = 494) with stroke, 11.11% (n = 496) with sepsis, 8.08% (n = 361) with infectious diseases, 5.6% (n = 250) with severe respiratory disorders, 1.81% (n = 81) with inflammatory bowel disease, 1.05% (n = 47) with obesity, 0.20% (n = 9) with neurologic disorders, and 0.02% (n = 1) with acute rheumatic fever. Among those with 180-day continuous enrollment after the index date (n = 3511), 51.81% (n = 1819) received anticoagulant therapy only, 2.48% (n = 87) received mechanical compression treatment only (stocking or pneumatic compression), and 4.41% (n = 155) received both during hospitalization. Anticoagulant therapy rates ranged from 88.64% (obesity) to 32.39% (inflammatory bowel disease). Among anticoagulant therapy patients, 740 patients (40.68%) received low-molecular weight heparin only and 806 patients (44.31%) received unfractionated heparin. After risk adjustment, compared with patients without VTE prophylaxis, anticoagulant prophylaxis patients had lower VTE (3.62% vs. 4.27%, P < 0.04) and readmission rates (24.22% vs. 27.95%, P < 0.02) during the 6 months post-index hospital admission. In conclusion anticoagulant prophylaxis is underutilized and is associated with reduced VTE risk and a decrease in rehospitalizations for medically ill patients. PMID:23466619
Baser, Onur; Liu, Xianchen; Phatak, Hemant; Wang, Li; Mardekian, Jack; Kawabata, Hugh; Petersel, Danielle; Hamilton, Melissa; Ramacciotti, Eduardo
Pulmonary arterial hypertension (PAH) is a progressive disease characterized by a vasculopathy that results in sustained elevation of pulmonary artery pressures, which ultimately leads to right ventricular failure (RVF) and death. Several advances have been made in the treatment of PAH, but it remains a major cause of morbidity and mortality. Managing an acutely ill patient with PAH is especially challenging. The mechanisms of RVF are incompletely understood; these patients do not tolerate fluid shifts well and there are no controlled trials to assess superiority of a certain approach. This article outlines an approach based on current understanding of RVF in PAH and recommends an approach based on the pathophysiology, current evidence and experience. PMID:23362817
OBJECTIVE: To identify which noninvasive ventilation (NIV) masks are most commonly used and the problems related to the adaptation to such masks in critically ill patients admitted to a hospital in the city of São Paulo, Brazil. METHODS: An observational study involving patients ? 18 years of age admitted to intensive care units and submitted to NIV. The reason for NIV use, type of mask, NIV regimen, adaptation to the mask, and reasons for non-adaptation to the mask were investigated. RESULTS: We evaluated 245 patients, with a median age of 82 years. Acute respiratory failure was the most common reason for NIV use (in 71.3%). Total face masks were the most commonly used (in 74.7%), followed by full face masks and near-total face masks (in 24.5% and 0.8%, respectively). Intermittent NIV was used in 82.4% of the patients. Adequate adaptation to the mask was found in 76% of the patients. Masks had to be replaced by another type of mask in 24% of the patients. Adequate adaptation to total face masks and full face masks was found in 75.5% and 80.0% of the patients, respectively. Non-adaptation occurred in the 2 patients using near-total facial masks. The most common reason for non-adaptation was the shape of the face, in 30.5% of the patients. CONCLUSIONS: In our sample, acute respiratory failure was the most common reason for NIV use, and total face masks were the most commonly used. The most common reason for non-adaptation to the mask was the shape of the face, which was resolved by changing the type of mask employed.
da Silva, Renata Matos; Timenetsky, Karina Tavares; Neves, Renata Cristina Miranda; Shigemichi, Liane Hirano; Kanda, Sandra Sayuri; Maekawa, Carla; Silva, Eliezer; Eid, Raquel Afonso Caserta
Acute kidney injury (AKI) is a common and frequently fatal illness in critically ill patients, with a high associated-mortality. Early recognition of kidney injury and prompt corrective measures may improve outcome. Finding an early, accurate and reproducible biomarker for AKI is a research priority. In recent years, many urinary or plasma proteins have been investigated, some of them promising, but the ideal biomarker remains to be discovered. Cystatin C, neutrophil gelatinase-associated lipocalin, interleukin-18, fatty acid-binding proteins and kidney injury molecule 1 seem to be more accurate markers for AKI as compared with the traditional serum creatinine. However, their ability to predict worsening of AKI and need for renal replacement therapy (RRT) is not clear, and current available data are insufficient to recommend the use of these biomarkers routinely for clinical decision-making. Thus, using a combination of different urinary and plasma biomarkers and clinical observations, such as oliguria, may modify the clinical variability for therapeutic interventions, such as RRT initiation, and improve outcome. The purpose of this review was to summarize recent findings concerning biomarkers for AKI, especially in the intensive care unit setting, to highlight their strengths and weaknesses, and to determine their usefulness in clinical practice. PMID:23032924
Gonzalez, F; Vincent, F
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 ill patients 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.
This study investigated the illness perceptions of patients with interstitial cystitis (IC) and their experience of psychological distress using the Revised Illness Perceptions Questionnaire (IPQ-R). The extent to which this measure adequately captures the illness representations of this group was also evaluated through semi-structured interviews. Forty-four patients with IC attending an out-patient clinic at a large UK hospital completed a
Jane Heyhoe; Rebecca Lawton
The issue of tight glucose control with intensive insulin therapy in critically ill patients remains controversial. Although compelling evidence supports this strategy in postoperative patients who have undergone cardiac surgery, the use of tight glucose control has been challenged in other situations, including in medical critically ill patients and in those who have undergone non-cardiac surgery. Similarly, the mechanisms that
Philippe Devos; Jean-Charles Preiser
Background: Acute kidney injury (AKI) is a frequent complication in hospitalized patients, especially in those in intensive care units (ICU). The RIFLE classification might be a valid prognostic factor for critically ill cancer patients. The present study aims to evaluate the discriminatory capacity of RIFLE versus other general prognostic scores in predicting hospital mortality in critically ill cancer patients. Methods:
Alexandre Braga Libório; Krasnalhia Lívia S. Abreu; Geraldo B. Silva Jr; Rafael S. A. Lima; Adller G. C. Barreto; Orivaldo A. Barbosa; Elizabeth F. Daher
During recent years increasing attention has been given to the quality of survival in critical care. Health-related quality of life (HRQOL) is an important issue both for patients and their families. Furthermore, admission to the intensive care unit can have adverse psychological effects in critically ill patients. Recent studies conducted in critically ill patients have measured HRQOL. However, usually absent
José GM Hofhuis; Henk F van Stel; Augustinus JP Schrijvers; Johannes H Rommes; Jan Bakker; Peter E Spronk
Background: A pregnant woman is usually young and in good health until she suffers from some acute injury. Her prognosis will hopefully be better if she receives timely intensive care. Materials and Methods: The aims of this study were to study the indications of medical intensive care unit (MICU) transfers for critically ill pregnant and postpartum females, biochemical and hematological profile, organ failure, ICU interventions, outcome of mother/fetus, APACHE II score and its correlation with mortality. Study Design and Setting: It is a prospective observational study, carried out in the MICU of a tertiary care teaching hospital over a period of 18 months. One hundred and twenty-two pregnant and postpartum females (up to 42 days after delivery) were studied. Results and Conclusion: Maternal age >30 years was associated with high mortality (68.2%). Majority of the females were admitted in the third trimester (50 patients) and postpartum period (41 patients), and mortality was highest in the postpartum period (39%). Increasing parity and gravida was associated with significantly high mortality (59.5%). Acute viral hepatitis E (45 patients) was most common indication for MICU transfer, followed by malaria and pregnancy-induced hypertension. The mortality rate was 30.3%. The most common cause of death was acute viral hepatitis E (24 patients), with hepatic failure (53 patients) being the most common organ failure. Majority of the females (88 patients) were ANC registered. Low Glasgow coma score and high APACHE II score on admission were associated with significantly high mortality (85.2%). Prompt treatment with oseltamivir in H1N1 infection was associated with good maternal and fetal outcomes.
Bhadade, Rakesh; de' Souza, Rosemarie; More, Anirudha; Harde, Minal
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.
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
We studied changes in cardio-respiratory synchronization and dynamics of cardiovascular system during transition from mechanical ventilation to spontaneous respiration in critically ill patients. This observational study exploits a standard clinical practice---the spontaneous breathing trial (SBT). The SBT consists of a period of mechanical ventilation, followed by a period of spontaneous breathing, followed by resumption of mechanical ventilation. We collected continuous respiratory, cardiac (EKG), and blood pressure signals of mechanically ventilated patients before, during and after SBT. The data were analyzed by means of spectral analysis, phase dynamics, and entropy measures. Mechanical ventilation appears to affect not only the lungs but also the cardiac and vascular systems. Spontaneous cardiovascular rhythms are entrained by the mechanical ventilator and are drawn into synchrony. Sudden interruption of mechanical ventilation causes gross desynchronization, which is restored by reinstitution of mechanical ventilation. The data suggest (1) therapies intended to support one organ system may propagate unanticipated effects to other organ systems and (2) sustained therapies may adversely affect recovery of normal organ system interactions.
Burykin, Anton; Buchman, Timothy
Introduction During sepsis the endocrine, immune and nervous systems elaborate a multitude of biological responses. Little is known regarding the mechanisms responsible for the final circulating erythropoietin (EPO) and renin levels in septic shock. The aim of the present study was to assess the role of EPO and renin as biological markers in patients with septic shock. Methods A total of 44 critically ill patients with septic shock were evaluated. Results Nonsurvivors had significantly higher serum EPO levels than did survivors on admission (median [minimum–maximum]; 61 [10–602] versus 20 [5–369]). A negative relationship between serum EPO and blood haemoglobin concentrations was observed in the survivor group (r = -0.61; P < 0.001). In contrast, in the nonsurvivors the serum EPO concentration was independent of the blood haemoglobin concentration. Furthermore, we observed significant relationships between EPO concentration and lactate (r = 0.5; P < 0.001), arterial oxygen tension/fractional inspired oxygen ratio (r = -0.41; P < 0.005), arterial pH (r = -0.58; P < 0.001) and renin concentration (r = 0.42; P < 0.005). With regard to renin concentration, significant correlations with lactate (r = 0.52; P < 0.001) and arterial pH (r = -0.33; P < 0.05) were observed. Conclusion Our findings show that EPO and renin concentrations increased in patients admitted to the intensive care unit with septic shock. Renin may be a significant mediator of EPO upregulation in patients with septic shock. Further studies regarding the regulation of EPO expression are clearly warranted.
Tamion, Fabienne; Le Cam-Duchez, Veronique; Menard, Jean-Francois; Girault, Christophe; Coquerel, Antoine; Bonmarchand, Guy
All the studies performed in many industrialized countries have shown that the mortality-rates of mentally-ill patients are higher than expected, despite of a recent trend indicating a diminishing difference by comparison with control-groups (review in Corten et al). In France, the works by Casadebaig and Quemada focused on the mortality-rates of psychiatric in-patients from 1968 to 1982 cannot unfortunately be performed nowadays because of an administrative change in the nation-wide death-registration. This is the main reason for the purpose of a longitudinal study on this topic for the next years in our country. The chief goals are concerned with public health and with analytical epidemiology: defining the Standardized Mortality Ratios (SMR) globally and by cause of death for the most typical clinical groups. Methodology and feasibility. The main methodological issues have to be examined first before implementation. Theoretically, one should wait that a multicentric longitudinal survey could be representative of the whole population of french mentally in and out-patients. Actually, this study will be more likely performed with collaborative centers agreeing for data-collection; and secondly, it will be necessary to control that these collaborative centers do not differ significantly from the other public psychiatry-departments for the main variables that may influence the mortality-rates. The definition of cases and their identification will be done according to the International Classification of Disorders (ICD) considering its ninth and tenth revision. This research also needs to include a large number of patients because of statistical constraints.(ABSTRACT TRUNCATED AT 250 WORDS) PMID:1600890
Guillaud-Bataille, J M; Quemada, N; Casadebaig, F; Gausset, M F; Terra, J L
There are increasing reports of a wide variety of unexplained ill-effects associated with the occupational use of visual display terminals (VDTs); these include psychological complaints such as headache, irritability, and fatigue, musculoskeletal pains, dry or burning eyes, deteriorating eyesight, cataracts, facial dermatitis, and pregnancy abnormalities. Many VDTs emit near-ultraviolet (UV-A) radiation in amounts ranging from 200 to 1500 times less than the present U.S. safety standard of 1.0 X 10(-3) W/cm2. Although the possibility of a radiation hazard from VDTs is widely discounted, various points of circumstantial evidence are marshalled in this paper in support of the hypothesis that prolonged exposure to even these low amounts of UV-A radiation may result in progressive increases in sensitivity to UV-A and in cumulative biologic damage. It is further proposed that UV-A produces the ill-effects by catabolizing vitamin A in skin and plasma into highly active metabolites, the gradual accumulation of which results in an endogenous form of vitamin A intoxication. In addition to producing the skin and systemic effects of hypervitaminosis A, these metabolites presumably enter the fetal circulation, leading to pregnancy abnormalities similar to those associated with high doses of the vitamin for the treatment of skin disorders. PMID:4033154
Mawson, A R
Sixty four patients were referred for cardiac transplantation from a single cardiac team at this hospital between October 1984 and December 1986. Of these patients, 33 were referred for urgent transplantation, all of whom required intensive treatment in hospital with intravenous infusions of cardiac drugs, intra-aortic balloon counterpulsation, peritoneal dialysis, ventilation, or any combination of these to sustain life. Of these 33 patients, six died while awaiting transplantation, one was removed from the waiting list for a transplant, and 26 received cardiac transplants. There were five deaths within 24 hours of operation and one death 10 days after the operation. Twenty of those who had surgery had a successful outcome of transplantation, but there was one late death 10 weeks postoperatively and a further death 31 months after surgery. Eighteen patients were alive and well 10 to 33 months (mean 19·4 months) after transplantation, with an overall survival rate after surgery of 69%. Provided that surgery can be performed before renal failure has progressed such that renal transplantation is necessary, the results are excellent (surgical survival 85·5%) and, we believe, justify the expenditure and staffing requirements necessary to treat these terminally ill patients. ImagesFIG 1FIG 2
Mulcahy, David; Wright, Christine; Mockus, Lorna; Yacoub, Magdi; Fox, Kim
Objective To examine whether chronically ill patients’ perceptions of their role relationships with their physicians are associated with levels of patient activation. Data Sources Random digit dial survey of 8,140 chronically ill patients and the Area Resource File. Study Design Cross-sectional, multivariate analysis of the relationship between dimensions of patient–physician role relationships and level of patient activation. The study controlled for variables related to patient demographics, socioeconomic status, health status, and market and family context. Principal Findings Higher perceived quality of interpersonal exchange with physicians, greater fairness in the treatment process, and more out-of-office contact with physicians were associated with higher levels of patient activation. Treatment goal setting was not significantly associated with patient activation. Conclusion Patient–physician relationships are an important factor in patients taking a more active role in their health and health care. Efforts to increase activation that focus only on individual patients ignore the important fact that the nature of roles and relationships between provider and patient can shape the behaviors and attitudes of patients in ways that support or discourage patient activation.
Alexander, Jeffrey A; Hearld, Larry R; Mittler, Jessica N; Harvey, Jillian
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
Claudine Herzlich; Janine Pierret
Mentally ill people may face barriers to receiving elective surgical procedures due to societal stigma, and the cognitive, behavioral, and interpersonal deficits associated with metal illness. Using data from a cohort of elderly Medicare beneficiaries in 2007, we examined whether the mentally ill have less access than persons without mental illness to several common procedures that are typically non-emergent and performed at the discretion of the provider and patient. Results suggest that Medicare patients with mental illness are between 30 and 70 percent less likely to receive these “referral-sensitive” surgical procedures. Those who did undergo an elective procedure generally experienced poorer outcomes both in the hospital and after discharge. Efforts to improve the access and outcomes of nonpsychiatric care for mentally ill patients are warranted.
Li, Yue; Cai, Xueya; Du, Hang; Glance, Laurent G.; Lyness, Jeffrey M.; Cram, Peter; Mukamel, Dana B.
Mentally ill people may face barriers to receiving elective surgical procedures as a result of societal stigma and the cognitive, behavioral, and interpersonal deficits associated with mental illness. Using data from a cohort of elderly Medicare beneficiaries in 2007, we examined whether the mentally ill have less access than people without mental illness to several common procedures that are typically not for emergencies and are performed at the discretion of the provider and the patient. Results suggest that Medicare patients with mental illness are 30-70 percent less likely than others to receive these "referral-sensitive" surgical procedures. Those who did undergo an elective procedure generally experienced poorer outcomes both in the hospital and after discharge. Efforts to improve access to and outcomes of nonpsychiatric care for mentally ill patients are warranted. PMID:21734205
Li, Yue; Cai, Xueya; Du, Hang; Glance, Laurent G; Lyness, Jeffrey M; Cram, Peter; Mukamel, Dana B
Examined the joint effects of private body consciousness (PBC) and degree of illness-related physical impairment on treatment regimen adherence in a sample of 52 hemodialysis patients. Predicted the effect of PBC on adherence would vary as a function of patients' level of illness-related physical impairment. Results are discussed in terms of…
Christensen, Alan J.; And Others
Background: Raised intra-abdominal pressure (IAP) accompanied by evidence of organ dysfunction constitutes abdominal compartment syndrome (ACS). The ACS is now becoming an increasingly recognised fatal entity in the critically ill surgical and traumatized patients receiving critical care. The objectives were to determine the frequency of abdominal compartment syndrome (ACS) in critically ill surgical and traumatised patients and to identify the
Muhammad Saaiq; Syed Aslam Shah; Tanwir Khaliq
A group of women were interviewed about their construction of their illness experiences before they saw a physician and subsequently over a period of several months following consultation. It was found that the physician's input was one of many components of their post-consultation understanding of their illness. The women built up their understandings in an interactive process, drawing significantly on
Linda M. Hunt; Brigitte Jordan; Susan Irwin
The objective of the paper is to review the literature and provide recommendations for use of aminoglycoside antibiotics in critically ill obese patients. Literature search in PubMed for all articles on the use of aminoglycosides in critically ill obese patients was conducted, and all articles related to pharmacokinetics in obesity were reviewed. Bibliographies of all searched manuscripts were also reviewed in an attempt to find additional references. Although aminoglycoside pharmacokinetics have been described in detail, data on aminoglycoside use and appropriate dose modification in critically ill obese patients are very limited. Knowledge on aminoglycoside pharmacokinetics and use in critically ill obese patients is incomplete. Pathophysiologic changes in obesity can result in sub- or supra-therapeutic aminoglycoside plasma concentrations, especially in the presence of sepsis. Rigorous clinical studies are needed to establish aminoglycoside dosing guidelines in critically ill obese patients with sepsis.
Velissaris, Dimitrios; Karamouzos, Vasilios; Marangos, Markos; Pierrakos, Charalampos; Karanikolas, Menelaos
The objective of the paper is to review the literature and provide recommendations for use of aminoglycoside antibiotics in critically ill obese patients. Literature search in PubMed for all articles on the use of aminoglycosides in critically ill obese patients was conducted, and all articles related to pharmacokinetics in obesity were reviewed. Bibliographies of all searched manuscripts were also reviewed in an attempt to find additional references. Although aminoglycoside pharmacokinetics have been described in detail, data on aminoglycoside use and appropriate dose modification in critically ill obese patients are very limited. Knowledge on aminoglycoside pharmacokinetics and use in critically ill obese patients is incomplete. Pathophysiologic changes in obesity can result in sub- or supra-therapeutic aminoglycoside plasma concentrations, especially in the presence of sepsis. Rigorous clinical studies are needed to establish aminoglycoside dosing guidelines in critically ill obese patients with sepsis. PMID:24883145
Velissaris, Dimitrios; Karamouzos, Vasilios; Marangos, Markos; Pierrakos, Charalampos; Karanikolas, Menelaos
AIM: To investigate the proximal gastric motor response to duodenal nutrients in critically ill patients with long-standing type 2 diabetes mellitus. METHODS: Proximal gastric motility was assessed (using a barostat) in 10 critically ill patients with type 2 diabetes mellitus (59 ± 3 years) during two 60-min duodenal infusions of Ensure® (1 and 2 kcal/min), in random order, separated by 2 h fasting. Data were compared with 15 non-diabetic critically ill patients (48 ± 5 years) and 10 healthy volunteers (28 ± 3 years). RESULTS: Baseline proximal gastric volumes were similar between the three groups. In diabetic patients, proximal gastric relaxation during 1 kcal/min nutrient infusion was similar to non-diabetic patients and healthy controls. In contrast, relaxation during 2 kcal/min infusion was initially reduced in diabetic patients (p < 0.05) but increased to a level similar to healthy humans, unlike non-diabetic patients where relaxation was impaired throughout the infusion. Duodenal nutrient stimulation reduced the fundic wave frequency in a dose-dependent fashion in both the critically ill diabetic patients and healthy subjects, but not in critically ill patients without diabetes. Fundic wave frequency in diabetic patients and healthy subjects was greater than in non-diabetic patients. CONCLUSION: In patients with diabetes mellitus, proximal gastric motility is less disturbed than non-diabetic patients during critical illness, suggesting that these patients may not be at greater risk of delayed gastric emptying.
Nguyen, Nam Q; Fraser, Robert J; Bryant, Laura K; Chapman, Marianne; Holloway, Richard H
Clinical parameters, intensive care unit (ICU) course, abdominal computed tomography (CT) scans, and the clinical decisions of 53 critically ill patients were reviewed to determine the influence of the CT scan. No scans were positive before the eighth day. Sensitivity was 48% and specificity, 64%. Seventeen (23%) scans of the 72 provided beneficial results: eight localized abscesses that were drained; nine were negative and not operated on. Five (7%) scans provided detrimental information: scan negative with abscess discovered or scan positive but negative laparotomy. Fifty (70%) scans were either of no help or not used in management. The mortality rate was 50% when CT led to an intervention, and 47% in the entire group. Hospital charges were +33,408. Personnel time and cost were 497 hours and +3658; of the total +37,066, 77% (+28,541) could be considered wasted. From these data, it was concluded that CT scans should be used to confirm abscesses, not to search for a source of sepsis.
Norwood, S H; Civetta, J M
Critically ill, mechanically ventilated, patients were monitored with manometry, spirometry, and capnography during intrahospital transport out of the ICU. Patients functioned as their own control, and medical personnel were 'blinded' to capnography for 5...
D. P. Stoltzfus
Mechanical ventilation is used in most of the aeroevacuations of critically ill patients. Patients and mechanical ventilators suffer from variations in the environmental pressure, partial pressure of oxygen, humidity, luminosity, accelerations and vibrati...
A. Hernandez Abadia de Barbara A. Gil Heras J. A. Lopez Lopez F. Rios Tejada
ObjectiveTo assess gastrointestinal function in critically ill patients receiving muscle relaxant and to test clinical tolerance to enteral nutrition.Design and settingProspective study in an intensive care unit.Patients20 critically ill patients requiring sedation with muscle relaxant to obtain adequate mechanical ventilation.Measurements and resultsPatients were randomly selected to receive infusions of opioid sedation during the first session (session 1) and the same
Fabienne Tamion; Karine Hamelin; Annie Duflo; Christophe Girault; Jean-Christophe Richard; Guy Bonmarchand
The following article is a response to the position paper of the Hastings Center, "Ethical Challenges of Chronic Illness", a product of their three year project on Ethics and Chronic Care. The authors of this paper, three prominent bioethicists, Daniel Callahan, Arthur Caplan, and Bruce Jennings, argue that there should be a different ethic for acute and chronic care. In pressing this distinction they provide philosophical grounds for limiting medical care for the elderly and chronically ill. We give a critical survey of their position and reject it as well as any attempt to characterize the physician-patient relationship as a commercial contract. We emphasize, as central features of good medical practice, a commitment to be the patient's agent and a determination to acquire and be guided by knowledge. These commitments may sometimes conflict with efforts to have the physician serve as an instrument of social and economic policies limiting medical care. PMID:1905745
Moros, D A; Rhodes, R; Baumrin, B; Strain, J J
Background The current investigation examined the psychometric properties of the Internalized Stigma of Mental Illness (ISMI) scale in a sample of patients with mental illness. In addition to the internal consistency, test-retest reliability, and concurrent validity that previous studies have tested for the ISMI, we extended the evaluation to its construct validity and measurement invariance using confirmatory factor analysis (CFA). Methods Three hundred forty-seven participants completed two questionnaires (i.e., the ISMI and the Depression and Somatic Symptoms Scale [DSSS]), and 162 filled out the ISMI again after 50.23±31.18 days. Results The results of this study confirmed the frame structure of the ISMI; however, the Stigma Resistance subscale in the ISMI seemed weak. In addition, internal consistency, test-retest reliability, and concurrent validity were all satisfactory for all subscales and the total score of the ISMI, except for Stigma Resistance (??=?0.66; ICC?=?0.52, and r?=?0.02 to 0.06 with DSSS). Therefore, we hypothesize that Stigma Resistance is a new concept rather than a concept in internalized stigma. The acceptable fit indices supported the measurement invariance of the ISMI across time, and suggested that people with mental illness interpret the ISMI items the same at different times. Conclusion The clinical implication of our finding is that clinicians, when they design interventions, may want to use the valid and reliable ISMI without the Stigma Resistance subscale to evaluate the internalized stigma of people with mental illness.
Chang, Chih-Cheng; Wu, Tsung-Hsien; Chen, Chih-Yin; Wang, Jung-Der; Lin, Chung-Ying
Bury's (1982) argument that the onset of a chronic illness represents a biographical disruption has become paradigmatic in the sociology of illness studies. More recently Bury (1991, 1997) himself Williams (2000) and other medical sociologists have argued that the notion of illness as biographical disruption needs re-examination. Following a phenomenological approach, in this paper the author draws on different narrative models (Labov and Waletzky 1967 and Ricoeur 1980) to analyze how patients orient to the onset of chronic illness as the complicating action. The data comprise eight narratives collected in South America: three correspond to patients with renal failure, and five to patients with HIV/AIDS disease. It is observed that in some cases, patients' complicating actions are rather oriented to experiences of poverty, drug addiction, and criminality that took place prior to their onset of their illnesses. These experiences, instead of the onset of their illnesses, occupy the place of the complicating action in these patients' narratives. The author discusses that in the studies of illness narratives, it is difficult to operate from a different paradigm, but argues that conflating the onset of chronic illness with a biographical disruption may confuse the episodic dimension of narrative with the configurational dimension. PMID:22616353
OBJECTIVES The purpose of this study was to describe dosage regimens and treatment outcomes in critically ill children receiving ethacrynic acid continuous infusions (CI). METHODS This retrospective cross-sectional study evaluated patients less than 18 years of age who received ethacrynic acid CI with a duration exceeding 12 hours, from January 1, 2007, through January 31, 2012. The primary objective was to determine the mean/median doses of ethacrynic acid CI. Secondary objectives were to assess surrogate efficacy markers (e.g., urine output [UOP], fluid balance) and the number of patients with electrolyte abnormalities or metabolic alkalosis. Descriptive statistics were used. A series of repeated measures analyses of variance were conducted to assess differences in surrogate efficacy markers and in adverse events that occurred pre-, mid-, and posttherapy. RESULTS Nine patients were included. The mean ± SD initial and maximum doses (mg/kg/hr) were 0.13 ± 0.07 (median 0.1; range, 0.08–0.3) and 0.17 ± 0.08 (median, 0.16; range 0.09–0.3), respectively. The median UOP (mL/kg/hr) pre-, mid-, and postinfusions (interquartile range [IQR]) were 2.4 (1.8–3.2), 4.2 (3.5–6), and 4 (3.4–5.3), respectively. The median fluid balance (mL; IQR) was 189 (90–526), ?258 (?411.7 to 249) and ?113.5 (?212.5 to 80.2), respectively. There were statistically significant differences in UOP and fluid balance pre- versus mid-therapy (0.014) and pre- versus posttherapy (p=0.010). No significant differences were noted with magnesium and potassium. Five children (55.6%) developed metabolic alkalosis. CONCLUSIONS This study provides preliminary evidence for ethacrynic acid CI in children. The median initial dose and maximum dose in this cohort were 0.13 mg/kg/hr and 0.17 mg/kg/hr, respectively. Larger prospective studies are needed to confirm these findings.
Miller, Jamie L.; Schaefer, Jared; Tam, Matthew; Harrison, Donald L.; Johnson, Peter N.
The quality of nursing care as perceived by hospitalized patients with advanced illness has not been examined. A concept of quality nursing care for this population was developed by integrating the literature on constructs defining quality nursing care with empirical findings from interviews of 16 patients with advanced illness. Quality nursing care was characterized as competence and personal caring supported by professionalism and delivered with an appropriate demeanor. Although the attributes of competence, caring, professionalism, and demeanor were identified as common components of quality care across various patient populations, the caring domain increased in importance when patients with advanced illness perceived themselves as vulnerable. Assessment of quality nursing care for patients with advanced illness needs to include measures of patient perceptions of vulnerability.
Izumi, Shigeko; Baggs, Judith G.; Knafl, Kathleen A.
Introduction: Illness script theory offers explanations for expert-novice differences in clinical reasoning. However, it has mainly focused on diagnostic (Dx) performance, while patient management (Mx) has been largely ignored. The aim of the present study was to show the role of Mx knowledge in illness script development and how it relates to…
Monajemi, Alireza; Schmidt, Henk G.; Rikers, Remy M. J. P.
Studied the relationship between an unstructured global rating of severity of illness and structured ratings of individual symptoms (e.g., Brief Psychiatric Rating Scale) in 278 25-60 yr old depressed women. Correlational analyses revealed that patients rated as more severely ill were those showing psychomotor retardation, depressive delusions, agitation, guilt, initial insomnia, hopelessness, suicidal tendencies, verbal complaint of depressed feelings and
Abram Chipman; Eugene S. Paykel
Recent theory and evidence suggests that bodily self-focusing tendencies (e.g., private body consciousness) may be associated with medical regimen adherence among chronically ill patients. The present study examined the joint effects of private body consciousness and degree of illness- related physical impairment on treatment regimen adherence in a sample of 52 hemodialysis pa- tients. It was predicted that the effect
Alan J. Christensen; John S. Wiebe; Dawn L. Edwards; John D. Michels; William J. Lawton
Objective. To evaluate the performance of procalcitonin (PCT), interleukin-6 (IL-6), C-reactive protein, leukocyte count, D-dimer, and antithrombin III at onset of septic episode and 24 h later in prediction of hospital mortality in critically ill patients with suspected sepsis. Design and setting. Prospective, cohort study in two university hospital intensive care units. Patients. 61 critically ill patients with suspected sepsis.
Ville Pettilä; Marja Hynninen; Olli Takkunen; Pentti Kuusela; Matti Valtonen
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 ill patients. DESIGN: Prospective cohort study. SETTING: Adult intensive care department of a university medical center. PATIENTS: Critically ill patients (n = 399). INTERVENTIONS: A guideline for pressure
Erik H. de Laat; Peter Pickkers; Lisette Schoonhoven; Ton Feuth; Theo van Achterberg
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 ill patients 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
Background: Intra-hospital transport of critically ill patients is a challenging task. However, despite the improvements in intra-hospital transport practices, adverse event incidents remain high and constitute a significant risk for the transport of the critically ill ICU patients. Objectives: To observe the number and types of unexpected-events (UEs) occurring during intra-hospital transport of critically ill ICU patients. Interventions provided along with outcome. Materials and Methods: This was a prospective observational study of 254 intra-hospital critically-ill ICU patients of our hospital transported for diagnostic purposes during April 2012 - March 2013. The escorting intensivist completed the data of unexpected events during transport. Results: A total of 254 patients were observed prospectively for UEs during intra-hospital transfer of critically ill patients. The overall UEs observed were 139 among 64 patients. Among the UEs which occurred, the maximum were miscellaneous causes [89 (64.00%)] like oxygen probe [38 (27.33%)] or ECG lead displacement [27 (19.42%)]. Major events like fall in spo2 >5% observed in 15 (10.79%) patients, BP variation > 20% from baseline in 22 (15.82%) patients, altered mental status in 5 (3.59%), and arrhythmias in 6 (4.31%) patients. Among 64 (100%) patients with UEs, 3 (2.15%) patients with serious adverse events have been aborted from transport. Conclusion: Unexpected-events (UEs) are common during transport of critically ill ICU patients and these adverse events can be reduced when critically ill patients are accompanied by intensivist/medically qualified person during transport and following strict transport guidelines.
Venkategowda, Pradeep M.; Rao, Surath M.; Mutkule, Dnyaneshwar. P.; Taggu, Alai. N.
Peripheral nerve changes in critically ill patients are common, sepsis being the most important risk factor. The aim of our study is to investigate interval neurophysiological changes in non septic mechanically ventilated critically ill patients, a group who has not been the focus of previous studies. Consecutive non septic mechanically ventilated critically ill patients were included. Baseline nerve conduction studies (NCS) were done within 3 days of intensive care unit admission, and 48 hours after the initiation of mechanical ventilation, and were followed up 7-8 days later. Sural and ulnar sensory, and median and peroneal motor nerves were tested. Nine patients were studied, five (56%) showed significant changes in their NCS compared to baseline. The peroneal and sural nerve amplitudes significantly dropped in all of the five affected patients, with drop of those of the median motor nerves in two, and ulnar sensory nerves in three patients. In conclusion, interval changes in peripheral nerves can exist in critically ill mechanically ventilated non septic patients. The pattern is similar to critically ill patients with sepsis. Theories of possible pathophysiology of critical illness neuropathy should not merely depend on the presence of sepsis as a trigger and other mechanisms should be investigated. PMID:22854770
El-Salem, Khalid; Khassawneh, Basheer; Alrefai, Ali; Dwairy, Abdel Raheem; Rawashdeh, Sukaina
Compared accuracy of an actuarial procedure for the prediction of community violence by patients with mental illnesses to accuracy of clinicians' concern ratings of patient violence. Data came from a study of 357 pairs of patients seen in a psychiatric emergency room. Actuarial predictions based only on patients' histories of violence were more…
Gardner, William; And Others
PURPOSE: The aim of this study was to examine the illness beliefs and locus of control of patients with recent onset pseudoseizures and to compare these with patients with recent onset epilepsy. METHODS: Twenty consecutive patients with pseudoseizures of recent onset (mean duration 5.4 months) were compared with 20 consecutive patients with recent onset epilepsy on their responses to (a)
Jon Stone; Michael Binzer; Michael Sharpe
Background The context of the study is the increased assessment and treatment of persons with mental illness in general hospital settings by general health staff, as the move away from mental hospitals gathers pace in low and middle income countries. The purpose of the study was to examine whether general attitudes of hospital staff towards persons with mental illness, and extent of mental health training and clinical experience, are associated with different attitudes and behaviours towards a patient with mental illness than towards a patients with a general health problem - diabetes. Methods General hospital health professionals in Malaysia were randomly allocated one of two vignettes, one describing a patient with mental illness and the other a patient with diabetes, and invited to complete a questionnaire examining attitudes and health care practices in relation to the case. The questionnaires completed by respondents included questions on demographics, training in mental health, exposure in clinical practice to people with mental illness, attitudes and expected health care behaviour towards the patient in the vignette, and a general questionnaire exploring negative attitudes towards people with mental illness. Questionnaires with complete responses were received from 654 study participants. Results Stigmatising attitudes towards persons with mental illness were common. Those responding to the mental illness vignette (N = 356) gave significantly lower ratings on care and support and higher ratings on avoidance and negative stereotype expectations compared with those responding the diabetes vignette (N = 298). Conclusions Results support the view that, in the Malaysian setting, patients with mental illness may receive differential care from general hospital staff and that general stigmatising attitudes among professionals may influence their care practices. More direct measurement of clinician behaviours than able to be implemented through survey method is required to support these conclusions.
Plasma fractional removal rates (k2) of Intralipid injected in parallel with /sup 125/I albumin were analyzed in five healthy males and nine critically ill patients. The k2 values of critically ill patients were similar to those of healthy subjects. However, the initial plasma concentrations of Intralipid calculated by extrapolation to zero-time (y0) were markedly different. The mean y0 value in the critically ill patients was 43% that of healthy subjects. No plasma loss of /sup 125/I albumin occurred throughout the test. Intralipid to /sup 125/I albumin plasma concentration ratios during the removal phase paralleled the curves obtained from the iv fat tolerance test. This suggests that these ratios depend on Intralipid clearance rather than leakage from the circulation. The immediate loss of Intralipid suggests that the pulmonary vasculature, the first capillary bed through which the emulsion passes, could be the site where a substantial uptake of the emulsion occurs in critically ill patients.
Lindh, A.; Roessner, S.
The purpose of this study was to describe the relationship between intrinsic and extrinsic factors and central venous catheter infections in acutely ill patients. Intrinsic factors (inherent) included sex, age, diagnoses, surgical procedures, and medical ...
H. F. Edwards
Medication noncompliance contributes significantly to recurrence of symptoms and readmission to the hospital of schizophrenic patients. The purpose of this study was to determine factors identified by patients, family members, and nurses for patients' noncompliance. The Health Belief Model provided a theoretical framework. The sample consisted of 11 triads with a noncompliant schizophrenic patient, a family member, and a primary nurse in each triad. A structured interview was developed to assess stated reasons for noncompliance and factors relating to the patient's illness, medication practices, stressors, life-style, and support systems. Results showed that many patients stated they did not need medication or needed less than the amount prescribed. Family members and nurses agreed that the majority of patients did not believe that they needed medication. When asked if they thought they had a mental illness, most patients denied that they were ill. Other stated reasons for noncompliance were drug/alcohol use, and, for one patient, medication side effects. Additional findings were patients' low self-esteem; lack of knowledge about medications; inability to identify stressors in patients' lives; inability to identify early symptoms of relapse; patients' need for support from families; and families' stress from patients' abusive, unpredictable behavior. Use of the Health Belief Model is appropriate to study noncompliance in mentally ill patients if perception of illness threat is assessed. Conclusions were that patients and families could benefit from more knowledge of schizophrenia and its treatment, more awareness of stressors and signs of relapse, and improved mutual problem solving. Studies are needed to assess the effects of patients' denial of illness, denial of need for medication, and self-image/self-esteem on medication noncompliance. PMID:1399520
Mulaik, J S
The aims of this study were to examine gender differences in symptoms, functioning, substance use problems and substance use correlates in patients with serious mental illness. The current study is cross-sectional, and data were collected using the Health of the Nation Outcome Scales for Severe Mental Illness (HoNOS-SMI) questionnaire. The questionnaire was completed by the patients' therapists. The study included
Turid Møller Olsø; Camilla Buch Gudde; Elin Wullum; Olav M. Linaker
The aims of this study were to examine gender differences in symptoms, functioning, substance use problems and substance use correlates in patients with serious mental illness. The current study is cross-sectional, and data were collected using the Health of the Nation Outcome Scales for Severe Mental Illness (HoNOS-SMI) questionnaire. The questionnaire was completed by the patients' therapists. The study included
Turid Møller Olsø; Camilla Buch Gudde; Elin Wullum; Olav M. Linaker
Dental fear is a barrier to receiving dental care, particularly for those patients who also suffer from mental illnesses. The current study examined United States dental professionals’ perceptions of dental fear experienced by patients with mental illness, and frequency of sedation of patients with and without mental illness. Dentists and dental staff members (n = 187) completed a survey about their experiences in treating patients with mental illness. More participants agreed (79.8%) than disagreed (20.2%) that patients with mental illness have more anxiety regarding dental treatment (p < .001) than dental patients without mental illness. Further, significantly more participants reported mentally ill patients’ anxiety is “possibly” or “definitely” a barrier to both receiving (96.8%; p < .001) and providing (76.9%; p < .01) dental treatment. Despite reporting more fear in these patients, there were no significant differences in frequency of sedation procedures between those with and without mental illness, regardless of type of sedation (p’s > .05). This lack of difference in sedation for mentally ill patients suggests hesitancy on the part of dental providers to sedate patients with mental illness and highlights a lack of clinical guidelines for this population in the US. Suggestions are given for the assessment and clinical management of patients with mental illness.
Heaton, Lisa J.; Hyatt, Halee A.; Huggins, Kimberly Hanson; Milgrom, Peter
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 Illness patients 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
In a group of 1066 heroin addicts, who were seeking treatment for opioid agonist treatment, we looked for differences in historical, demographic, and clinical characteristics, between patients with different levels of awareness of illness (insight). The results showed that, in the cohort studied, a majority of subjects lacked insight into their heroin-use behavior. Compared with the impaired-insight group, those who possessed insight into their illness showed significantly greater awareness of past social, somatic, and psychopathological impairments, and had a greater number of past treatment-seeking events for heroin addiction. In contrast with other psychiatric illnesses, the presence of awareness appears to be related to the passing of time and to the worsening of the illness. Methodologies to improve the insight of patients should, therefore, be targeted more directly on patients early in their history of heroin dependence, because the risk of lack of insight is greatest during this period.
Maremmani, Angelo Giovanni Icro; Rovai, Luca; Rugani, Fabio; Pacini, Matteo; Lamanna, Francesco; Bacciardi, Silvia; Perugi, Giulio; Deltito, Joseph; Dell'Osso, Liliana; Maremmani, Icro
Terminally ill patients often hope that death will come quickly. They may broach this wish with their physicians, and even request assistance in hastening death. Thoughts about accelerating death usually do not reflect a sustained desire for suicide or euthanasia, but have other important meanings that require exploration. When patients ask for death to be hastened, the following areas should be explored: the adequacy of symptom control; difficulties in the patient's relationships with family, friends, and health workers; psychological disturbances, especially grief, depression, anxiety, organic mental disorders, and personality disorders; and the patient's personal orientation to the meaning of life and suffering. Appreciation of the clinical determinants and meanings of requests to hasten death can broaden therapeutic options. In all cases, patient requests for accelerated death require ongoing discussion and active efforts to palliate physical and psychological distress. In those infrequent instances when a patient with persistent, irremediable suffering seeks a prompt and comfortable death, the physician must confront the moral, legal, and professional ramifications of his or her response. Rarely, acceding to the patient's request for hastening death may be the least terrible therapeutic alternative. PMID:7522432
Block, S D; Billings, J A
Fifty consecutive critically ill patients 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 ill patients. 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
Since the amalgamation of mental institutions with acute hospitals there has been an increase in presentations of patients with mental illness to the Emergency Department. The first point of contact for the patient attending the Emergency Department is typically triage. It is the point where emergency care begins with the nurse assessing the patient and assigning a triage category that
Jacqueline de Lacy
Background Health condition is one of the basic factors affecting satisfaction with life, and the level of illness acceptance. The purpose of the study was to analyse the level of illness acceptance, the level of satisfaction with life among malaria patients, and the level of trust placed in the physician and the nurse. Methods The study employs the method of diagnostic survey based on standardised AIS and SWLS scales, as well as Anderson and Dedrick’s PPTS and PNTS scales. Results The average AIS level was 12 points, while the average level of SwL at the SWLS scale was 16.5 points. The average level of trust in the physician and the nurse amounted to 50.6 points and 51.4 points, respectively. The correlation between the level of illness acceptance and self-evaluated satisfaction with life was statistically significant, with R?=?0.56. The marital status influenced the level of illness acceptance with p?0.05 and the level of satisfaction with life with p?0.05. The employment status affected the level of satisfaction with life with p?0.05 and the level of illness acceptance with p?0.05. Conclusions The majority of malaria patients did not accept their illness, while the level of satisfaction with life was low. The majority of respondents trusted their physician and nurse. There is a statistically significant correlation between the level of illness acceptance and the self-evaluated satisfaction with life. The marital status had a statistically significant effect on the acceptance of illness and the satisfaction with life. The individuals who had a job demonstrated higher levels of quality of life and illness acceptance.
Clonidine hydrochloride, administered intravenously (2 micrograms/kg) during the second non-rapid eye movement period, was significantly less suppressant of rapid eye movement sleep in 10 depressed patients with primary major affective illness, according to Research Diagnostic Criteria, than in three groups of matched subjects (10 normal controls, 10 patients with minor depression, and 10 patients with generalized anxiety). These results suggest that depressed patients with major primary affective illness have down-regulated alpha 2-adrenergic receptors. These findings are consistent with the cholinergic-aminergic balance hypothesis of depression and support the aminergic side of the concept. Finally, the rapid eye movement sleep response to clonidine could provide a new biological marker of affective illness. PMID:1322119
Schittecatte, M; Charles, G; Machowski, R; Garcia-Valentin, J; Mendlewicz, J; Wilmotte, J
Summary Background: Some investigators believe that a proportion of chronically unwell patients, many with fatigue, have an underlying rickettsial disease. Aim: To investigate the prevalence of markers of rickettsial infection in patients with chronic illnesses. Design: Observational study. Methods: A 526 patient cohort with chronic ill- nesses from Melbourne, Australia and 400 control patients from Newcastle, Australia were assessed using
N. Unsworth; S. Graves; C. Nguyen; G. Kemp; J. Graham; J. Stenos
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
The aim of this paper was to define emotional responses of the patients with diagnosed schizophrenic psychosis to their illness. It was also intended to recognize the attitudes of patients' families and more distant social environment towards them. The study was conducted on 84 patients of the Neuropsychiatric Hospital, both hospitalized and ambulant, treated in Mental Outpatient Clinic and, simultaneously, taken care of by Social Self-Help Home "Misericordia". All the examined patients met the diagnostic criteria in accordance with ICD-10 for schizophrenic psychosis or schizophrenic disorder; all were in the period of symptomatic remission. The study was carried out in the years 2000-2001, using the distributed inquiry questionnaire technique. The supplementary source of information was case records of the examined patients. The predominant feelings of schizophrenics at the moment of becoming aware of having fallen ill with mental disease were fear (anxiety) and sorrow. The passage of time caused changes in emotional responses to mental illness. At the moment of the study the predominant feelings were the acceptance of illness and the sense of inferiority because of it. The sufferers of schizophrenia experienced mainly sympathy, acceptance of the illness and indifference in the environment outside the family circle. PMID:12898908
Zo?nierczuk-Kieliszek, Dorota; Zak, Barbara
PURPOSE Whether patients with 1 or more chronic illnesses are more or less likely to receive recommended preventive services is unclear and an important public health and health care system issue. We addressed this issue in a large national practice-based research network (PBRN) that maintains a longitudinal database derived from electronic health records. METHODS We conducted a cross-sectional study as of October 1, 2011, of the association between being up to date with 10 preventive services and the prevalence of 24 chronic illnesses among 667,379 active patients aged 18 years or older in 148 member practices in a national PBRN. We used generalized linear mixed models to assess for the association of being up to date with each preventive service as a function of the patient’s number of chronic conditions, adjusted for patient age and encounter frequency. RESULTS Of the patients 65.4% had at least 1 of the 24 chronic illnesses. For 9 of the 10 preventive services there were strong associations between the odds of being up to date and the presence of chronic illness, even after adjustment for visit frequency and patient age. Odds ratios increased with the number of chronic conditions for 5 of the preventive services. CONCLUSIONS Rather than a barrier, the presence of chronic illness was positively associated with receipt of recommended preventive services in this large national PBRN. This finding supports the notion that modern primary care practice can effectively deliver preventive services to the growing number of patients with multiple chronic illnesses.
Ornstein, Steven M.; Jenkins, Ruth G.; Litvin, Cara B.; Wessell, Andrea M.; Nietert, Paul J.
BACKGROUND: Severe mental illness (SMI) has been associated with more medical co-morbidity and less cardiovascular procedure use for older patients with myocardial infarction. However, it is unknown whether SMI is associated with increased long term mortality risk among patients presenting with acute coronary syndromes (ACS). We tested the hypothesis that SMI is associated with higher one-year mortality following ACS hospitalization.
Mary E Plomondon; P Michael Ho; Li Wang; Gwendolyn T Greiner; James H Shore; Joseph T Sakai; Stephan D Fihn; John S Rumsfeld
The aim of this cross-sectional study was to quantify patients' personal beliefs about the necessity of their prescribed medication and their concerns about taking it and to assess relations between beliefs and reported adherence among 324 patients from four chronic illness groups (asthma, renal, cardiac, and oncology). The findings revealed considerable variation in reported adherence and beliefs about medicines within
Robert Horne; John Weinman
Psychiatric community-based services are being developed in Malaysia currently to ensure more comprehensive mental health care to especially patients with severe mental illness. Assertive Community Treatment (ACT) as one of the earliest component of community-based services has been observed to be useful and able to provide favourable outcomes in this group of patients. Though the paradigm shift has gradually occurred
Z Ruzanna; M Marhani
The current trend in medical history-taking calls for physicians to encourage patients to tell the story of their illness in narrative form This dissertation examines the structure and function of the narratives that emerge out of medical interviews of physicians and elderly patients. Two assumptions underlie this research: first, there is a strong human tendency to make sense of the
Susan Schottenfels Eggly
New Japanese diagnostic criteria were prepared for disseminated intravascular coagulation (DIC) in critically ill patients and their usefulness was compared with the criteria of the International Society of Thrombosis and Haemostasis (ISTH) and those of the Japan Ministry of Health and Welfare (JMHW). In a retrospective study of patients with platelet counts of less than 150 × 103\\/mL, 52 cases
Satoshi Gando; Hideo Wada; Hidesaku Asakura; Toshiaki Iba; Yutaka Eguchi; Kohji Okamoto; Yasuhiro Ohtomo; Kazuo Kawasugi; Shin Koga; Kazuhide Koseki; Hajime Tsuji; Toshihiko Mayumi; Atsuo Murata; Masao Nakagawa; Shigeatu Endo
Studies have shown that early enteral nutrition in critically ill patients 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
There is controversy over whether traditional intermittent bolus dosing or continuous infusion of beta-lactam antibiotics is preferable in critically ill patients. 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 ill patients 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 ill patients do exist, a large-scale, prospective, multinational trial with a robust design is required.
INTRODUCTION: To assess the value of elective cricothyroidotomy for airway management in critically ill trauma patients with technically challenging neck anatomy. MATERIALS AND METHODS: A retrospective chart review of patients admitted to the Trauma Service at a Level I Trauma Center who underwent cricothyroidotomy for elective airway management over a 40-month period from January 1997 to April 2000. Comparison was
Christina G Rehm; Sandra M Wanek; Eliot B Gagnon; Slone K Pearson; Richard J Mullins
Considers how physicians' nonverbal communication is sometimes associated with patients' affective satisfaction. Examines the relationship between physicians' nonverbal rapport building and patients' disclosure of information related to the subjective component of illness. Considers implications for understanding the role of physicians' nonverbal…
Duggan, Ashley P.; Parrott, Roxanne L.
Introduction and Objectives. Nutritional knowledge of the patients is important in dietary adherence. This study aimed to determine the relationship between illness perceptions and nutritional knowledge with the amounts of sodium intake among rural hypertensive patients. Methods. In a cross-sectional study, 671 hypertensive patients were selected in a multistage random sampling from the rural areas of Ardabil city, Iran, in 2013. Data were collected using a questionnaire consisting of four sections and were analyzed using Pearson correlation and multiple linear regressions by SPSS-18. Results. The mean of sodium intake in the uncontrolled hypertensive patients was 3599 ± 258?mg/day and significantly greater than controlled group (2654 ± 540?mg/day) (P < 0.001). Knowledge and illness perceptions could predict 47.2% of the variation in sodium intake of uncontrolled group. A significant negative relationship was found between knowledge and illness perceptions of uncontrolled hypertensive patients with dietary sodium intake (r = ?0.66, P < 0.001 and r = ?0.65, P < 0.001, resp.). Conclusion. Considering the fact that patients' nutritional knowledge and illness perceptions could highly predict their sodium intake, the importance of paying more attention to improve patients' information and perceptions about hypertension is undeniable, especially among the uncontrolled hypertensive patients.
Azadbakht, Leila; Sharifirad, Gholamreza; Mahaki, Behzad; Sharghi, Afshan
Introduction and Objectives. Nutritional knowledge of the patients is important in dietary adherence. This study aimed to determine the relationship between illness perceptions and nutritional knowledge with the amounts of sodium intake among rural hypertensive patients. Methods. In a cross-sectional study, 671 hypertensive patients were selected in a multistage random sampling from the rural areas of Ardabil city, Iran, in 2013. Data were collected using a questionnaire consisting of four sections and were analyzed using Pearson correlation and multiple linear regressions by SPSS-18. Results. The mean of sodium intake in the uncontrolled hypertensive patients was 3599 ± 258?mg/day and significantly greater than controlled group (2654 ± 540?mg/day) (P < 0.001). Knowledge and illness perceptions could predict 47.2% of the variation in sodium intake of uncontrolled group. A significant negative relationship was found between knowledge and illness perceptions of uncontrolled hypertensive patients with dietary sodium intake (r = -0.66, P < 0.001 and r = -0.65, P < 0.001, resp.). Conclusion. Considering the fact that patients' nutritional knowledge and illness perceptions could highly predict their sodium intake, the importance of paying more attention to improve patients' information and perceptions about hypertension is undeniable, especially among the uncontrolled hypertensive patients. PMID:24678414
Kamran, Aziz; Azadbakht, Leila; Sharifirad, Gholamreza; Mahaki, Behzad; Sharghi, Afshan
Introduction: During the last decades the number of people living with cancer has increased steadily because of better survival rates. Surviving cancer does however not imply that the illness has disappeared from the patient’s life. Healthcare use remains higher for years. This may relate to physical problems such as fatigue or lymphoedema resulting from cancer treatment, but mental health and
P. M. Rijken; M. Zegers; M. Heijmans
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 ill patients. 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 ICU,
Viktoria D Mayr; Martin W Dünser; Veronika Greil; Stefan Jochberger; Günter Luckner; Hanno Ulmer; Barbara E Friesenecker; Jukka Takala; Walter R Hasibeder; NA Halpern; SM Pastores; RJ Greenstein; E Azoulay; C Adrie; A De Lassence; F Pochard; D Moreau; G Thiery; C Cheval; P Moine; M Garrouste-Orgeas; C Alberti; WA Knaus; DP Wagner; JE Zimmerman; EA Draper; DD Benoit; KH Vandewoude; JM Decruyenaere; EA Hoste; FA Colardyn; B Afessa; IJ Morales; PD Scanlon; SG Peters; Y Arabi; QA Ahmed; S Haddad; A Aljumah; A Al-Shimemeri; B Bernieh; M Al Hakim; Y Boobes; E Siemkovics; H El Jack; E Estenssoro; A Dubin; E Laffaire; H Canales; G Saenz; M Moseinco; M Pozo; A Gomez; N Baredes; G Jannello; H Khouli; A Afrasiabi; M Shibli; R Hajal; CR Barrett; P Homel; L Chang; CF Horng; YC Huang; YY Hsieh; DJ Bentrem; JJ Yeh; MF Brennan; R Kiran; DP Jaques; Y Fong; RN Pugh; IM Murray-Lyon; JL Dawson; MC Pietroni; R Williams; A de Rijk; W Schaufeli; JR Le Gall; S Lemeshow; F Saulnier; GR Bramer; KM Flegal; CL Ogden; CL Johnson; JT Crosson; MM Levy; MP Fink; JC Marshall; E Abraham; D Angus; D Cook; J Cohen; SM Opal; JL Vincent; G Ramsay; JE Nelson; DE Meier; A Litke; DA Natale; RE Siegel; RS Morrison; F Konrad; T Marx; H Wiedeck; J Kilian; G Rocher; P Sjokvist; P Dodek; L Griffith; A Freitag; J Varon; C Bradley; G Van den Berghe; P Wouters; F Weekers; C Verwaest; F Bruyninckx; M Schetz; D Vlasselaers; P Ferdinande; P Lauwers; R Bouillon; CM Martin; AD Hill; K Burns; LM Chen; SP Keenan; KD Busche; L McCarthy; KJ Inman; WJ Sibbald; RJ Hall; GM Rocker; E Rivers; B Nguyen; S Havstad; J Ressler; A Muzzin; B Knoblich; E Peterson; M Tomlanovich; D De Backer; M Varpula; M Tallgren; K Saukkonen; LM Voipio-Pulkki; V Pettila; G Bernardin; C Pardier; F Tiger; P Deloffre; M Mattei; PGH Metnitz; CG Krenn; H Steltzer; T Lang; J Ploder; K Lenz; W Druml; S Uchino; JA Kellum; R Bellomo; GS Doig; H Morimatsu; S Morgera; I Tan; C Bouman; E Macedo; Goldhill; A Sumner; J Latour; V Lopez-Camps; M Rodriguez-Serra; JS Giner; A Nolasco; C Alvarez-Dardet; M Trivedi; SA Ridley; MM Treggiari; JA Romand; CB Wallis; HT Dvaies; AJ Shearer; EE Alvarez-Leon; R Elosua; A Zamora; E Aldasoro; J Galcera; H Vanaclocha; A Segura; M Fiol; J Turumbay; G Perez; SH Wanzer; DD Federman; SJ Adelstein; CK Cassel; EH Cassem; RE Cranford; EW Hook; B Lo; CG Moertel; P Safar; J Purdie; J Trofe; TM Beebe; JF Buell; MJ Hanaway; RR Alloway; TG Gross; ES Woodle; F Fieux; B Jordan; R Moreno; AL Rosenberg; C Watts; HJ Freyberger; M Albus; A De Maio; MB Torres; RH Reeves; RJA Goris; TPA te Boekhorst; JKS Nuytinck; JS Gimbrere
INTRODUCTION: It has been proposed that intensive care unit (ICU)-acquired weakness (ICUAW) should be assessed using the sum of manual muscle strength test scores in 12 muscle groups (the sum score). This approach has been tested in patients with Guillain-Barré syndrome, yet little is known about the feasibility or test characteristics in other critically ill patients. We studied the feasibility
Catherine L Hough; Binh K Lieu; Ellen S Caldwell
The data of a sociological survey of 1042 mentally ill patients are presented. The aim of the investigation was to study different aspects of daily functioning of patients with mental diseases. It has been shown that the negative consequences of mental disease are seen at every level (professional, family and social) of daily functioning. PMID:24662345
Nekrasov, M A; Khritinin, D F
"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
Shinjo, Takuya; Okada, Masakuni
This study examined the latent structure of a number of measures of mental health (MH) and mental illness (MI) in substance use disorder outpatients to determine whether they represent two independent dimensions, as Keyes (2005) found in a community sample. Seven aspects of MI assessed were assessed - optimism, personal meaning, spirituality/religiosity, social support, positive mood, hope, and vitality. MI was assessed with two measures of negative psychological moods/states, a measure of antisociality, and the Addiction Severity Index's recent psychiatric and family-social problem scores. Correlational and exploratory factor analyses revealed that MH and MI appear to reflect two independent, but correlated, constructs. However, optimism and social support had relatively high loadings on both factors. Antisociality and the family-social problem score failed to load significantly on the MI factor. Confirmatory factor analysis supported the existence of two obliquely related, negatively correlated dimensions. Study findings, although generally supporting the independence of MH and MI, suggest that the specific answers to this question may be influenced by the constructs and assessments used to measure them. PMID:21052520
Alterman, Arthur I; Cacciola, John S; Ivey, Megan A; Coviello, Donna M; Lynch, Kevin G; Dugosh, Karen L; Habing, Brian
Background Indirect assessment of mean pulmonary arterial pressure (MPAP) may assist management of critically ill patients with pulmonary hypertension and right heart dysfunction. MPAP can be estimated as the sum of echocardiographically derived mean right ventricular to right atrial systolic pressure gradient and right atrial pressure; however, this has not been validated in critically ill patients. Methods This prospective validation study was conducted in patients undergoing pulmonary artery catheterisation during intensive care admission. Pulmonary artery catheter (PAC) measurements of MPAP were contemporaneously compared to MPAP estimated utilising transthoracic echocardiography (TTE)-derived mean right ventricular to right atrial systolic pressure gradient added to invasively measured right atrial pressure. Results Of 53 patients assessed, 23 had estimable MPAP using TTE. The mean difference between TTE- and PAC-derived MPAP was 1.9?mmHg (SD 5.0), with upper and lower limits of agreement of 11.6 and ?7.9?mmHg, respectively. The median absolute percentage difference between TTE- and PAC-derived MPAP was 7.5%. Inter-rater reliability assessment was performed for 15 patients, giving an intra-class correlation coefficient of 0.96 (95% confidence intervals, 0.89 to 0.99). Conclusions This echocardiographic method of estimating MPAP in critically ill patients was not equivalent to invasively measured MPAP, based on our predefined clinically acceptable range (±5?mmHg). The accuracy of this method in critically ill patients was similar to the results obtained in ambulatory patients and compared favourably with regard to the accuracy with echocardiographic estimation of systolic pulmonary arterial pressure. The utility of this technique is limited by frequent inability to obtain an adequate tricuspid regurgitant time-velocity integral in critically ill patients.
Background For patients recovering from severe acute illness, admission to a long-term acute care hospital (LTAC) is an increasingly common alternative to continued management in an intensive care unit. Objective To examine the effectiveness of LTAC transfer in patients with chronic critical illness. Research Design Retrospective cohort study in United States hospitals from 2002 to 2006. Subjects Medicare beneficiaries with chronic critical illness, defined as mechanical ventilation and at least 14 days of intensive care. Measures Survival, costs and hospital readmissions. We used multivariate analyses and instrumental variables to account for differences in patient characteristics, the timing of LTAC transfer and selection bias. Results A total of 234,799 patients met our definition of chronic critical illness. Of these, 48,416 (20.6%) were transferred to an LTAC. In the instrumental variable analysis, patients transferred to an LTAC experienced similar survival compared to patients who remained in an intensive care unit (adjusted hazard ratio = 0.99, 95% CI: 0.96 to 1.01, p=0.27). Total hospital-related costs in the 180 days following admission were lower among patients transferred to LTACs (adjusted cost difference = -$13,422, 95% CI: -26,662 to -223, p=0.046). This difference was attributable to a reduction in skilled nursing facility admissions (adjusted admission rate difference = -0.591 (95% CI: -0.728 to -0.454, p <0.001). Total Medicare payments were higher (adjusted cost difference = $15,592, 95% CI: 6,343 to 24,842, p=0.001). Conclusions Patients with chronic critical illness transferred to LTACs experience similar survival compared with patients who remain in intensive care units, incur fewer health care costs driven by a reduction in post-acute care utilization, but invoke higher overall Medicare payments.
Kahn, Jeremy M.; Werner, Rachel M.; David, Guy; Have, Thomas R. Ten; Benson, Nicole M.; Asch, David A.
People with severe mental disorders (SMDs) have a higher mortality rate and reduced life expectancy compared to the general population. Factors that contribute to higher mortality rates include a higher rate of smoking and increased incidence of obesity from lifestyle, diet, or medication side effects. Cancer treatment may exacerbate mood and psychotic symptoms in patients with SMD. Some of the medications used in cancer treatment or the medications used to alleviate the side effects of cancer treatment can have adverse reactions with psychotropic medications. This article examines problems that patients with SMD encounter with their cancer diagnosis and treatment. Oncology nurses in any clinical setting play a pivotal role in identifying the special needs of a patient with SMD and must become familiar with psychosocial issues, psychotropic medications, and SMD to educate and advocate for these patients and their families. Collaborating and coordinating care between oncology and psychiatry providers is needed for optimal patient outcomes. PMID:23022930
Thomson, Kate; Henry, Barb
Environmental illness, a hypothesized disease caused by exposure to substances such as combustion products, pesticides, food additives, and Candida albicans, is discussed. The case of a patient with environmental illness and systemic candidiasis for six weeks with ketoconazole, liver enzyme concentrations increased. One month after discontinuation of ketoconazole, the liver enzyme concentrations decreased; however, over the next five months, liver enzymes and bilirubin increased. The patient developed encephalopathy and eventually was transferred to a medical center for possible liver transplant. A review of the literature pertaining to ketoconazole hepatotoxicity is also presented.16 references.
Brusko, C.S.; Marten, J.T. (Purdue University School of Pharmacy and Pharmacal Sciences, Lafayette, IN (United States))
Disabled and chronically ill patients face many obstacles in maintaining oral hygiene at an appropriate level. Such a situation is caused, inter alia, by the fact that those people are less predisposed manually, but also by a lack of understanding of the need for carrying out systematic hygienic measures by disabled themselves as well as their parents or caregivers. Technical difficulties during the procedure of teeth cleaning are also a problem. Currently, specialized products designed to help disabled and chronically ill patients and their caregivers to perform daily preventive treatments are available on the market. PMID:23789303
This study is based on an analysis of the Semyu 112 nursing files which detected an elevated number of patients suffering pain while moved by our services; 16% of the cases registered this situation. Even though this percentage may seem low, it should be considered a high percentage if one bears in mind the therapeutic arsenal at our disposal and the advanced training we have received, as well as the suffering a patient experiences and the consequences this pain could have for vital functions. A large number of patients moved who suffered pain went untreated, and many others did not receive any analgesics but rather sedatives (neuro-surgical evaluations) blood vessel dilators, or other similar pharmaceuticals. Only 39.71% of patients who suffered pain were treated with analgesics which should make us reflect and look for improvements for this situation. PMID:17474366
Salado, Jaime Sánchez; Rodríguez, José Manuel De La Fuente
The clinical and socioeconomic burden of gastro-esophageal reflux disease (GERD) is considerable. The primary symptom of GERD is heartburn, but it may also be associated with extraesophageal manifestations, such as asthma, chest pain and otolaryngologic disorders. The objective of the study was to describe the impact of heartburn on patients' Health-Related Quality of Life (HRQL) in Poland, using validated generic and disease-specific instruments to measure patient-reported outcomes. Patients with symptoms of heartburn completed the Polish versions of the Gastrointestinal Symptom Rating Scale (GSRS), the Quality of Life in Reflux and Dyspepsia questionnaire (QOLRAD), the Short Form-36 (SF-36) and the Hospital Anxiety and Depression (HAD) scale. Frequency and severity of heartburn during the previous 7 days were also recorded. 135 patients completed the assessments (mean age of 44 years, SD = 15; 61% female). 55% of patients had moderate symptoms and nearly two thirds (64%) had symptoms on 5 or more days in the previous week. Patients were most bothered by symptoms of reflux (mean GSRS score of 4.1, on a scale of 1 [not bothered] to 7 [very bothered]), indigestion (3.5) and abdominal pain (3.2). As a result of their symptoms, patients experienced impaired vitality (mean QOLRAD score of 3.8, on a scale of 1 to 7, where 1 represents the most severe impact on daily functioning), problems with food and drink (3.9), emotional distress (4.1) and sleep disturbance (4.7). Using HAD, 32% of heartburn patients were anxious and 10% were depressed. In conclusion it should be stated that there is consistent evidence that GERD substantially impairs all aspects of health-related quality of life. PMID:16013413
Regu?a, Jaros?aw; Kulich, Károly R; Stasiewicz, Jan; Jasi?ski, Boles?aw; Carlsson, Jonas; Wiklund, Ingela
In recent years the prognosis and survival of chronic and acute heart failure (HF) patients has been steadily improving; however, many patients develop advanced chronic HF which is characterized by worsening of symptoms, unplanned hospital admission due to acute decompensation, development of complications, such as life-threatening arrhythmia and shorter life span. Optimal medical therapy is supplemented by interventional cardiology, cardiovascular implantable electronic devices (CIEDs), minimally invasive valve replacement or repair, circulatory mechanical support and heart transplantation. Medical indications and informed consent are essential prerequisites for successfully implementing treatment goals. For patients who are incapable of decisions a legally defined surrogate decision-maker has the same right to refuse or request the withdrawal of treatment as the patient would have if the patient had decision-making capability. As the use of circulatory mechanical support becomes increasingly more prevalent, ethical issues are likely to arise at an increasing rate, as will social and legal ramifications. The concept of turning off an implanted device as death nears is challenging because of ethical and technical concerns. The same holds true for CIEDs. A palliative care approach is applicable to heart failure patients and is particularly relevant to those with advanced disease. Palliative care should be integrated as part of a team approach to comprehensive HF care and should not be reserved for those who are expected to die within days or weeks. PMID:23612917
Janssens, U; Reith, S
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
Hypomagnesaemia is common finding in current medical practice mainly in critically ill, post-operative patients and patients\\u000a admitted to ICU in tertiary cancer cases. Magnesium has been directly implicated in hypokalemia, hypocalcaemia and dysrrthymias.\\u000a We report a case of 60 year old patient, suffering from rectal carcinoma for a period of one year with confirmed hypokalemia,\\u000a hypocalcaemia and hyponatremia. Magnesium supplementation
Shailja Gupta; Sakshi Sodhi; Jaskiran Kaur; Jaskiran Yamini
Objective: To evaluate the impact of two different comorbidity measures on the 6-month mortality of severely ill cancer patients. Design and setting: Prospective cohort study in a ten-bed oncological medical- surgical intensive care unit (ICU). Patients: A total of 772 consecutive patients were included over a 45- month period. The mean age was 57.6€16.4 years, and 642 (83%) pa- tients
Márcio Soares; Jorge I. F. Salluh; Carlos Gil Ferreira; Ronir R. Luiz; Nelson Spector; José R. Rocco
The agents of human febrile illness can vary by region and country suggesting that diagnosis, treatment, and control programs need to be based on a methodical evaluation of area-specific etiologies. From December 2006 to December 2009, 9,997 individuals presenting with acute febrile illness at nine health care clinics in south-central Cambodia were enrolled in a study to elucidate the etiologies. Upon enrollment, respiratory specimens, whole blood, and serum were collected. Testing was performed for viral, bacterial, and parasitic pathogens. Etiologies were identified in 38.0% of patients. Influenza was the most frequent pathogen, followed by dengue, malaria, and bacterial pathogens isolated from blood culture. In addition, 3.5% of enrolled patients were infected with more than one pathogen. Our data provide the first systematic assessment of the etiologies of acute febrile illness in south-central Cambodia. Data from syndromic-based surveillance studies can help guide public health responses in developing nations.
Kasper, Matthew R.; Blair, Patrick J.; Touch, Sok; Sokhal, Buth; Yasuda, Chadwick Y.; Williams, Maya; Richards, Allen L.; Burgess, Timothy H.; Wierzba, Thomas F.; Putnam, Shannon D.
Introduction Both patient- and context-specific factors may explain the conflicting evidence regarding glucose control in critically ill patients. Blood glucose variability appears to correlate with mortality, but this variability may be an indicator of disease severity, rather than an independent predictor of mortality. We assessed blood glucose coefficient of variation as an independent predictor of mortality in the critically ill. Methods We used eProtocol-Insulin, an electronic protocol for managing intravenous insulin with explicit rules, high clinician compliance, and reproducibility. We studied critically ill patients from eight hospitals, excluding patients with diabetic ketoacidosis and patients supported with eProtocol-insulin for?24 hours or with?10 glucose measurements. Our primary clinical outcome was 30-day all-cause mortality. We performed multivariable logistic regression, with covariates of age, gender, glucose coefficient of variation (standard deviation/mean), Charlson comorbidity score, acute physiology score, presence of diabetes, and occurrence of hypoglycemia?60 mg/dL. Results We studied 6101 critically ill adults. Coefficient of variation was independently associated with 30-day mortality (odds ratio 1.23 for every 10% increase, P?0.001), even after adjustment for hypoglycemia, age, disease severity, and comorbidities. The association was higher in non-diabetics (OR?=?1.37, P?0.001) than in diabetics (OR 1.15, P?=?0.001). Conclusions Blood glucose variability is associated with mortality and is independent of hypoglycemia, disease severity, and comorbidities. Future studies should evaluate blood glucose variability.
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.
Givens, Melissa L.
Objective Investigate whether high-quality chronic care delivery improved the experiences of patients. Design This study had a longitudinal design. Setting and Participants We surveyed professionals and patients in 17 disease management programs targeting patients with cardiovascular diseases, chronic obstructive pulmonary disease, heart failure, stroke, comorbidity and eating disorders. Main Outcome Measures Patients completed questionnaires including the Patient Assessment of Chronic Illness Care (PACIC) [T1 (2010), 2637/4576 (58%); T2 (2011), 2314/4330 (53%)]. Professionals' Assessment of Chronic Illness Care (ACIC) scores [T1, 150/274 (55%); T2, 225/325 (68%)] were used as a context variable for care delivery. We used two-tailed, paired t-tests to investigate improvements in chronic illness care quality and patients' experiences with chronic care delivery. We employed multilevel analyses to investigate the predictive role of chronic care delivery quality in improving patients' experiences with care delivery. Results Overall, care quality and patients' experiences with chronic illness care delivery significantly improved. PACIC scores improved significantly from 2.89 at T1 to 2.96 at T2 and ACIC-S scores improved significantly from 6.83 at T1 to 7.18 at T2. After adjusting for patients' experiences with care delivery at T1, age, educational level, marital status, gender and mental and physical quality of life, analyses showed that the quality of chronic care delivery at T1 (P < 0.001) and changes in care delivery quality (P < 0.001) predicted patients' experiences with chronic care delivery at T2. Conclusion This research showed that care quality and changes therein predict more positive experiences of patients with various chronic conditions over time.
Cramm, Jane Murray; Nieboer, Anna Petra
OBJECTIVE. The burden of illness can influence treatment decisions, but there are limited data comparing the performance of different illness burden measures. We assessed the correlations between five previously validated measures of illness burden and global health and physical function and evaluated how each measure correlates with breast cancer treatment patterns in older women. DATA SOURCE: A cohort of 718 women > 67 years with early-stage breast cancer formed the study group. STUDY DESIGN/DATA COLLECTION METHODS: The study made a cross-sectional comparison of illness burden measures (Charlson index, Index of Co-existent Diseases, cardiopulmonary burden of illness, patient-specific life expectancy, and disease counts) and physical function and self-rated global health status. Data were collected from records and patient interviews. PRINCIPAL FINDINGS: All of the measures were significantly correlated with each other and with physical function and self-rated health (p < .001). After controlling for age and stage, life expectancy had the largest effect on surgical treatment, followed by self-rated physical function and health; life expectancy was also independent of physical function. For instance, women with higher life expectancy and better self-rated physical function and health were more likely to receive breast conservation and radiation than sicker women. Women with higher physical functioning were more likely to receive adjuvant chemotherapy than women with lower functioning. CONCLUSIONS: Several measures of illness burden were associated with breast cancer therapy, but each measure accounted for only a small amount of variance in treatment patterns. Future work is needed to develop and validate measures of burden of illness that are feasible, comprehensive, and relevant for diverse clinical and health services objectives.
Mandelblatt, J S; Bierman, A S; Gold, K; Zhang, Y; Ng, J H; Maserejan, N; Hwang, Y T; Meropol, N J; Hadley, J; Silliman, R A
Traumatic experiences and posttraumatic stress disorder (PTSD) are more frequent in patients with serious mental illness than in the general population. This study included 102 patients with schizophrenia, bipolar disorder, and schizoaffective disorder, according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria. Epidemiological and clinical data were collected using the Brief Psychiatric Rating Scale and Traumatic Life Events and Distressing Event questionnaires. We found a high number of traumatic experiences, and 15.1% of the patients met all criteria for PTSD. We found no differences based on diagnosis or sex, although there was a nonsignificant trend toward greater PTSD comorbidity in women. Among patients with serious mental illness and PTSD, 64.3% had made some attempt at suicide at some point in life, compared with 37.4% of patients without PTSD. PMID:22833878
Álvarez, María-José; Roura, Pere; Foguet, Quintí; Osés, Anna; Solà, Judit; Arrufat, Francesc-Xavier
Pituitary adenomas, even after successful treatment, are associated with cognitive impairments. It is unclear whether these deficits are a consequence of unspecific factors associated with having a chronic illness and whether the cognitive dysfunctions exceed those of other chronically ill patients. Thirty-eight patients with transsphenoidal surgery for pituitary adenomas and 38 patients undergoing L-thyroxine replacement therapy after thyroid surgery were studied neuropsychologically with established tests. Executive function was examined with the Trail-Making Test A and B, working memory with the digit span test, attention with the digit symbol test, verbal memory with the German version of the Auditory Verbal Learning and Memory Test, and general verbal intelligence by a vocabulary test. Attention (p = .007), attentional speed (p = .0004), executive control (p = .04), and working memory (p = .01), were significantly reduced in patients with pituitary adenomas compared with other chronically ill patients. In contrast, no differences were found between the groups for verbal memory (all subtests: p ? .06). Patients with successful surgery for pituitary adenomas show also in comparison with other chronically ill patients an increased risk for deficits in certain aspects of cognitive function, including attention and working memory, supporting the relevance of the brain lesion and its treatment for these dysfunctions. PMID:21205414
Müssig, Karsten; Besemer, Britta; Saur, Ralf; Klingberg, Stefan; Häring, Hans-Ulrich; Gallwitz, Baptist; Leyhe, Thomas
Piperacillin-tazobactam is frequently used for empirical and targeted therapy of infections in critically ill patients. Considerable pharmacokinetic (PK) variability is observed in critically ill patients. By estimating an individual's PK, dosage optimization Bayesian estimation techniques can be used to calculate the appropriate piperacillin regimen to achieve desired drug exposure targets. The aim of this study was to establish a population PK model for piperacillin in critically ill patients and then analyze the performance of the model in the dose optimization software program BestDose. Linear, with estimated creatinine clearance and weight as covariates, Michaelis-Menten (MM) and parallel linear/MM structural models were fitted to the data from 146 critically ill patients with nosocomial infection. Piperacillin concentrations measured in the first dosing interval, from each of 8 additional individuals, combined with the population model were embedded into the dose optimization software. The impact of the number of observations was assessed. Precision was assessed by (i) the predicted piperacillin dosage and by (ii) linear regression of the observed-versus-predicted piperacillin concentrations from the second 24 h of treatment. We found that a linear clearance model with creatinine clearance and weight as covariates for drug clearance and volume of distribution, respectively, best described the observed data. When there were at least two observed piperacillin concentrations, the dose optimization software predicted a mean piperacillin dosage of 4.02 g in the 8 patients administered piperacillin doses of 4.00 g. Linear regression of the observed-versus-predicted piperacillin concentrations for 8 individuals after 24 h of piperacillin dosing demonstrated an r2 of >0.89. In conclusion, for most critically ill patients, individualized piperacillin regimens delivering a target serum piperacillin concentration is achievable. Further validation of the dosage optimization software in a clinical trial is required.
Felton, T. W.; Roberts, J. A.; Lodise, T. P.; Van Guilder, M.; Boselli, E.; Neely, M. N.
Critically ill patients after extended surgical procedures are at high risk for postoperative infections. The overall incidence of sepsis increased constantly over the last decade, whereas sepsis-related mortality decreased, due to new intensive care options. After extended intra-abdominal surgery the abdomen is the predominant focus of sepsis, followed by respiratory tract infections. Unspecific clinical signs lead to the diagnosis of
C. Lichtenstern; J. Schmidt; H. P. Knaebel; E. Martin; M. W. Büchler; M. A. Weigand
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,…
King, Judy; Taylor, Maurice C.
This article describes the critical ingredients of the assertive community treatment (ACT) model for people with severe mental illness and then reviews the evidence regarding its effectiveness and cost effectiveness. ACT is an intensive mental health program model in which a multidisciplinary team of professionals serves patients who do not readily use clinic-based services, but who are often at high
Gary R. Bond; Robert E. Drake; Kim T. Mueser; Eric Latimer
The Assertive Community Treatment model of mental health service delivery has been extensively studied and has undergone various modifications over the past twenty years. This article describes a modified ACT Team approach to the treatment of individuals who suffer from severe comorbid mental illness and substance abuse. Demographics of patients who are chosen to receive these intensive services, service utilization
Dane Wingerson; Richard K. Ries
Summary Background Long-term complications of critical illness include intensive care unit (ICU)-acquired weakness and neuropsychiatric disease. Immobilisation secondary to sedation might potentiate these problems. We assessed the effi cacy of combining daily interruption of sedation with physical and occupational therapy on functional outcomes in patients receiving mechanical ventilation in intensive care. Methods Sedated adults (?18 years of age) in the
William D Schweickert; Mark C Pohlman; Anne S Pohlman; Celerina Nigos; Amy J Pawlik; Cheryl L Esbrook; Linda Spears; Megan Miller; Mietka Franczyk; Deanna Deprizio; Gregory A Schmidt; Amy Bowman; Rhonda Barr; Kathryn E McCallister; Jesse B Hall; John P Kress
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
Debby Bright; Wendy Walker; Julian Bion
The effect of Positive End Expiratory Pressure (PEEP) on the hepatic elimination of low to moderate extraction ratio drugs has not been clearly defined. We prospectively investigated the effect of PEEP on the clearance of theophylline in 30 (20 males and 10 females) intubated critically ill adult patients with acute lung injury\\/acute respiratory distress syndrome (ALI\\/ARDS). The Mean (±SD) age
Naser Hadavand; Mojtaba Mojtahedzadeh; Sima Sadray; Reza Shariat Moharreri; Bijan Shafaghi; Mohammad Reza Khajavi; Poneh Salari
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
Tracy A. Grogan; David J. Kramer
Despite many years of study, questions remain about why patients do or do not take medicines and what can be done to change their behaviour. Hypertension is poorly controlled in the UK and poor compliance is one possible reason for this. Recent questionnaires based on the self-regulatory model have been successfully used to assess illness perceptions and beliefs about medicines.
S Ross; A Walker; M J MacLeod
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 ill patients.
Nomikos, Iakovos; Kyriazi, Maria; Vamvakopoulou, Dimitra; Sidiropoulos, Andreas; Apostolou, Athanasios; Kyritsaka, Aspasia; Athanassiou, Evangelos; Vamvakopoulos, Nikolaos C.
Infections in critically ill patients are associated with persistently poor clinical outcomes. These patients have severely altered and variable antibiotic pharmacokinetics and are infected by less susceptible pathogens. Antibiotic dosing that does not account for these features is likely to result in suboptimum outcomes. In this Review, we explore the challenges related to patients and pathogens that contribute to inadequate antibiotic dosing and discuss how to implement a process for individualised antibiotic therapy that increases the accuracy of dosing and optimises care for critically ill patients. To improve antibiotic dosing, any physiological changes in patients that could alter antibiotic concentrations should first be established; such changes include altered fluid status, changes in serum albumin concentrations and renal and hepatic function, and microvascular failure. Second, antibiotic susceptibility of pathogens should be confirmed with microbiological techniques. Data for bacterial susceptibility could then be combined with measured data for antibiotic concentrations (when available) in clinical dosing software, which uses pharmacokinetic/pharmacodynamic derived models from critically ill patients to predict accurately the dosing needs for individual patients. Individualisation of dosing could optimise antibiotic exposure and maximise effectiveness. PMID:24768475
Roberts, Jason A; Abdul-Aziz, Mohd H; Lipman, Jeffrey; Mouton, Johan W; Vinks, Alexander A; Felton, Timothy W; Hope, William W; Farkas, Andras; Neely, Michael N; Schentag, Jerome J; Drusano, George; Frey, Otto R; Theuretzbacher, Ursula; Kuti, Joseph L
Introduction: Excessive fluid administration in critically ill post-traumatic patients is common and is associated with poorer outcomes. Once resuscitation is complete; however, assisted diuresis with furosemide is not an option commonly exercised. We hypothesize that diuresis with furosemide in hemodynamically stable, critically ill trauma patients is safe and effective in promoting diuresis. Materials and Methods: In this retrospective chart review, all injured patients admitted to the trauma ICU between March 2007 and June 2009 were identified. Data collection included demographic data, traumatic mechanism, physiologic data, laboratory data, medications, complications, ventilator days, ICU and hospital length of stay. Statistical analyses using two-sample t tests, Wilcoxon rank sum tests, chi-square tests, paired t-tests, and one-sample signed rank tests were performed. Results: Of 162 screened patients, 85 were identified as eligible. Twenty-seven patients (31.8%) received furosemide within the first 14 ICU days, and there were no significant differences in age, ISS, gender, blunt mechanism, co-morbid conditions, overall complications, or mortality when compared to patients who did not receive diuresis. Furosemide administration resulted in a median of 45% increased 24 h urine output and a median of 82% less 24 h net fluid gain without any significant change in HR, MAP, CVP, Hct, creatinine, or potassium. Conclusions: Administration of furosemide in stable, significantly fluid positive critically ill trauma patients results in significantly increased urine output and significantly less net fluid gain with no detrimental effect on hemodynamic parameters or laboratory values.
Yeh, Daniel Dante; Tang, Julin F.; Chang, Yuchiao
We examined stigma experiences and its impact among patients (n = 41) hospitalized for mental illness. We studied their characteristics contributing to the expectation, intensity, and frequency of stigma they could experience. Opinions were compared on the Experiences with the Stigma of Mental Illness scale measuring stigma experiences and impact. There were differences on perceived stigma in: being 19 years or younger at first symptom or treatment, having had one previous psychiatric hospitalizations and having attended one or more outpatient sessions. Those having attended outpatient sessions, being previously hospitalized or younger suffered more impact. PMID:22052428
Oleniuk, Ashley; Duncan, C Randy; Tempier, Raymond
Surgeons are relatively new to palliative care, but there is a growing recognition of the contributions they can and should make. These go as much to the psychosocial support of the patient as they do to the technical aspects of their craft. The same qualities of proactivity and mastery of technique that stand the surgeon in good stead in the operating room can be acquired and mastered to make him or her equally effective in the hitherto nontraditional arenas of palliative care. PMID:11406448
Milch, R A
The proper use of antidotes in the intensive care setting when combined with appropriate general supportive care may reduce the morbidity and mortality associated with severe poisonings. The more commonly used antidotes that may be encountered in the intensive care unit (N-acetylcysteine, ethanol, fomepizole, physostigmine, naloxone, flumazenil, sodium bicarbonate, octreotide, pyridoxine, cyanide antidote kit, pralidoxime, atropine, digoxin immune Fab, glucagon, calcium gluconate and chloride, deferoxamine, phytonadione, botulism antitoxin, methylene blue, and Crotaline snake antivenom) are reviewed. Proper indications for their use and knowledge of the possible adverse effects accompanying antidotal therapy will allow the physician to appropriately manage the severely poisoned patient. PMID:16946442
Betten, David P; Vohra, Rais B; Cook, Matthew D; Matteucci, Michael J; Clark, Richard F
Widespread emergence of multidrug resistant (MDR) bacterial pathogens is a problem of global dimension. MDR infections are difficult to treat and frequently associated with high mortality. More than one antibiotic is commonly used to treat such infections, but scientific evidence does not favor use of combination therapy in most cases. However, there are certain subgroups where combination therapy may be beneficial, e.g. sepsis due to carbapenem-resistant Enterobacteriaceae (CRE), bacteremic pneumococcal pneumonia, and patients with multiple organ failure. Well-designed prospective studies are needed to clearly define the role of combination therapy in these subgroups.
Ahmed, Armin; Azim, Afzal; Gurjar, Mohan; Baronia, Arvind Kumar
Awareness of the importance of maintaining physical health for patients with severe mental illnesses has recently been on the increase. Although there are several elements contributing to poor physical health among these patients as compared with the general population, risk factors for cardiovascular disease such as smoking, diabetes mellitus, hypertension, dyslipidemia, metabolic syndrome, and obesity are of particular significance due to their relationship with mortality and morbidity. These patients present higher vulnerability to cardiovascular risk factors based on several issues, such as genetic predisposition to certain pathologies, poor eating habits and sedentary lifestyles, high proportions of smokers and drug abusers, less access to regular health care services, and potential adverse events during pharmacological treatment. Nevertheless, there is ample scientific evidence supporting the benefits of lifestyle interventions based on diet and exercise designed to minimize and reduce the negative impact of these risk factors on the physical health of patients with severe mental illnesses.
Hypertensive disorders, postpartum hemorrhage, and sepsis are the most common indications for intensive care unit admission among obstetric patients. In general, ICU mortality is low, and better than would be predicted using available mortality prediction tools. Provision of care to this special population requires an intimate understanding of physiologic changes that occur during pregnancy. Clinicians must be aware of the way various diagnostic and treatment choices can affect the mother and fetus. Most clinically necessary radiographic tests can be safely performed and fall under the maternal radiation exposure limit of less than 0.05 Gray (Gy). Careful attention must be paid to acid-base status, oxygenation, and ventilation when faced with respiratory failure necessitating intubation. Cesarean delivery can be justified after 4 minutes of cardiac arrest and may improve fetal and maternal outcomes. The treatment of obstetric patients in the ICU introduces complexities and challenges that may be unfamiliar to many critical care physicians; teamwork and communication with obstetricians is crucial. PMID:21841145
Honiden, Shyoko; Abdel-Razeq, Sonya S; Siegel, Mark D
It has been extensively demonstrated that an elevated heart rate is a modifiable, independent risk factor for cardiovascular events. A high heart rate increases myocardial oxygen consumption and reduces diastolic perfusion time. It can also increase ventricular diastolic pressures and induce ventricular arrhythmias. Critical care patients are prone to develop a stress induced cardiac impairment and consequently an increase in sympathetic tone. This in turn increases heart rate. In this setting, however, heart rate lowering might be difficult because the effects of inotropic drugs could be hindered by heart rate reducing drugs like beta-blockers. Ivabradine is a new selective antagonist of funny channels. It lowers heart rate, reducing the diastolic depolarization slope. Moreover, ivabradine is not active on sympathetic pathways, thus avoiding any interference with inotropic amines. We reviewed the literature available regarding heart rate control in critical care patients, focusing our interest on the use of ivabradine to assess the potential benefits of the drug in this particular setting. PMID:23064879
De Santis, Vincenzo; Vitale, Domenico; Santoro, Anna; Magliocca, Aurora; Porto, Andrea Giuseppe; Nencini, Cecilia; Tritapepe, Luigi
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
Regional citrate anticoagulation in continuous venovenous hemofiltration in critically ill patients with a high risk of bleeding.BackgroundSystemic heparinization is associated with a high rate of bleeding when used to maintain patency of the extracorporeal circuit during continuous renal replacement therapy (CRRT) in critically ill patients. Regional anticoagulation can be achieved with citrate, but previously described techniques are cumbersome and associated
Runolfur Palsson; John L. Niles
INTRODUCTION: Tracheostomy is one of the more commonly performed procedures in critically ill patients 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 ill patients
Anthony Delaney; Sean M Bagshaw; Marek Nalos
BACKGROUND: Several models for mortality prediction have been constructed for critically ill patients with haematological malignancies in recent years. These models have proven to be equally or more accurate in predicting hospital mortality in patients with haematological malignancies than ICU severity of illness scores such as the APACHE II or SAPS II 1. The objective of this study is to
T Verplancke; S Van Looy; D Benoit; S Vansteelandt; P Depuydt; F De Turck; J Decruyenaere
. The purpose of this study was to investigate the incidence of aspiration following extubation in critically ill trauma patients.\\u000a This prospective pilot study included 20 consecutive trauma patients who required orotracheal intubation for at least 48 hours.\\u000a All subjects underwent a bedside transnasal fiberoptic endoscopic evaluation of swallowing at 24 ± 2 hr after extubation to\\u000a determine objectively aspiration
Steven B. Leder; Stephen M. Cohn; Beth A. Moller
Patients with acute medical illnesses are at increased risk of venous thromboembolism (VTE), a significant cause of morbidity\\u000a and mortality. Thromboprophylaxis is recommended in these patients but questions remain regarding the optimal duration of\\u000a therapy. The aim of this study is to determine whether oral rivaroxaban is non-inferior to standard-duration (approximately\\u000a 10 days) subcutaneous (s.c.) enoxaparin for the prevention of VTE
Alexander Thomas Cohen; Theodore Erich Spiro; Harry Roger Büller; Lloyd Haskell; Dayi Hu; Russell Hull; Alexandre Mebazaa; Geno Merli; Sebastian Schellong; Alex Spyropoulos; Victor Tapson
OBJECTIVE: Implementation of strict glucose control in most intensive care units has resulted in increased use of point-of-care glucose devices in the intensive care unit. The aim of this study was to determine the reliability of point-of-care testing glucose meters among critically ill patients under intensive insulin treatment. DESIGN: Prospective observational study. PATIENTS: Intensive care unit and non-intensive care unit
Cornelia W. E. Hoedemaekers; Jacqueline M. T. Klein Gunnewiek; Marieke A. Prinsen; Johannes L. Willems; Johannes G. Van der Hoeven
Patterns of reinstitutionalization following psychiatric hospitalization for individuals with serious mental illnesses (SMI)\\u000a vary by medical and psychiatric health care settings. This report presents rates of reinstitutionalization across care settings\\u000a for 35,527 patients following psychiatric discharge in the Department of Veterans Affairs (VA) health system, a national health\\u000a care system. Over a 7-year follow-up period, 30,417 patients (86%) were reinstitutionalized.
Cheryl Irmiter; John F. McCarthy; Kristen L. Barry; Soheil Soliman; Frederic C. Blow
Etomidate is an induction agent known for its smooth intubating conditions and cardiovascular stability. Studies, however, have shown that a single dose of etomidate can result in a prolonged adrenal insufficiency. The impact of this in patients with sepsis has been a matter for debate. This review presents a pro/con case for using etomidate in hemodynamically unstable critically ill patients and provides guidance for alternative induction techniques and when the use of etomidate might be justified despite these concerns.
Objectives. We compared venous thromboembolism (VTE) prophylaxis practices and incidence in critically ill cirrhotic versus noncirrhotic patients and evaluated cirrhosis as a VTE risk factor. Methods. A cohort of 798 critically ill patients followed for the development of clinically detected VTE were categorized according to the diagnosis of cirrhosis. VTE prophylaxis practices and incidence were compared. Results. Seventy-five (9.4%) patients had cirrhosis with significantly higher INR (2.2 ± 0.9 versus 1.3 ± 0.6, P < 0.0001), lower platelet counts (115,000 ± 90,000 versus 258,000 ± 155,000/?L, P < 0.0001), and higher creatinine compared to noncirrhotic patients. Among cirrhotics, 31 patients received only mechanical prophylaxis, 24 received pharmacologic prophylaxis, and 20 did not have any prophylaxis. Cirrhotic patients were less likely to receive pharmacologic prophylaxis (odds ratio, 0.08; 95% confidence interval (CI), 0.04–0.14). VTE occurred in only two (2.7%) cirrhotic patients compared to 7.6% in noncirrhotic patients (P = 0.11). The incidence rate was 2.2 events per 1000 patient-ICU days for cirrhotic patients and 3.6 events per 1000 patient-ICU days for noncirrhotics (incidence rate ratio, 0.61; 95% CI, 0.15–2.52). On multivariate Cox regression analysis, cirrhosis was not associated with VTE risk (hazard ratio, 0.40; 95% CI, 0.10–1.67). Conclusions. In critically ill cirrhotic patients, VTE incidence did not statistically differ from that in noncirrhotic patients.
Al-Dorzi, Hasan M.; Tamim, Hani M.; Aldawood, Abdulaziz S.; Arabi, Yaseen M.
Critically ill patients generally receive moxifloxacin intravenously to achieve rapid bacterial killing. An early switch from intravenous to enteral moxifloxacin may be considered because of its good oral bioavailability in healthy volunteers. Since bioavailability may be altered in critically ill patients due to pathophysiological changes, this study aimed to investigate whether enteral moxifloxacin is bioequivalent to intravenous moxifloxacin in such patients. Blood samples were obtained from 4 critically ill patients before and at serial time-points after intravenous and enteral administration. In all patients, lower maximum plasma concentration (C(max)) and area under the plasma concentration-time curve during the 24-h observation period (AUC(24h)) values were observed after enteral administration compared to those after intravenous administration. This resulted in lower C(max)/minimum inhibitory concentration (MIC) and AUC(24h)/MIC values, which are 2 indices predicting the antibacterial efficacy of moxifloxacin. Despite the limited number of subjects, we conclude that a switch from intravenous to enteral moxifloxacin is not recommended in these patients, because the 2 administration forms are not bioequivalent. PMID:22804100
de Smet, Julie; Colpaert, Kirsten; de Paepe, Peter; van Bocxlaer, Jan; Decruyenaere, Johan; Boussery, Koen
Ganciclovir is an antiviral agent that is frequently used in critically ill patients with cytomegalovirus (CMV) infections. Continuous venovenous hemodiafiltration (CVVHDF) is a common extracorporeal renal replacement therapy in intensive care unit patients. The aim of this study was to investigate the pharmacokinetics of ganciclovir in anuric patients undergoing CVVHDF. Population pharmacokinetic analysis was performed for nine critically ill patients with proven or suspected CMV infection who were undergoing CVVHDF. All patients received a single dose of ganciclovir at 5 mg/kg of body weight intravenously. Serum and ultradiafiltrate concentrations were assessed by high-performance liquid chromatography, and these data were used for pharmacokinetic analysis. Mean peak and trough prefilter ganciclovir concentrations were 11.8 ± 3.5 mg/liter and 2.4 ± 0.7 mg/liter, respectively. The pharmacokinetic parameters elimination half-life (24.2 ± 7.6 h), volume of distribution (81.2 ± 38.3 liters), sieving coefficient (0.76 ± 0.1), total clearance (2.7 ± 1.2 liters/h), and clearance of CVVHDF (1.5 ± 0.2 liters/h) were determined. Based on population pharmacokinetic simulations with respect to a target area under the curve (AUC) of 50 mg · h/liter and a trough level of 2 mg/liter, a ganciclovir dose of 2.5 mg/kg once daily seems to be adequate for anuric critically ill patients during CVVHDF.
Kitzberger, Reinhard; Drolz, Andreas; Zauner, Christian; Jager, Walter; Bohmdorfer, Michaela; Kraff, Stefanie; Fritsch, Achim; Thalhammer, Florian; Fuhrmann, Valentin; Schenk, Peter
Objective Families and other surrogate decision-makers for chronically critically ill patients 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 ill patients 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.
Context: Prevalence of adrenal insufficiency (AI) is not uncommon in HIV infected population. However, AI is rarely diagnosed in clinical practice because many patients have non-specific symptoms and signs. Critical illness in such patients further complicates the evaluation of adrenal function. A 1?gm ACTH test can be used for diagnosis, since it results in more physiological levels of ACTH. A serum cortisol of <18 ?g/dL, 30 or 60-minutes after ACTH test has been accepted as indicative of AI, but many experts advocate the normal cortisol response should exceed 25 ?g/dL, in critically ill patients. Aim: To determine the prevalence of AI in critically ill AIDS patients, by using 1 ?g ACTH test and also, to compare the diagnostic criteria for adrenal insufficiency between cortisol response of <18 ?g/dL and <25 ?g/dL. Settings and Design: This prospective study was done in the Department of Medicine. Materials and Methods: After taking blood for basal plasma cortisol from AIDS affected fifty adult men and women aged over 18 yrs, 1 ?g ACTH was given intravenously, and blood samples were again collected at 30 and 60 minutes for plasma cortisol estimation. Statistical analysis: It was done by Mann-Whitney test. Results: Prevalence of AI was 74% (37 patients) and 92% (46 patients), when the peak stimulated cortisol level of <18 ?g/dL and <25 ?g/dL, respectively, was used. Conclusion: AI is more prevalent in critically ill AIDS patients. Hence, this test can be performed for early intervention and better management.
Shashidhar, P. K.; Shashikala, G. V.
Introduction Malnutrition is a frequent problem associated with detrimental clinical outcomes in critically ill patients. To avoid malnutrition, most studies focus on the prevention of inadequate nutrition delivery, whereas little attention is paid to the potential role of exocrine pancreatic insufficiency (EPI). In this trial, we aim to evaluate the prevalence of EPI and identify its potential risk factors in critically ill adult patients without preexisting pancreatic diseases. Methods In this prospective cross-sectional study, we recruited 563 adult patients with critical illnesses. All details of the patients were documented, stool samples were collected three to five days following the initiation of enteral nutrition, and faecal elastase 1 (FE-1) concentrations were assayed using an enzyme-linked immunosorbent assay kit. Blood samples were also taken to determine serum amylase and lipase activity. Results The percentages of recruited patients with EPI (FE-1 concentration <200 ?g/g) and severe EPI (FE-1 concentration <100 ?g/g) were 52.2% and 18.3%, respectively. The incidences of steatorrhea were significantly different (P < 0.05) among the patients without EPI, with moderate EPI (FE-1 concentration = 100 to 200 ?g/g) and severe EPI (FE-1 concentration < 100 ?g/g). Both multivariate logistic regression analysis and z-tests indicated that the occurrence of EPI was closely associated with shock, sepsis, diabetes, cardiac arrest, hyperlactacidemia, invasive mechanical ventilation and haemodialysis. Conclusions More than 50% of critically ill adult patients without primary pancreatic diseases had EPI, and nearly one-fifth of them had severe EPI. The risk factors for EPI included shock, sepsis, diabetes, cardiac arrest, hyperlactacidemia, invasive mechanical ventilation and haemodialysis. Trial registration NCT01753024
Introduction Invasive fungal infections are alarmingly common in intensive care unit patients; invasive fungal infections are associated with increased morbidity and mortality. Risk factors are the increased use of indwelling central venous catheters, the use of broad spectrum antibiotics, parenteral nutrition, renal replacement therapy and immunosuppression. Diagnosis of these infections might be complicated, requiring tissue cultures. In addition, therapy of invasive fungal infections might be difficult, given the rising resistance of fungi to antifungal agents. Case presentation We describe the case of a 28-year-old Greek man with yeast central nervous system infection. Conclusions Difficult-to-treat fungal infections may complicate the clinical course of critically ill patients and render their prognosis unfavorable. This report presents a case that was rare and difficult to treat, along with a thorough review of the investigation and treatment of these kinds of fungal infections in critically ill patients.
Empirically validated psychosocial interventions have been shown to improve adjustment and coping among cancer patients. Therefore, an emerging standard of practice is to integrate supportive services for cancer patients into the medical management of the disease. However, unanticipated barriers may negatively influence receptivity to psychosocial services. For example, among the general population, two-thirds of individuals in need of psychiatric services do not receive them. Numerous barriers have been reported that interfere with receipt of mental health services among members of the general population. In addition to access issues, stigma associated with mental illness and its treatment represents a significant barrier to care. Stigma associated with mental illness and mental health services use is an under-researched barrier to the effective management of the psychosocial sequelae of a cancer diagnosis and treatment. This article reviews the relevant literature on mental health stigma and makes recommendations for increasing access to psychosocial services for cancer patients and their families. PMID:19761070
Matthews, Alicia K; Corrigan, Patrick W; Rutherford, Judith Lee
The objective of this study was to determine the effectiveness of a telephone-facilitated depression care protocol in older, medically ill adults compared to routine care. A 12-week double blind randomized controlled trial was conducted in recently discharged primary care patients (N?=?124). Depression was assessed with the Patient Health Questionnaire-9. Primary care providers were notified of the level of depression severity and indications for treatment, but neither they nor the patients were contacted by a psychiatrist or other mental health professional. The primary outcome was initiation of treatment. Secondary outcomes were symptoms reduction and depression remission rates. There were no significant outcome differences between the facilitated and routine care groups. This study showed that older, medically ill adults may require a level of depression care that goes beyond a telephone-facilitated protocol. PMID:23572444
Pickett, Yolonda R; Kennedy, Gary J; Freeman, Katherine; Cummings, Johnine; Woolis, William
Objective Acute kidney injury is a common complication in critically ill patients, and the RIFLE, AKIN and KDIGO criteria are used to classify these patients. The present study's aim was to compare these criteria as predictors of mortality in critically ill patients. Methods Prospective cohort study using medical records as the source of data. All patients admitted to the intensive care unit were included. The exclusion criteria were hospitalization for less than 24 hours and death. Patients were followed until discharge or death. Student's t test, chi-squared analysis, a multivariate logistic regression and ROC curves were used for the data analysis. Results The mean patient age was 64 years old, and the majority of patients were women of African descent. According to RIFLE, the mortality rates were 17.74%, 22.58%, 24.19% and 35.48% for patients without acute kidney injury (AKI) in stages of Risk, Injury and Failure, respectively. For AKIN, the mortality rates were 17.74%, 29.03%, 12.90% and 40.32% for patients without AKI and at stage I, stage II and stage III, respectively. For KDIGO 2012, the mortality rates were 17.74%, 29.03%, 11.29% and 41.94% for patients without AKI and at stage I, stage II and stage III, respectively. All three classification systems showed similar ROC curves for mortality. Conclusion The RIFLE, AKIN and KDIGO criteria were good tools for predicting mortality in critically ill patients with no significant difference between them.
Levi, Talita Machado; de Souza, Sergio Pinto; de Magalhaes, Janine Garcia; de Carvalho, Marcia Sampaio; Cunha, Andre Luiz Barreto; Dantas, Joao Gabriel Athayde de Oliveira; Cruz, Marilia Galvao; Guimaraes, Yasmin Laryssa Moura; Cruz, Constanca Margarida Sampaio
An estimated 2-3% of all hospitalized patients become critically ill. These patients are in a state of relative immune exhaustion, which cripples their response to infections. Patients are sicker, have many comorbidities, and undergo complex procedures. This clinical picture, combined with increasing technologies and improved survival, presents unique challenges and demands a high level of services and expertise over a prolonged period of time. Long-term acute care hospitals provide these services, and the migration of chronically critically ill patients to these institutions facilitates defining (and quantifying) the spectrum of disease and how to best manage them. The prevalence of multidrug-resistant organism colonization and infection upon arrival to long-term acute care hospitals is high. Admission screening, and appropriate isolation and infection control practices can prevent transmission of these organisms. The implementation of ventilator-associated pneumonia prevention protocols, blood stream infection prevention protocols, and minimizing Foley urinary catheter use can decrease hospital-acquired infection rates and keep them low. In addition, specific attention is required to environmental services and surface and equipment cleaning. A well organized infection control program and an antimicrobial stewardship program have become indispensable to achieve these goals. All of these key principles and recommendations are also relevant to the chronically ill patient in acute care hospital ICUs and step-down units. PMID:22663971
Cabrera-Cancio, Margarita R
The aim of the present study was to quantify the severity of acute illness in patients with tick-borne encephalitis and to ascertain this approach by comparing it to standard clinical assessment. We designed scoring system for quantification of the severity of acute illness in patients with tick-borne encephalitis. Certain number of points was allotted to the presence, intensity, and duration of individual symptoms/signs. According to the obtained score the disease was classified as mild, moderate, and severe. Tick-borne encephalitis was assessed clinically as mild when only signs/symptoms of meningeal involvement were found, moderate in case of monofocal neurological signs and/or mild to moderate signs/symptoms of central nervous system dysfunction, and severe in patients with multifocal neurological signs and/or symptoms of severe dysfunction of central nervous system. By designed scoring system 282 adult patients, 146 males and 136 females, average aged 52.2?±?15.5 years (range 15–82 years), with confirmed tick-borne encephalitis, were prospectively assessed. In 279/282 (98.9%) patients the severity according to clinical assessment matched with the score ranges for mild, moderate, and severe disease. The proposed approach enables precise and straightforward appraisal of the severity of acute illness and could be useful for comparison of findings within/between study groups.
Bogovic, Petra; Logar, Mateja; Avsic-Zupanc, Tatjana; Strle, Franc; Lotric-Furlan, Stanka
Background: Limitations of life-support interventions, by either withholding or withdrawing support, are integrated parts of intensive care unit (ICU) activities and are ethically acceptable. The end-of-life legal aspects and practices in United Arab Emirates ICUs are rarely mentioned in the medical literature. The objective of this study was to examine the current practice of limiting futile life-sustaining therapies in our ICU, modalities for implementing of these decisions, and documentations in dying critically ill patients. Materials and Methods: This was a retrospective observational study conducted at our ICU. We studied all ICU patients who died from September 2008 to February 2009. Patients’ baseline demo-graphics, past medical problems, diagnosis on admission to ICU, and decision to withhold, withdraw and their modalities were collected. Methods: This was a retrospective observational study conducted at our ICU. We studied all ICU patients who died from September 2008 to February 2009. Patients’ baseline demo-graphics, past medical problems, diagnosis on admission to ICU, and decision to withhold, withdraw and their modalities were collected. Results: The electronic medical records of 67 patients were reviewed. The commonest method of limiting therapy was no escalation 53.6%. Interventions were withheld in 41.5%. “Do not resuscitate” order was documented in only 16.3%. The commonest method of documenting limitation of therapy was discussion with the family and documenting the prognosis and futility of additional therapy (73.3%). Patients who died early (<48 hrs) compared to patients who died late (>48 hrs) of ICU admission received terminal cardiopulmonary resuscitation more frequently (P < 0.007), had less frequent prognosis documentation (P < 0.009), and had more vasopressors administered (P < 0.006). Conclusion: Withholding therapy after discussion with the family was the preferred mode of limiting therapy in a dying patient.
Masood, Ur Rahman; Said, Abuhasna; Faris, Chedid; Al Mussady, Mousab; Al Jundi, Amer
OBJECTIVE: Describe the major discrepancies between the clinical and postmortem findings in critically ill cancer patients admitted to the medical intensive care unit (MICU). MATERIALS AND METHODS: Retrospectively review of the medical records of all cancer patients who were admitted to the MICU and underwent postmortem examination over 6 year period. The records were reviewed for demographics, Acute Physiology and Chronic Health Evaluation (APACHE) II score, clinical cause of death, and postmortem findings. RESULTS: There were 70 patients who had complete medical records. Mean age was 54.7 years (standard deviation (SD) ±14.8 years). Twenty-six patients had hematopoeitic stem cell transplantation (group I), 21 patients had hematological malignancies (group II), and 23 patients had solid malignancies (group III). The APACHE II score on admission to the MICU was 24.2 ± 8.0. Sixty-seven patients were mechanically ventilated, and the MICU stay was (mean ± SD) 9.0 ± 11.6 days. Major discrepancies between the clinical and postmortem diagnoses (Goldman classes I and II) were detected in 15 patients (21%). The most common missed diagnoses were aspergillosis, pulmonary embolism, and cancer recurrence. There were no differences between groups regarding the rate of major discrepancies. CONCLUSION: Despite the advances in the diagnosis and treatment of critically ill cancer patients, autopsies continue to show major discrepancies between the clinical and postmortem diagnoses. Autopsy is still useful in this patient population.
Khawaja, Owais; Khalil, Mohammad; Zmeili, Omar; Soubani, Ayman O.
Background Meropenem is a carbapenem antibiotic commonly used in critically ill patients to treat severe infections. The available pharmacokinetic (PK) data has been mostly obtained from healthy volunteers as well as from clinical studies addressing selected populations, often excluding the elderly and also patients with renal failure. Our aim was to study PK of meropenem in a broader population of septic critically ill patients. Methods We characterized the PK of meropenem in 15 critically ill patients during the first 36 hrs of therapy. Aditionally, whenever possible, we collected a second set of late plasma samples after 5 days of therapy to evaluate PK intra-patient variability and its correlation with clinical course. Patients received meropenem (1 g every 8 hrs IV). Drug plasma profiles were determined by high-performance liquid chromatography. The PK of meropenem was characterized and compared with clinical parameters. Results Fifteen septic critically ill patients (8 male, median age 73 yrs) were included. The geometric mean of the volume of distribution at the steady state (Vss)/weight was 0.20 (0.15-0.27) L/kg. No correlation of Vss/weight with severity or comorbidity scores was found. However the Sequential Organ Failure Assessment score correlated with the Vss/weight of the peripheral compartment (r2?=?0.55, p?=?0.021). The median meropenem clearance (Cl) was 73.3 (45–120) mL/min correlated with the creatinine (Cr) Cl (r2?=?0.35, p?=?0.033). After 5 days (N?=?7) although Vss remained stable, a decrease in the proportion of the peripheral compartment (Vss2) was found, from 61.3 (42.5-88.5)% to 51.7 (36.6-73.1)%. No drug accumulation was noted. Conclusions In this cohort of septic, unselected, critically ill patients, large meropenem PK heterogeneity was noted, although neither underdosing nor accumulation was found. However, Cr Cl correlated to meropenem Cl and the Vss2 decreased with patient’s improvement.
Investigated dream content of 104 dreams from nine terminally ill patients with estimated life expectancy of one year or less. Found differences between dreams of terminally ill and dreams of physically healthy individuals, suggesting an adaptive withdrawal and process of social and emotional disengagement by terminally ill individuals. (Author/NB)
Objective. To evaluate the vitamin D status of our critically ill patients and its relevance to mortality. Patients and Methods. We performed a prospective observational study in the medical intensive care unit of a university hospital between October 2009 and March 2011. Vitamin D levels were measured and insufficiency was defined as <20?ng/mL. Results. Two hundred and one patients were included in the study. The median age was 66 (56–77) and the majority of patients were male (56%). The median serum level of vitamin D was 14,9?ng/mL and 139 (69%) patients were vitamin D insufficient on admission. While we grouped the ICU patients as vitamin D insufficient and sufficient, vitamin D insufficient patients had more severe acute diseases and worse laboratory values on admission. These patients had more morbidities and were exposed to more invasive therapies during stay. The mortality rate was significantly higher in the vitamin D insufficient group compared to the vitamin D sufficient group (43% versus 26%, P = 0,027). However, logistic regression analysis demonstrated that vitamin D insufficiency was not an independent risk factor for mortality. Conclusion. Vitamin D insufficiency is common in our critically ill patients (69%), but it is not an independent risk factor for mortality.
Turkoglu, Melda; Tuncel, Ayse Fitnat; Cand?r, Burcu Arslan; Bildac?, Yelda Deligoz; Pasaoglu, Hatice
Background Mortality among critically ill patients with candidemia is very high. We sought to determine whether the choice of initial antifungal therapy is associated with survival among these patients, using need for mechanical ventilatory support as a marker of critical illness. Methods Cohort analysis of outcomes among mechanically ventilated patients with candidemia from the 24 North American academic medical centers contributing to the Prospective Antifungal Therapy (PATH) Alliance registry. Patients were included if they received either fluconazole or an echinocandin as initial monotherapy. Results Of 5272 patients in the PATH registry at the time of data abstraction, 1014 were ventilated and concomitantly had candidemia, with 689 eligible for analysis. 28-day survival was higher among the 374 patients treated initially with fluconazole than among the 315 treated with an echinocandin (66% versus 51%, P?.001). Initial fluconazole therapy remained associated with improved survival after adjusting for non-treatment factors in the overall population (hazard ratio .75, 95% CI .59–.96), and also among patients with albicans infection (hazard ratio .62, 95% CI .44–.88). While not statistically significant, fluconazole appeared to be associated with higher mortality among patients infected with glabrata (HR 1.13, 95% CI .70–1.84). Conclusions Among ventilated patients with candidemia, those receiving fluconazole as initial monotherapy were significantly more likely to survive than those treated with an echinocandin. This difference persisted after adjustment for non-treatment factors.
Progression of critically ill patients from Systemic Inflammatory Response Syndrome (SIRS) to Multiple Organ Dysfunction Syndrome (MODS) accounts for more than 75% of deaths in adult surgical intensive care units. Currently, there is no practical clinical technique to predict the progression of SIRS or MODS. In this report, we describe an NMR-based metabonomic method to aid detection of these conditions based on abnormal metabolic signatures. We applied pattern recognition methods to analyze one-dimensional (1)H NMR spectra of SIRS and MODS patient sera. By using Principal Component Analysis (PCA) and Partial Least Squares-Discriminant Analysis (PLS-DA), we could distinguish critically ill patients (n = 52) from healthy controls (n = 26). After noise reduction by Orthogonal Signal Correction (OSC), PLS-DA was also able to clearly discriminate SIRS and MODS patients. The corresponding coefficients indicated that spectra responsible for the discrimination were located in delta3.06-3.86 NMR integral regions from SIRS, mainly composed of sugars, amino acids and glutamine signals, and delta1.18-1.3 and delta4.02-4.1 integral regions of MODS serum samples, principally consisted of various proton signals of fatty acyl chains and glycerol backbone of lipids, along with creatinine and lactate. Our results are consistent with the clinical observations that carbohydrate and amino acid levels changes in the early course of critical illness (SIRS stage) and significant disturbances in fat metabolism and development of organ abnormalities become the characteristics in the late stage (MODS). These data suggest that NMR-based metabonomic approach can be developed to diagnose the disease progress of critically ill patients. PMID:19835422
Mao, Hailei; Wang, Huimin; Wang, Bin; Liu, Xia; Gao, Hongchang; Xu, Min; Zhao, Hongsheng; Deng, Xiaoming; Lin, Donghai
Background Randomized controlled trial evidence supports a restrictive strategy of red blood cell (RBC) transfusion, but significant variation in clinical transfusion practice persists. Patient characteristics other than hemoglobin levels may influence the decision to transfuse RBCs and explain some of this variation. Our objective was to evaluate the role of patient comorbidities and severity of illness in predicting inpatient red blood cell transfusion events. Methods We developed a predictive model of inpatient RBC transfusion using comprehensive electronic medical record (EMR) data from 21 hospitals over a four year period (2008-2011). Using a retrospective cohort study design, we modeled predictors of transfusion events within 24 hours of hospital admission and throughout the entire hospitalization. Model predictors included administrative data (age, sex, comorbid conditions, admission type, and admission diagnosis), admission hemoglobin, severity of illness, prior inpatient RBC transfusion, admission ward, and hospital. Results The study cohort included 275,874 patients who experienced 444,969 hospitalizations. The 24 hour and overall inpatient RBC transfusion rates were 7.2% and 13.9%, respectively. A predictive model for transfusion within 24 hours of hospital admission had a C-statistic of 0.928 and pseudo-R2 of 0.542; corresponding values for the model examining transfusion through the entire hospitalization were 0.872 and 0.437. Inclusion of the admission hemoglobin resulted in the greatest improvement in model performance relative to patient comorbidities and severity of illness. Conclusions Data from electronic medical records at the time of admission predicts with very high likelihood the incidence of red blood transfusion events in the first 24 hours and throughout hospitalization. Patient comorbidities and severity of illness on admission play a small role in predicting the likelihood of RBC transfusion relative to the admission hemoglobin.
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
The escalating number of emergency department (ED) visits, length of stay, and hospital overcrowding have been associated with an increasing number of critically ill patients cared for in the ED. Existing physiologic scoring systems have traditionally been used for outcome prediction, clinical research, quality of care analysis, and benchmarking in the intensive care unit (ICU) environment. However, there is limited experience with scoring systems in the ED, while early and aggressive intervention in critically ill patients in the ED is becoming increasingly important. Development and implementation of physiologic scoring systems specific to this setting is potentially useful in the early recognition and prognostication of illness severity. A few existing ICU physiologic scoring systems have been applied in the ED, with some success. Other ED specific scoring systems have been developed for various applications: recognition of patients at risk for infection; prediction of mortality after critical care transport; prediction of in-hospital mortality after admission; assessment of prehospital therapeutic efficacy; screening for severe acute respiratory syndrome; and prediction of pediatric hospital admission. Further efforts at developing unique physiologic assessment methodologies for use in the ED will improve quality of patient care, aid in resource allocation, improve prognostic accuracy, and objectively measure the impact of early intervention in the ED.
Hargrove, Jenny; Nguyen, H Bryant
The escalating number of emergency department (ED) visits, length of stay, and hospital overcrowding have been associated with an increasing number of critically ill patients cared for in the ED. Existing physiologic scoring systems have traditionally been used for outcome prediction, clinical research, quality of care analysis, and benchmarking in the intensive care unit (ICU) environment. However, there is limited experience with scoring systems in the ED, while early and aggressive intervention in critically ill patients in the ED is becoming increasingly important. Development and implementation of physiologic scoring systems specific to this setting is potentially useful in the early recognition and prognostication of illness severity. A few existing ICU physiologic scoring systems have been applied in the ED, with some success. Other ED specific scoring systems have been developed for various applications: recognition of patients at risk for infection; prediction of mortality after critical care transport; prediction of in-hospital mortality after admission; assessment of prehospital therapeutic efficacy; screening for severe acute respiratory syndrome; and prediction of pediatric hospital admission. Further efforts at developing unique physiologic assessment methodologies for use in the ED will improve quality of patient care, aid in resource allocation, improve prognostic accuracy, and objectively measure the impact of early intervention in the ED. PMID:16137387
Hargrove, Jenny; Nguyen, H Bryant
Critically ill patients experience severe stress, inflammation and clinical conditions which may increase the utilization and metabolic turnover of vitamin B-6 and may further increase their oxidative stress and compromise their antioxidant capacity. This study was conducted to examine the relationship between vitamin B-6 status (plasma and erythrocyte PLP) oxidative stress, and antioxidant capacities in critically ill surgical patients. Thirty-seven patients in surgical intensive care unit of Taichung Veterans General Hospital, Taiwan, were enrolled. The levels of plasma and erythrocyte PLP, serum malondialdehyde, total antioxidant capacity, and antioxidant enzyme activities (i.e., superoxide dismutase (SOD), glutathione S-transferase, and glutathione peroxidase) were determined on the 1st and 7th days of admission. Plasma PLP was positively associated with the mean SOD activity level on day 1 (r = 0.42, P < 0.05), day 7 (r = 0.37, P < 0.05), and on changes (? (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.
Cheng, Chien-Hsiang; Huang, Shih-Chien; Chiang, Ting-Yu; Wong, Yueching
Background It is currently unclear whether parenteral selenium supplementation should be recommended in the management of critically ill patients. Here we conducted a systematic review and meta-analysis to assess the efficacy of parenteral selenium supplementation on clinical outcomes. Methods/Principal Findings Randomized trials investigating parenteral selenium supplementation administered in addition to standard of care to critically ill patients were included. CENTRAL, Medline, EMBASE, the Science Citation Index, and CINAHL were searched with complementary manual searches. The primary outcome was all-cause mortality. Trials published in any language were included. Two authors independently extracted data and assessed trial quality. A third author was consulted to resolve disagreements and for quality assurance. Twelve trials were included and meta-analysis was performed on nine trials that recruited critically ill septic patients. These comprised 965 participants in total. Of these, 148 patients (30.7%) in the treatment groups, and 180 patients (37.3%) in control groups died. Parenteral selenium treatment significantly reduced all-cause mortality in critically ill patients with sepsis (relative risk [RR] 0.83, 95% CI 0.70–0.99, 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 ill patients with sepsis. Owing to the varied methodological quality of the studies, future high-quality randomized trials that directly focus on the effect of adequate-duration of parenteral selenium supplementation for severe septic patients are needed to confirm our results. Clinicians should consider these findings when treating this high-risk population. Systematic Review Registration PROSPERO 2011; CRD42011001768
Huang, Ting-Shuo; Shyu, Yu-Chiau; Chen, Huang-Yang; Lin, Li-Mei; Lo, Chia-Ying; Yuan, Shin-Sheng; Chen, Pei-Jer
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 ill patients. Methods An observational, cohort study of critically ill patients was performed in a tertiary care hospital. Critically ill patients 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 ill patients 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
Communication between patient and providers is extremely important, especially for the treatment of chronically ill patients, characterized by a biopsychosocial disease model. This article presents an overview of the current status of research on patient-provider communication in 3 selected areas: the communication preferences of chronically ill persons, the correlation between communication and relevant endpoints, and interventions to improve patient-provider communication. One major result of the research is that patients display a rather high degree of inter- and intra-individual variability with respect to the preference of certain communication styles (e.g. patient participation); there are differences among them, and they develop varying preferences in the course of their illness. However, communicative behavior of the provider that is generally perceived by many patients to be positive can also be identified: affective behavior (for example, asking the patient about his/her feelings, being sensitive to these feelings and responding to them), providing information in an understandable, proactive manner, and attempting to understand the patient's perceptions, expectations, and cognitive concepts. Successful communication requires a certain congruence between the patient's communication preferences and the provider's behavior. It has been sufficiently documented in literature that successful communication leads to greater adherence. The correlation to patient satisfaction is not documented quite as clearly but has often been shown. The findings vary with respect to the improvement in the patient's health status. The effectiveness of communication training for providers has been documented quite well regarding the immediate endpoints in patient-provider interaction (e.g., patient-oriented behavior); the evidence with respect to medium-term endpoints such as patient satisfaction varies, also due to the number of possible operationalizations of the endpoints. Supplementing provider training with communication-related training for patients appears to be an important and useful method as many studies have shown that the behavior of providers can be influenced using relatively simple measures that start with the patient. There is a need for further development of research on patient-provider communication, in particular with respect to a more solid theoretical basis, integration of methods including qualitative and quantitative methods, self-evaluations, and interaction analyses, and also concerning conducting more longitudinal studies. PMID:20963669
Background Personality traits have been associated with physician-rated illness burden cross-sectionally, but longitudinal associations between personality and objective medical morbidity remain unclear. Purpose To examine associations between personality and physician-rated illness burden 4 years prospectively in older primary care patients. Method At baseline, patients (average age = 75, SD = 6.6, 62% female) completed the NEO-Five Factor Inventory. At baseline and 4 yearly follow-ups, a physician completed the Cumulative Illness Rating Scale based on medical records. Results Linear mixed effects models revealed that higher neuroticism and lower conscientiousness predicted worse average illness burden longitudinally. Relatively disagreeable persons (25th percentile) accumulated morbidity at a 33% faster rate than agreeable (75th percentile) peers. At the final follow-up, a person at the 75th percentile of neuroticism and the 25th percentile of conscientiousness and agreeableness showed morbidity comparable to a peer of average personality but 10 years older. An individual at the 25th percentile of neuroticism and 75th percentile of conscientiousness and agreeableness showed end-point illness burden comparable to a peer of average personality but 10 years younger. 21% of the morbidity associated with neuroticism was explained by total cholesterol. History of hypertension, smoking, alcohol/drug abuse, and affective symptoms of depression each explained 10% or less of the other observed personality effects. Conclusion Personality plays a non-trivial role in healthy aging among older persons. Brief personality assessment may identify at-risk older persons for closer monitoring, enhance the accuracy of medical prognosis, and provide clues for clinical interventions to promote better health.
Chapman, Benjamin P.; Roberts, Brent; Lyness, Jeff; Duberstein, Paul
Introduction. Serum procalcitonin (PCT) diagnosed sepsis in critically ill patients; however, its prediction for survival is not well established. We evaluated the prognostic value of dynamic changes of PCT in sepsis patients. Methods. A prospective observational study was conducted in adult ICU. Patients with systemic inflammatory response syndrome (SIRS) were recruited. Daily PCT were measured for 3 days. 48 h PCT clearance (PCTc-48) was defined as percentage of baseline PCT minus 48 h PCT over baseline PCT. Results. 95 SIRS patients were enrolled (67 sepsis and 28 noninfectious SIRS). 40% patients in the sepsis group died in hospital. Day 1-PCT was associated with diagnosis of sepsis (AUC 0.65 (95% CI, 0.55 to 0.76)) but was not predictive of mortality. In sepsis patients, PCTc-48 was associated with prediction of survival (AUC 0.69 (95% CI, 0.53 to 0.84)). Patients with PCTc-48 > 30% were independently associated with survival (HR 2.90 (95% CI 1.22 to 6.90)). Conclusions. PCTc-48 is associated with prediction of survival in critically ill patients with sepsis. This could assist clinicians in risk stratification; however, the small sample size, and a single-centre study, may limit the generalisability of the finding. This would benefit from replication in future multicentre study.
Mat Nor, Mohd Basri; Md Ralib, Azrina
Background The aim of the present pilot study was to determine if pulse photoplethysmography amplitude (PPGA) could be used as an indicator of critical illness and as a predictor of higher need of care in emergency department patients. Methods This was a prospective observational study. We collected vital signs and one minute of pulse photoplethysmograph signal from 251 consecutive patients admitted to a university hospital emergency department. The patients were divided in two groups regarding to the modified Early Warning Score (mEWS): > 3 (critically ill) and???3 (non-critically ill). Photoplethysmography characteristics were compared between the groups. Results Sufficient data for analysis was acquired from 212 patients (84.5%). Patients in critically ill group more frequently required intubation and invasive hemodynamic monitoring in the ED and received more intravenous fluids. Mean pulse photoplethysmography amplitude (PPGA) was significantly lower in critically ill patients (median 1.105 [95% CI of mean 0.9946-2.302] vs. 2.476 [95% CI of mean 2.239-2.714], P?=?0.0257). Higher variability of PPGA significantly correlated with higher amount of fluids received in the ED (r?=?0.1501, p?=?0.0296). Conclusions This pilot study revealed differences in PPGA characteristics between critically ill and non-critically ill patients. Further studies are needed to determine if these easily available parameters could help increase accuracy in triage when used in addition to routine monitoring of vital signs.
Objective To study differences between working and sick-listed chronic repetitive strain injury (RSI) patients in the Netherlands with respect to indices of quality of life and illness perception. Methods In a cross-sectional design, one questionnaire was sent to all 3,250 members of the national RSI patient association. For descriptive purposes, demographics, work status and complaint-related variables such as severity, type, duration, and extent of complaints were asked for. Indices of quality of life were assessed through seven SF-36 subscales (physical (role) functioning, emotional role functioning, social functioning, pain, mental health and vitality). A work-ability estimate and VAS scales were used to assess complaint-related decrease in quality of life. Illness perception was assessed through the brief illness perception questionnaire (IPQ-B). Working patients and sick-listed patients were identified. Tests between the two independent groups were performed and P-values < 0.01 were considered significant. Results Data from 1,121 questionnaires were used. Two-thirds of the respondents worked and one-third were sick-listed. Average duration of complaints was over 5 years in both groups. The sick-listed patients reported significantly more severe and extensive complaints than did the working patients. In addition, sick-listed patients reported significantly poorer mental health, physical (role) functioning, emotional role functioning, pain, vitality, and work-ability. With respect to illness perception, both groups showed the same concerns about their complaints, but sick-listed patients had significantly more distorted perceptions in their emotional response, identity, treatment control, personal control, timeline, and life consequences. Complaint-related decrease in quality of life was 31% in the working patients and 49% in the sick-listed patients. Conclusion The study found a greater number and severe complaints among sick-listed chronic RSI patients and a considerably decreased quality of life because of their complaints. These findings may allow for a better treatment focus in the future.
Frings-Dresen, Monique H. W.
Introduction Clinicians and specialty societies often emphasize the potential importance of natural light for quality care of critically ill patients, but few studies have examined patient outcomes associated with exposure to natural light. We hypothesized that receiving care in an intensive care unit (ICU) room with a window might improve outcomes for critically ill patients with acute brain injury. Methods This was a secondary analysis of a prospective cohort study. Seven ICU rooms had windows, and five ICU rooms did not. Admission to a room was based solely on availability. We analyzed data from 789 patients with subarachnoid hemorrhage (SAH) admitted to the neurological ICU at our hospital from August 1997 to April 2006. Patient information was recorded prospectively at the time of admission, and patients were followed up to 1 year to assess mortality and functional status, stratified by whether care was received in an ICU room with a window. Results Of 789 SAH patients, 455 (57.7%) received care in a window room and 334 (42.3%) received care in a nonwindow room. The two groups were balanced with regard to all patient and clinical characteristics. There was no statistical difference in modified Rankin Scale (mRS) score at hospital discharge, 3 months or 1 year (44.8% with mRS scores of 0 to 3 with window rooms at hospital discharge versus 47.2% with the same scores in nonwindow rooms at hospital discharge; adjusted odds ratio (aOR) 1.01, 95% confidence interval (95% CI) 0.67 to 1.50, P = 0.98; 62.7% versus 63.8% at 3 months, aOR 0.85, 95% CI 0.58 to 1.26, P = 0.42; 73.6% versus 72.5% at 1 year, aOR 0.78, 95% CI 0.51 to 1.19, P = 0.25). There were also no differences in any secondary outcomes, including length of mechanical ventilation, time until the patient was able to follow commands in the ICU, need for percutaneous gastrostomy tube or tracheotomy, ICU and hospital length of stay, and hospital, 3-month and 1-year mortality. Conclusions The presence of a window in an ICU room did not improve outcomes for critically ill patients with SAH admitted to the ICU. Further studies are needed to determine whether other groups of critically ill patients, particularly those without acute brain injury, derive benefit from natural light.
Objective To evaluate the benefits and harms of antithrombin III in critically ill patients.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
Objective: Criteria for plasma volume expander selection in critically ill patients remain contro- versial. This study evaluated prefer- ences of intensivists regarding plas- ma volume expanders. Design: In- ternational survey using a 75-item questionnaire. Participants and setting: All members of the European and French Societies of Intensive Care Medicine (n=2,415 in 1,610 adult ICUs in Europe and elsewhere) were invited
Frédérique Schortgen; Nicolas Deye; Laurent Brochard
Introduction There are no universally accepted diagnostic criteria for gastrointestinal failure in critically ill patients. In the present\\u000a study we tested whether the occurrence of food intolerance (FI) and intra-abdominal hypertension (IAH), combined in a 5-grade\\u000a scoring system for assessment of gastrointestinal function (the Gastrointestinal Failure [GIF] score), predicts mortality.\\u000a The prognostic value of the GIF score alone and in combination
Annika Reintam; Pille Parm; Reet Kitus; Joel Starkopf; Hartmut Kern
The best laxative for terminal cancer patients treated with opioids still remains to be determined. This comparative study was conducted with the objective of determining treatment and cost efficiency for senna and lactulose in terminal cancer patients treated with opioids. The methodology used a randomized, open, parallel group design. The study was conducted in the Palliative Care Unit in one
Yolanda Agra; Antonio Sacristán; Manuel González; Miguel Ferrari; Azucena Portugués; Maria José Calvo
The objective of this study was to determine if the orally disintegrating tablet formulation of olanzapine, Zyprexa Zydis, would facilitate antipsychotic medication compliance in acutely ill, non-compliant patients. Eighty-five acutely ill patients with schizophrenia or schizoaffective disorder who met medication non-compliance criteria received open-label olanzapine orally disintegrating tablets (1020 mgd) for up to 6 wk. Improvement in medication compliance was assessed using various rating scales to measure changes in psychopathology, medication-taking and compliance attitudes, and nursing care burden. Safety variables were also measured. Significant improvement from baseline was demonstrated in the Positive and Negative Syndrome Scale total score at Week 1 and subsequently (p0.001). Significant improvement from baseline was also seen in various scales measuring medication compliance, attitude, and nursing care burden (p0.05). Olanzapine orally disintegrating tablets were well-tolerated. Olanzapine orally disintegrating tablets may benefit acutely ill, non-compliant schizophrenic patients by facilitating acceptance of active antipsychotic drug therapy. PMID:12890301
Kinon, Bruce J; Hill, Angela L; Liu, Hong; Kollack-Walker, Sara
Introduction This study was conducted to provide Intensive Care Units and Emergency Departments with a set of practical procedures (check-lists) for managing critically-ill adult patients in order to avoid complications during intra-hospital transport (IHT). Methods Digital research was carried out via the MEDLINE, EMBASE, CINAHL and HEALTHSTAR databases using the following key words: transferring, transport, intrahospital or intra-hospital, and critically ill patient. The reference bibliographies of each of the selected articles between 1998 and 2009 were also studied. Results This review focuses on the analysis and overcoming of IHT-related risks, the associated adverse events, and their nature and incidence. The suggested preventive measures are also reviewed. A check-list for quick execution of IHT is then put forward and justified. Conclusions Despite improvements in IHT practices, significant risks are still involved. Basic training, good clinical sense and a risk-benefit analysis are currently the only deciding factors. A critically ill patient, prepared and accompanied by an inexperienced team, is a risky combination. The development of adapted equipment and the widespread use of check-lists and proper training programmes would increase the safety of IHT and reduce the risks in the long-term. Further investigation is required in order to evaluate the protective role of such preventive measures.
Objectives. To define the role of procalcitonin in the differential diagnosis, prognosis and follow-up of critically ill patients. Design: Prospective study during the 2-year period from January 1998-2000. Patients: One hundred nineteen critically ill patients: 29 with systemic inflammatory response syndrome (SIRS) without any signs of infection, 11 with sepsis, 17 with severe sepsis, 10 with septic shock and 52
Evangelos J. Giamarellos-Bourboulis; Anna Mega; Paraskevi Grecka; Nektaria Scarpa; George Koratzanis; George Thomopoulos; Helen Giamarellou
Objective: To determine the pharmacokinetics and absolute bioavailability of ciprofloxacin in 12 critically ill patients receiving\\u000a continuous enteral feeding. Design: a prospective, cross-over study. Setting: 12-bed surgical intensive care unit in a University Hospital. Patients: 12 stable critically ill patients on mechanical ventilation and receiving continuous enteral feeding (Normoral fibres)\\u000a without diarrhea or excessive residual gastric contents ( < 200
O. Mimoz; V. Binter; A. Jacolot; A. Edouard; M. Tod; O. Petitjean; K. Samii
Aim: The aim and objective of this scientific research article is to explore the literature with intent to raise attention to the perfidiousness of the experiences of men as palliative caregivers of people living with HIV/AIDS and other terminal illnesses. Methods: The article has utilized eclectic data sources in Botswana and elsewhere. Results: The findings indicate that care giving position of men has been found beset by: retrogressive gender unfriendly cultures; patriarchy; weaker gender empowerment campaigns; and inadequate male involvement in care. Conclusions: The article recommends: (1) a paradigm shift of structural gender dynamics; (2) making AIDS care programmes both gender sensitive and gender neutral; (3) Strengthening gender mainstreaming; (4) diluting cultures and patriarchy; (5) and signing and domesticating SADC gender protocol and other gender friendly international agreements by Botswana government.
Based on the psychoanalytic reading of Homer’s Iliad whose principal theme is “Achilles’ rage” (the semi-mortal hero invulnerable in all of his body except for his heel, hence “Achilles’ heel” has come to mean a person’s principal weakness), we aimed to assess whether “narcissistic rage” has an impact on several psychosocial variables in patients with severe physical illness across time. In 878 patients with cancer, rheumatological diseases, multiple sclerosis, inflammatory bowel disease, and glaucoma, we assessed psychological distress (SCL-90 and GHQ-28), quality of life (WHOQOL-BREF), interpersonal difficulties (IIP-40), hostility (HDHQ), and defense styles (DSQ). Narcissistic rage comprised DSQ “omnipotence” and HDHQ “extraverted hostility”. Hierarchical multiple regressions analyses were performed. We showed that, in patients with disease duration less than one year, narcissistic rage had a minor impact on psychosocial variables studied, indicating that the rage was rather part of a “normal” mourning process. On the contrary, in patients with longer disease duration, increased rates of narcissistic rage had a great impact on all outcome variables, and the opposite was true for patients with low rates of narcissistic rage, indicating that narcissistic rage constitutes actually an “Achilles’ Heel” for patients with long-term physical illness. These findings may have important clinical implications.
Hyphantis, Thomas; Almyroudi, Augustina; Paika, Vassiliki; Goulia, Panagiota; Arvanitakis, Konstantinos
This article presents one of the segments of ethnographic research which was conducted over a two-year period, by means of participant observation, at the Chemical Dependency Center of the Brazilian Navy. Patients of 2 treatment groups were observed during 24 sessions of group therapy. Among the 22 existing patients of the two groups, 13 patients were randomly selected for individual interviews. Their illness and healing representations related to mental and behavioral disorders caused by drugs were examined, and also the influence of the work environment on patient involvement with drugs was investigated. Results show that patients believe that they are responsible for their illness and for their alcoholic sobriety and they also believe they will never be cured. Furthermore, they do not usually accept the on-going medical discourse or the Alcoholics Anonymous belief that they are recovering alcoholics; they build their own views about their diagnoses, prognoses, and treatments. There are cultural traits particular to the naval life that indicate that the categories analyzed are mainly social, and that certain work-related conditions lead to the emergence of alcoholism in many patients, despite the fact that drugs are commonly tackled from the administrative perspective. PMID:22534861
Halpern, Elizabeth Espindola; Leite, Ligia Maria Costa
Background Mental fitness for work is the ability of workers to perform their work without risks for themselves or others. Mental fitness was a neglected area of practice and research. Mental ill health at work seems to be rising as a cause of disablement. Psychiatrists who may have had no experience in relating mental health to working conditions are increasingly being asked to undertake these examinations. This research was done to explore the relationship of mental ill health and fitness to work and to recognize the differences between fit and unfit mentally ill patients. Methods This study was cross sectional one. All cases referred to Al-Amal complex for assessment of mental fitness during a period of 12 months were included. Data collected included demographic and clinical characteristics, characteristics of the work environment and data about performance at work. All data was subjected to statistical analysis. Results Total number of cases was 116, the mean age was 34.5 ± 1.4. Females were 35.3% of cases. The highly educated patients constitute 50.8% of cases. The decision of the committee was fit for regular work for 52.5%, unfit for 19.8% and modified work for 27.7%. The decision was appreciated only by 29.3% of cases. There were significant differences between fit, unfit and modified work groups. The fit group had higher level of education, less duration of illness, and better performance at work. Patients of the modified work group had more physical hazards in work environment and had more work shift and more frequent diagnosis of substance abuse. The unfit group had more duration of illness, more frequent hospitalizations, less productivity, and more diagnosis of schizophrenia. Conclusion There are many factors affecting the mental fitness the most important are the characteristics of work environment and the most serious is the overall safety of patient to self and others. A lot of ethical and legal issues should be kept in mind during such assessment as patient's rights, society's rights, and the laws applied to unfit people.
Introduction Higher lactate concentrations within the normal reference range (relative hyperlactatemia) are not considered clinically significant. We tested the hypothesis that relative hyperlactatemia is independently associated with an increased risk of hospital death. Methods This observational study examined a prospectively obtained intensive care database of 7,155 consecutive critically ill patients admitted to the Intensive Care Units (ICUs) of four Australian university hospitals. We assessed the relationship between ICU admission lactate, maximal lactate and time-weighted lactate levels and hospital outcome in all patients and also in those patients whose lactate concentrations (admission n = 3,964, maximal n = 2,511, and time-weighted n = 4,584) were under 2 mmol.L-1 (i.e. relative hyperlactatemia). Results We obtained 172,723 lactate measurements. Higher admission and time-weightedlactate concentration within the reference range was independently associated with increased hospital mortality (admission odds ratio (OR) 2.1, 95% confidence interval (CI) 1.3 to 3.5, P = 0.01; time-weighted OR 3.7, 95% CI 1.9 to 7.00, P < 0.0001). This significant association was first detectable at lactate concentrations > 0.75 mmol.L-1. Furthermore, in patients whose lactate ever exceeded 2 mmol.L-1, higher time-weighted lactate remained strongly associated with higher hospital mortality (OR 4.8, 95% CI 1.8 to 12.4, P < 0.001). Conclusions In critically ill patients, relative hyperlactataemia is independently associated with increased hospital mortality. Blood lactate concentrations > 0.75 mmol.L-1 can be used by clinicians to identify patients at higher risk of death. The current reference range for lactate in the critically ill may need to be re-assessed.
Background Patients identified with sepsis in the emergency department often are treated on the basis of the presumption of infection; however, various noninfectious conditions that require specific treatments have clinical presentations very similar to that of sepsis. Our aim was to describe the etiology of illness in patients identified and treated for severe sepsis in the emergency department. Methods We conducted a prospective observational study of patients treated with goal-directed resuscitation for severe sepsis in the emergency department. Inclusion criteria were suspected infection, 2 or more criteria for systemic inflammation, and evidence of hypoperfusion. Exclusion criteria were age of <18 years and the need for immediate surgery. Clinical data on eligible patients were prospectively collected for 2 years. Blinded observers used a priori definitions to determine the final cause of hospitalization. Results In total, 211 patients were enrolled; 95 (45%) had positive culture results, and 116 (55%) had negative culture results. The overall mortality rate was 19%. Patients with positive culture results were more likely to have indwelling vascular lines (P = .03) be residents of nursing homes (P = .04), and have a shorter time to administration of antibiotics in the emergency department (83 vs 97 min; P = .03). Of patients with negative culture results, 44% had clinical infections, 8% had atypical infections, 32% had noninfectious mimics, and 16% had an illness of indeterminate etiology. Conclusion In this study, we found that >50% of patients identified and treated for severe sepsis in the emergency department had negative culture results. Of patients identified with a sepsis syndrome at presentation, 18% had a noninfectious diagnosis that mimicked sepsis, and the clinical characteristics of these patients were similar to those of patients with culture-positive sepsis.
Heffner, Alan C.; Horton, James M.; Marchick, Michael R.; Jones, Alan E.
This study investigated the associations among trait perfectionism, perfectionistic self-presentation, Type D personality, and illness-specific coping styles in 100 cardiac rehabilitation patients. Participants completed the Multidimensional Perfectionism Scale, the Perfectionistic Self-Presentation Scale, the Type D Scale-14, and the Coping with Health Injuries and Problems Scale. Correlational analyses established that emotional preoccupation coping was associated with trait perfectionism, perfectionistic self-presentation, and Type D personality. Perfectionism was linked with both facets of the Type D construct (negative emotionality and social inhibition). Our results suggest that perfectionistic Type D patients have maladaptive coping with potential negative implications for their cardiac rehabilitation outcomes. PMID:23493864
Shanmugasegaram, Shamila; Flett, Gordon L; Madan, Mina; Oh, Paul; Marzolini, Susan; Reitav, Jaan; Hewitt, Paul L; Sturman, Edward D
Critically ill patients are at risk of developing stress ulcers in the upper digestive tract. Multiple risk factors have been associated with the development of this condition, with variable risk of association. Decades of research have suggested the benefit of using pharmacologic prophylaxis to reduce the incidence of clinically important upper gastrointestinal bleeding, with no reduction in overall mortality. It has been the standard of care to provide prophylaxis to patients at risk. Options for prophylaxis include: proton?pump inhibitors, histamine(2)?receptor antagonists, or sucralfate. The choice of prophylaxis depends on multiple factors including the presence of risk factors, risk for nosocomial pneumonia, and possibly cost. PMID:22354363
Alhazzani, Waleed; Alshahrani, Mohammed; Moayyedi, Paul; Jaeschke, Roman
Infections due to the yeast Rhodotorula are rare in humans. R. mucilaginosa is responsible for the majority of human cases, and immunocompromised individuals with central venous catheters are at greatest risk. There are few reports of bloodstream infections due to R. mucilaginosa in immunocompetent patients. We present a case report of fungemia due to R. mucilaginosa in an immunocompetent, critically ill patient, with good evolution with catheter removal and fluconazole therapy. We briefly review the spectrum of infections due to R. mucilaginosa and the management of bloodstream infections due to this yeast. PMID:22131080
Villar, Jesús Monterrubio; Velasco, Carmen González; Delgado, Juan Diego Jiménez
Infections due to the yeast Rhodotorula are rare in humans. R. mucilaginosa is responsible for the majority of human cases, and immunocompromised individuals with central venous catheters are at greatest risk. There are few reports of bloodstream infections due to R. mucilaginosa in immunocompetent patients. We present a case report of fungemia due to R. mucilaginosa in an immunocompetent, critically ill patient, with good evolution with catheter removal and fluconazole therapy. We briefly review the spectrum of infections due to R. mucilaginosa and the management of bloodstream infections due to this yeast. PMID:24475695
Monterrubio Villar, Jesu?; González Velasco, Carmen; Jiménez Delgado, Juan Diego
Introduction Higher body mass index (BMI) is associated with lower mortality in mechanically ventilated critically ill patients. However, it is yet unclear which body component is responsible for this relationship. Methods This retrospective analysis in 240 mechanically ventilated critically ill patients included adult patients in whom a computed tomography (CT) scan of the abdomen was made on clinical indication between 1 day before and 4 days after admission to the intensive care unit. CT scans were analyzed at the L3 level for skeletal muscle area, expressed as square centimeters. Cutoff values were defined by receiver operating characteristic (ROC) curve analysis: 110 cm2 for females and 170 cm2 for males. Backward stepwise regression analysis was used to evaluate low-muscle area in relation to hospital mortality, with low-muscle area, sex, BMI, Acute Physiologic and Chronic Health Evaluation (APACHE) II score, and diagnosis category as independent variables. Results This study included 240 patients, 94 female and 146 male patients. Mean age was 57 years; mean BMI, 25.6 kg/m2. Muscle area for females was significantly lower than that for males (102?±?23 cm2 versus 158?±?33 cm2; P?0.001). Low-muscle area was observed in 63% of patients for both females and males. Mortality was 29%, significantly higher in females than in males (37% versus 23%; P?=?0.028). Low-muscle area was associated with higher mortality compared with normal-muscle area in females (47.5% versus 20%; P?=?0.008) and in males (32.3% versus 7.5%; P?0.001). Independent predictive factors for mortality were low-muscle area, sex, and APACHE II score, whereas BMI and admission diagnosis were not. Odds ratio for low-muscle area was 4.3 (95% confidence interval, 2.0 to 9.0, P?0.001). When applying sex-specific cutoffs to all patients, muscle mass appeared as primary predictor, not sex. Conclusions Low skeletal muscle area, as assessed by CT scan during the early stage of critical illness, is a risk factor for mortality in mechanically ventilated critically ill patients, independent of sex and APACHE II score. Further analysis suggests muscle mass as primary predictor, not sex. BMI is not an independent predictor of mortality when muscle area is accounted for.
The survival rates of 380 critically ill intensive care patients (> 10 days intensive care, > 3 days mechanical ventilatory support) after gastrointestinal surgery were examined over 1 year following hospital discharge in a retrospective analysis of the years 1984-1994. Of the patients 57% survived intensive care medicine, 54% were discharged from hospital and 44% were still alive 1 year after discharge. Little difference was found between subgroups of gastrointestinal pathology. Of the survivors 28% had psychological problems in the first 6-12 months, 7% showed functional disorders and 3% showed prolonged periods of pain due to intensive therapy. PMID:9101856
Zumtobel, V; Hentsch, S; Kollig, E
Background: The number of Methicillin-resistant Staphylococcus aureus (MRSA) pneumonia cases is increasing in many European countries. In this observational study in one medical and three surgical\\u000a ICUs multiple interventions for the treatment and eradication of nosocomial MRSA-pneumonia were used.\\u000a \\u000a \\u000a \\u000a Patients and Methods: Twenty-one critically ill patients (age: 59 14 years, 15 males\\/6 females, 18 ventilator-associated, 3 nosocomial, clinical\\u000a pulmonary infection score >
C. Wenisch; H. Laferl; M. Szell; K. H. Smolle; A. Grisold; G. Bertha; R. Krause
Feed intolerance in the setting of critical illness should be treated promptly given its adverse impact on morbidity and mortality. The technical difficulty of postpyloric feeding tube placement and the morbidities associated with parenteral nutrition prevent these approaches being considered as first-line nutrition. Prokinetic agents are currently the mainstay of therapy for feed intolerance in the critically ill. Current information is limited but suggests that erythromycin or metoclopramide (alone or in combination) are effective in the management of feed intolerance in the critically ill and not associated with significant cardiac, haemodynamic or neurological adverse effects. However, diarrhoea is a very common gastrointestinal side effect, and can occur in up to 49% of patients who receive both erythromycin and metoclopramide. Fortunately, the diarrhoea associated with prokinetic treatments has not been linked to Clostridium difficile infection and settles soon after the drugs are ceased. Therefore, prolonged or prophylactic use of prokinetics should be avoided. If diarrhoea occurs, the drugs should be stopped immediately. To minimize avoidable adverse effects the ongoing need for prokinetic drugs in these patient should be reviewed daily.
Yi Mei, Swee Lin Chen
Objectives Determine levels of agreement among intensive care unit patients and their family members, nurses, and physicians (proxies) regarding patients’ symptoms and compare levels of mean intensity (i.e., the magnitude of a symptom sensation) and distress (i.e., the degree of emotionality that a symptom engenders) of symptoms among patients and proxy reporters. Design Prospective study of proxy reporters of symptoms in seriously ill patients. Settings Two intensive care units in a tertiary medical center in the Western United States. Patients Two hundred and forty-five intensive care unit patients, 243 family members, 103 nurses, and 92 physicians. Interventions None. Measurements and Main Results On the basis of the magnitude of intraclass correlation coefficients, where coefficients from .35 to .78 are considered to be appropriately robust, correlation coefficients between patients’ and family members’ ratings met this criterion (?.35) for intensity in six of ten symptoms. No intensity ratings between patients and nurses had intraclass correlation coefficients >.32. Three symptoms had intensity correlation coefficients of ?.36 between patients’ and physicians’ ratings. Correlation coefficients between patients and family members were >.40 for five symptom-distress ratings. No symptoms had distress correlation coefficients of ?.28 between patients’ and nurses’ ratings. Two symptoms had symptom-distress correlation coefficients between patients’ and physicians’ ratings at >.39. Family members, nurses, and physicians reported higher symptom-intensity scores than patients did for 80%, 60%, and 60% of the symptoms, respectively. Family members, nurses, and physicians reported higher symptom-distress scores than patients did for 90%, 70%, and 80% of the symptoms, respectively. Conclusions Patient–family intraclass correlation coefficients were sufficiently close for us to consider using family members to help assess intensive care unit patients’ symptoms. Relatively low intraclass correlation coefficients between intensive care unit clinicians’ and patients’ symptom ratings indicate that some proxy raters overestimate whereas others underestimate patients’ symptoms. Proxy overestimation of patients’ symptom scores warrants further study because this may influence decisions about treating patients’ symptoms.
Puntillo, Kathleen A.; Neuhaus, John; Arai, Shoshana; Paul, Steven M.; Gropper, Michael A.; Cohen, Neal H.; Miaskowski, Christine
Objective: To determine whether antibiotic prophylaxis reduces respiratory tract infections and overall mortality in unselected critically ill adult patients. Design: Meta-analysis of randomised controlled trials from 1984 and 1996 that compared different forms of antibiotic prophylaxis used to reduce respiratory tract infections and mortality with aggregate data and, in a subset of trials, data from individual patients. Subjects: Unselected critically ill adult patients; 5727 patients for aggregate data meta-analysis, 4343 for confirmatory meta-analysis with data from individual patients. Main outcome measures: Respiratory tract infections and total mortality. Results: Two categories of eligible trials were defined: topical plus systemic antibiotics versus no treatment and topical preparation with or without a systemic antibiotic versus a systemic agent or placebo. Estimates from aggregate data meta-analysis of 16 trials (3361 patients) that tested combined treatment indicated a strong significant reduction in infection (odds ratio 0.35; 95% confidence interval 0.29 to 0.41) and total mortality (0.80; 0.69 to 0.93). With this treatment five and 23 patients would need to be treated to prevent one infection and one death, respectively. Similar analysis of 17 trials (2366 patients) that tested only topical antibiotics indicated a clear reduction in infection (0.56; 0.46 to 0.68) without a significant effect on total mortality (1.01; 0.84 to 1.22). Analysis of data from individual patients yielded similar results. No significant differences in treatment effect by major subgroups of patients emerged from the analyses. Conclusions: This meta-analysis of 15 years of clinical research suggests that antibiotic prophylaxis with a combination of topical and systemic drugs can reduce respiratory tract infections and overall mortality in critically ill patients. This effect is significant and worth while, and it should be considered when practice guidelines are defined. Key messages Over 40% of patients who need ventilation in intensive care develop respiratory tract infections and about 30% may die in the units If the most effective antibiotic prophylaxis (that is, a protocol combining topical and systemic antibiotics) is used the incidence of respiratory tract infections can be reduced by 65% and total mortality by 20% A regimen of topical antibiotics alone reduces respiratory tract infections but does not influence survival The concern that widespread antibiotic use may lead to resistance cannot be confirmed or ruled out by this review. Trials with different design are probably warranted to handle this question This important effect of antibiotic prophylaxis with a combination of topical and systemic antibiotics on survival should be considered by intensivists when treatment policies are designed
D'Amico, Roberto; Pifferi, Silvia; Leonetti, Cinzia; Torri, Valter; Tinazzi, Angelo; Liberati, Alessandro
Tolerance of elemental (for example, Peptamen [PEP]) or free amino acid (for example, Vivonex TEN [VIV]) tube feeding diets is controversial, especially in the critically ill patient who is hypoalbuminemic. A prospective, randomized trial was conducted to compare differences between feeding PEP (n = 8) or VIV (n = 8) in critically ill, elderly (average age of 66 years) patients. Diets were administered through nasogastric or postpyloric feeding tubes. Eleven patients had diseases of the gastrointestinal tract; all underwent surgical treatment. Patients were fed each diet at full strength, beginning with 20 to 30 milliliters per hour and advancing by 10 to 20 milliliters every day until goal rate was reached, usually on day 4. Assessment was made for ability to comply with rate of tube feeding ordered, compliance with caloric goal and tolerance (as evidenced by abdominal discomfort and diarrhea). Diarrhea was qualitatively defined as more than three stools per day and then quantitatively as the mean number of stools daily. There were no significant differences between the two groups in terms of compliance with prescribed tube feeding order or caloric goal or the presence of diarrhea and abdominal discomfort. There was a significant difference between the two groups in terms of the actual number of stools per day (PEP equals 1.38 versus VIV equals 2.25, p less than 0.02). Serum albumin concentrations upon initiation of the diets were 2.3 grams per deciliter in both groups. We conclude that tolerance to the two diets were similar because it was possible to feed enterally either PEP or VIV in critically ill, hypoalbuminemic patients (serum albumin concentrations of less than 2.5 grams per deciliter) successfully, irrespective of diet. Although there were more stools in the VIV group, this did not reduce compliance with the goals. PMID:1542832
Borlase, B C; Bell, S J; Lewis, E J; Swails, W; Bistrian, B R; Forse, R A; Blackburn, G L
Introduction Glutamine rate of appearance (Ra) may be used as an estimate of endogenous glutamine production. Recently a technique employing a bolus injection of isotopically labeled glutamine was introduced, with the potential to allow for multiple assessments of the glutamine Ra over time in critically ill patients, who may not be as metabolically stable as healthy individuals. Here the technique was used to evaluate the endogenous glutamine production in critically ill patients in the fed state with and without exogenous glutamine supplementation intravenously. Methods Mechanically ventilated patients (n?=?11) in the intensive care unit (ICU) were studied on two consecutive days during continuous parenteral feeding. To allow the patients to be used as their own controls, they were randomized for the reference measurement during basal feeding without supplementation, before or after the supplementation period. Glutamine Ra was determined by a bolus injection of 13C-glutamine followed by a period of frequent sampling to establish the decay-curve for the glutamine tracer. Exogenous glutamine supplementation was given by intravenous infusion of a glutamine containing dipeptide, L-alanyl-L-glutamine, 0.28 g/kg during 20 hours. Results A 14% increase of endogenous glutamine Ra was seen at the end of the intravenous supplementation period as compared to the basal measurements (P?=?0.009). Conclusions The bolus injection technique to measure glutamine Ra to estimate the endogenous production of glutamine in critically ill patients was demonstrated to be useful for repetitive measurements. The hypothesized attenuation of endogenous glutamine production during L-alanyl-L-glutamine infusion given as a part of full nutrition was not seen.
Objective: To evaluate the clinical efficacy of levosimendan versus dobutamine in critically ill patients requiring inotropic support. Methods: Clinical trials were searched in PubMed, EMBASE, and the Cochrane Central Registry of Clinical Trials, as well as Web of Science. Studies were included if they compared levosimendan with dobutamine in critically ill patients requiring inotropic support, and provided at least one outcome of interest. Outcomes of interest included mortality, incidence of hypotension, supraventricular arrhythmias, and ventricular arrhythmias. Results: Data from a total of 3 052 patients from 22 randomized controlled trials (RCTs) were included in the analysis. Overall analysis showed that the use of levosimendan was associated with a significant reduction in mortality (269 of 1 373 [19.6%] in the levosimendan group, versus 328 of 1 278 [25.7%] in the dobutamine group, risk ratio (RR)=0.81, 95% confidence interval (CI) 0.70–0.92, P for effect=0.002). Subgroup analysis indicated that the benefit from levosimendan could be found in the subpopulations of cardiac surgery, ischemic heart failure, and concomitant ?-blocker therapy in comparison with dobutamine. There was no significant difference in the incidence of hypotension, supraventricular arrhythmias, or ventricular arrhythmias between the two drugs. Conclusions: In contrast with dobutamine, levosimendan is associated with a significant improvement in mortality in critically ill patients requiring inotropic support. Patients having cardiac surgery, with ischemic heart failure, and receiving concomitant ?-blocker therapy may benefit from levosimendan. More RCTs are required to address the questions about no positive outcomes in the subpopulation in a cardiology setting, and to confirm the advantages in long-term prognosis.
Huang, Xuan; Lei, Shu; Zhu, Mei-fei; Jiang, Rong-lin; Huang, Li-quan; Xia, Guo-lian; Zhi, Yi-hui
Abstract The prognosis of critically ill patients with cirrhosis is poor. Our aim was to identify an objective variable that can improve the prognostic value of the Model of End-Stage Liver Disease (MELD) score in patients who have cirrhosis and are admitted to the intensive care unit (ICU). This retrospective cohort study included 177 patients who had liver cirrhosis and were admitted to the ICU. Data pertaining to arterial blood gas-related parameters and other variables were obtained on the day of ICU admission. The overall ICU mortality rate was 36.2%. The bicarbonate (HCO3) level was found to be an independent predictor of ICU mortality (odds ratio, 2.3; 95% confidence interval [CI], 1.0-4.8; p?=?0.038). A new equation was constructed (MELD-Bicarbonate) by replacing total bilirubin by HCO3 in the original MELD score. The area under the receiver operating characteristic curve for predicting ICU mortality was 0.76 (95% CI, 0.69-0.84) for the MELD-Bicarbonate equation, 0.73 (95% CI, 0.65-0.81) for the MELD score, and 0.71 (95% CI, 0.63-0.80) for the Acute Physiology and Chronic Health Evaluation II score. Bicarbonate level assessment, as an objective and reproducible laboratory test, has significant predictive value in critically ill patients with cirrhosis. In contrast, the predictive value of total bilirubin is not as prominent in this setting. The MELD-Bicarbonate equation, which included three variables (international normalized ratio, creatinine level, and HCO3 level), showed better prognostic value than the original MELD score in critically ill patients with cirrhosis. PMID:24601755
Chen, Cheng-Yi; Pan, Chi-Feng; Wu, Chih-Jen; Chen, Han-Hsiang; Chen, Yu-Wei
Patients with advanced illness often spend time in an ICU, while nearly one-third of patients with advanced cancer who receive Medicare die in hospitals, often with failed ICU care. For most, death occurs following the withdrawal or withholding of life-sustaining treatments. The integration of palliative care is essential for high-quality critical care. Although palliative care specialists are becoming increasingly available, intensivists and other physicians are also expected to provide basic palliative care, including symptom treatment and communication about goals of care. Patients who are critically ill are often unable to make decisions about their care. In these situations, physicians must meet with family members or other surrogates to determine appropriate medical treatments. These meetings require clinical expertise to ensure that patient values are explored for medical decision making about therapeutic options, including palliative care. Meetings with families take time. Issues related to the disease process, prognosis, and treatment plan are complex, and decisions about the use or limitation of intensive care therapies have life-or-death implications. Inadequate reimbursement for physician services may be a barrier to the optimal delivery of high-quality palliative care, including effective communication. Appropriate documentation of time spent integrating palliative and critical care for patients who are critically ill can be consistent with the Current Procedural Terminology codes (99291 and 99292) for critical care services. The purpose of this article is to help intensivists and other providers understand the circumstances in which integration of palliative and critical care meets the definition of critical care services for billing purposes.
Nelson, Judith E.; Weissman, David E.; Hays, Ross M.; Mosenthal, Anne C.; Mulkerin, Colleen; Puntillo, Kathleen A.; Ray, Daniel E.; Bassett, Rick; Boss, Renee D.; Brasel, Karen J.; Campbell, Margaret L.; Cortez, Therese B.; Curtis, J. Randall
Introduction Optimal feeding of critically ill patients in the ICU is controversial. Existing guidelines rest on rather weak evidence. Whole body protein kinetics may be an attractive technique for assessing optimal protein intake. In this study, critically ill patients were investigated during hypocaloric and normocaloric IV nutrition. Methods Neurosurgical patients on mechanical ventilation (n?=?16) were studied during a 48-hour period. In random order 50% and 100% of measured energy expenditure was given as IV nutrition during 24 hours, corresponding to hypocaloric and normocaloric nutrition, respectively. At the end of each period, whole body protein turnover was measured using d5-phenylalanine and 13C-leucine tracers. Results The phenylalanine tracer indicated that whole-body protein synthesis was lower during hypocaloric feeding, while whole-body protein degradation and amino acid oxidation were unaltered, which resulted in a more negative protein balance, namely ?1.9?±?2.1 versus ?0.7?±?1.3 mg phenylalanine/kg/h (P?=?0.014). The leucine tracer indicated that whole body protein synthesis and degradation and amino acid oxidation were unaltered, but the protein balance was negative during hypocaloric feeding, namely ?0.3?±?0.5 versus 0.6?±?0.5 mg leucine/kg/h (P?0.001). Conclusion In the patient group studied, hypocaloric feeding was associated with a more negative protein balance, but the amino acid oxidation was not different. The protein kinetics measurements and the study’s investigational protocol were useful for assessing the efficacy of nutrition support on protein metabolism in critically ill patients.
Objective An augmented renal clearance has been described in some groups of critically ill patients, and it might induce sub-optimal concentrations of drugs eliminated by glomerular filtration, mainly antibiotics. Studies on its occurrence and determinants are lacking. Our goals were to determine the incidence and associated factors of augmented renal clearance and the effects on vancomycin concentrations and dosing in a series of intensive care unit patients. Methods We prospectively studied 363 patients admitted during 1 year to a clinical-surgical intensive care unit. Patients with serum creatinine >1.3mg/dL were excluded. Creatinine clearance was calculated from a 24-hour urine collection. Patients were grouped according to the presence of augmented renal clearance (creatinine clearance >120mL/min/1.73m2), and possible risk factors were analyzed with bivariate and logistic regression analysis. In patients treated with vancomycin, dosage and plasma concentrations were registered. Results Augmented renal clearance was present in 103 patients (28%); they were younger (48±15 versus 65±17 years, p<0.0001), had more frequent obstetric (16 versus 7%, p=0.0006) and trauma admissions (10 versus 3%, p=0.016) and fewer comorbidities. The only independent determinants for the development of augmented renal clearance were age (OR 0.95; p<0.0001; 95%CI 0.93-0.96) and absence of diabetes (OR 0.34; p=0.03; 95%CI 0.12-0.92). Twelve of the 46 patients who received vancomycin had augmented renal clearance and despite higher doses, had lower concentrations. Conclusions In this cohort of critically ill patients, augmented renal clearance was a common finding. Age and absence of diabetes were the only independent determinants. Therefore, younger and previously healthy patients might require larger vancomycin dosing.
Campassi, Maria Luz; Gonzalez, Maria Cecilia; Masevicius, Fabio Daniel; Vazquez, Alejandro Risso; Moseinco, Miriam; Navarro, Noelia Cintia; Previgliano, Luciana; Rubatto, Nahuel Paolo; Benites, Martin Hernan; Estenssoro, Elisa; Dubin, Arnaldo
Objective: To describe the state of glycemic control in noncritically ill diabetic patients admitted to the Puerto Rico University Hospital and adherence to current standard of care guidelines for the treatment of diabetes.Methods: This was a retrospective study of patients admitted to a general medicine ward with diabetes mellitus as a secondary diagnosis. Clinical data for the first 5 days and the last 24 hours of hospitalization were analyzed.Results: A total of 147 noncritically ill diabetic patients were evaluated. The rates of hyperglycemia (blood glucose ?180 mg/dL) and hypoglycemia (blood glucose <70 mg/dL) were 56.7 and 2.8%, respectively. Nearly 60% of patients were hyperglycemic during the first 24 hours of hospitalization (mean random blood glucose, 226.5 mg/dL), and 54.2% were hyperglycemic during the last 24 hours of hospitalization (mean random blood glucose, 196.51 mg/dL). The mean random last glucose value before discharge was 189.6 mg/dL. Most patients were treated with subcutaneous insulin, with basal insulin alone (60%) used as the most common regimen. The proportion of patients classified as uncontrolled receiving basal-bolus therapy increased from 54.3% on day 1 to 60% on day 5, with 40% continuing to receive only basal insulin. Most of the uncontrolled patients had their insulin dose increased (70.1%); however, a substantial proportion had no change (23.7%) or even a decrease (6.2%) in their insulin dose.Conclusion: The management of hospitalized diabetic patients is suboptimal, probably due to clinical inertia, manifested by absence of appropriate modification of insulin regimen and intensification of dose in uncontrolled diabetic patients. A comprehensive educational diabetes management program, along with standardized insulin orders, should be implemented to improve the care of these patients. PMID:24325996
Allende-Vigo, Myriam Zaydee; González-Rosario, Rafael A; González, Loida; Sánchez, Viviana; Vega, Mónica A; Alvarado, Milliette; Ramón, Raul O
Background and objective The purpose of this study was to evaluate the once daily dosing (ODD) program in critically ill Egyptian patients compared to individualized multiple daily dosing (MDD) in terms of clinical and bacteriological efficacy. In addition, the incidence of nephrotoxicity associated with both regimens in this specific group of patients was assessed. Methods Fifty-two patients with suspected or confirmed bacterial infections admitted to the Critical Care Medicine Department, Kasr El-Aini-Cairo University Hospitals comprised the study population. The amikacin group (30 patients) was sub-divided into 14 patients receiving amikacin ODD (1 g i.v.) and 16 patients receiving amikacin in MDD (500 mg i.v./dose). The gentamicin group (22 patients) was sub-divided into 10 patients receiving the drug ODD (240 mg i.v.) and 12 patients receiving gentamicin MDD (80 mg i.v./dose). Amikacin or gentamicin serum levels were determined by the enzyme multiplied immunoassay technique using Emit 2000. MDD regimen was adjusted based on the individual pharmacokinetic parameters using the Sawchuk–Zaske method. Results There was no significant difference between the two dosing regimens with regard to clinical and antibacterial efficacy or incidence of nephrotoxicity of both gentamicin and amikacin groups. In the ODD regimen, duration of treatment had no effect on increasing incidence of nephrotoxicity unlike the individualized MDD regimen. No dose adjustments were needed in the once daily dosing regimen since trough concentrations have never been above toxic level. Conclusions The study showed that the ODD regimen is preferred in critically ill patients to individualized MDD as shown by comparable efficacy, nephrotoxicity and lesser need for therapeutic drug monitoring and frequent dose adjustments required in the individualized MDD regimen.
Abdel-Bari, A.; Mokhtar, M. Sherif; Sabry, Nagwa Ali; El-Shafi, Sanaa Abd; Bazan, Naglaa Samir
Objectives Religious participation is positively associated with mental health, but attendance at worship services declines during serious illness. This study assessed whether home visits by clergy or laity provide benefits to seriously ill patients who may have difficulty attending religious services. Design and sample A cross-sectional study design nested in an observational epidemiologic cohort study. The regionally-representative sample of patients had metastatic lung, colorectal, breast, and prostate cancer (n=70), Class III and IV congestive heart failure (n=70), or chronic obstructive pulmonary disease with hypercapnea (n=70) and observed regarding clergy-laity support in their naturalistic environments. Measures Dependent variable: 10-item Center for Epidemiologic Studies – Depression scale. Independent variable: A one-item question measuring how much helpful support patients received from clergy or other persons from church, temple, synagogue, or mosque Covariates: demographic, health, social support, religiousness. Analysis Descriptive, bivariate, and general linear models Results Depressed mood was negatively associated with clergy-laity support in a non-linear pattern. Depressed mood was also positively associated with functional deficits and a lifetime history of difficulties related to religious involvement. Conclusions In lieu of worship attendance when people are sick, home visits by members of a patient’s religious community may bolster mood by providing continuity of instrumental, emotional, and spiritual support.
Hays, Judith C.; Wood, Laura; Steinhauser, Karen; Olson, Maren K.; Lindquist, Jennifer H.; Tulsky, James
Objective The economic implications of sedative choice in the management of patients receiving mechanical ventilation are unclear because of differences in costs and clinical outcomes associated with specific sedatives. Therefore, we aimed to determine the cost-effectiveness of the most commonly used sedatives prescribed for mechanically ventilated critically ill patients. Design, Setting, and Patients Adopting the perspective of a hospital, we developed a probabilistic decision model to determine if continuous propofol or intermittent lorazepam was associated with greater value when combined with daily awakenings. We also evaluated the comparative value of continuous midazolam in secondary analyses. We assumed that patients were managed in a medical intensive care unit and expected to require ventilation for at least 48 hours. Model inputs were derived from primary analysis of randomized controlled trial data, medical literature, Medicare reimbursement rates, pharmacy databases, and institutional data. Main Results We measured cost-effectiveness as costs per mechanical ventilator-free day within the first 28 days after intubation. Our base-case probabilistic analysis demonstrated that propofol dominated lorazepam in 91% of simulations and, on average, was both $6,378 less costly per patient and associated with over three additional mechanical ventilator-free days. The model did not reveal clinically meaningful differences between propofol and midazolam on costs or measures of effectiveness. Conclusion Propofol has superior value compared to lorazepam when used for sedation among the critically ill who require mechanical ventilation when used in the setting of daily sedative interruption.
Cox, Christopher E.; Reed, Shelby D.; Govert, Joseph A.; Rodgers, Jo E.; Campbell-Bright, Stacy; Kress, John P.; Carson, Shannon S.
Assessed whether attitudes toward suicide vary as function of type of illness that precipitates suicide. College students (N=455) responded to scenarios of suicide victim. Evaluations of suicide were most favorable when it occurred in response to terminal physical illness; less favorable in response to chronic, non-terminal physical illness; and…
Deluty, Robert H.
Purpose We wanted to analyze the use of nutrition support for terminal cancer patients, the effect of discussing withdrawal of nutrition support and do-not-resuscitate (DNR) consent on the use of intravenous nutrition during the patient's last week of life and at the time of death. Materials and Methods The study involved 362 patients with terminal cancer from four teaching hospitals, and they all died between January 1 2003 and December 31 2005. The basic demographic data, the use of intravenous nutrition during the patient's last week of life and at death, discussion of terminal nutrition withdrawal and DNR consent were evaluated. Results In the week before death, the patients received artificial nutrition such as total parenteral nutrition (31%), intravenous albumin infusion (25%), and feeding tube placements (9%). A discussion concerning withdrawal of nutrition support was limited to 25 (7%) patients. DNR consent was obtained from 294 (81%) patients. None of the patients were directly involved in any of these decisions. The discussion about withdrawal of terminal nutrition and DNR consent with the patient's surrogates did not have any effect on reducing the use of parenteral nutrition. Conclusion The majority of patients dying of terminal cancer were still given potentially futile nutritional support. Modern clinical guidelines and ethical education about nutritional support at the end of life care is urgently needed in Korean medical practice to provide proper administration of terminal nutrition for end of life care.
Kim, Do Yeun; Lee, Sang Min; Lee, Kyoung Eun; Lee, Hye Ran; Kim, Jee Hyun; Lee, Keun-Wook; Lee, Jong Seok
Background Continuous EEG monitoring (cEEG) of critically ill patients is frequently utilized to detect non-convulsive seizures (NCS)\\u000a and status epilepticus (NCSE). The indications for cEEG, as well as when and how to treat NCS, remain unclear. We aimed to\\u000a describe the current practice of cEEG in critically ill patients to define areas of uncertainty that could aid in designing\\u000a future research.
Nicholas S. Abend; Dennis J. Dlugos; Cecil D. Hahn; Lawrence J. Hirsch; Susan T. Herman
Intensive insulin therapy (IIT) for hyperglycemia in critically ill patients has become a standard practice. Target levels for glycemia have fluctuated since 2000, as evidence initially indicated that tight glycemic control to so-called normoglycemia (80–110 mg/dl) leads to the lowest morbidity and mortality without hypoglycemic complications. Subsequent studies have demonstrated minimal clinical benefit combined with greater hypoglycemic morbidity and mortality with tight glycemic control in this population. The consensus glycemic targets were then liberalized to the mid 100s (mg/dl). Handheld POC blood glucose (BG) monitors have migrated from the outpatient setting to the hospital environment because they save time and money for managing critically ill patients who require IIT. These devices are less accurate than hospital-grade POC blood analyzers or central laboratory analyzers. Three questions must be answered to understand the role of IIT for defined populations of critically ill patients: (1) How safe is IIT, with various glycemic targets, from the risk of hypoglycemia? (2) How tightly must BG be controlled for this approach to be effective? (3) What role does the accuracy of BG measurements play in affecting the safety of this method? For each state of impaired glucose regulation seen in the hospital, such as hyperglycemia, hypoglycemia, or glucose variability, the benefits, risks, and goals of treatment, including IIT, might differ. With improved accuracy of BG monitors, IIT might be rendered even more intensive than at present, because patients will be less likely to receive inadvertent overdosages of insulin. Greater doses of insulin, but with dosing based on more accurate glucose levels, might result in less hypoglycemia, less hyperglycemia, and less glycemic variability.
Klonoff, David C
ABSTRACT: INTRODUCTION: Candidemia in critically ill patients is usually a severe and life-threatening condition with a high crude mortality. Very few studies have focused on the impact of candidemia on ICU patient outcome and attributable mortality still remains controversial. This study was carried out to determine the attributable mortality of ICU-acquired candidemia in critically ill patients using propensity score matching analysis. METHODS: A prospective observational study was conducted of all consecutive non-neutropenic adult patients admitted for at least seven days to 36 ICUs in Spain, France, and Argentina between April 2006 and June 2007. The probability of developing candidemia was estimated using a multivariate logistic regression model. Each patient with ICU-acquired candidemia was matched with two control patients with the nearest available Mahalanobis metric matching within the calipers defined by the propensity score. Standardized differences tests (SDT) for each variable before and after matching were calculated. Attributable mortality was determined by a modified Poisson regression model adjusted by those variables that still presented certain misalignments defined as a SDT > 10%. RESULTS: Thirty-eight candidemias were diagnosed in 1,107 patients (34.3 episodes/1,000 ICU patients). Patients with and without candidemia had an ICU crude mortality of 52.6% versus 20.6% (P < 0.001) and a crude hospital mortality of 55.3% versus 29.6% (P = 0.01), respectively. In the propensity matched analysis, the corresponding figures were 51.4% versus 37.1% (P = 0.222) and 54.3% versus 50% (P = 0.680). After controlling residual confusion by the Poisson regression model, the relative risk (RR) of ICU- and hospital-attributable mortality from candidemia was RR 1.298 (95% confidence interval (CI) 0.88 to 1.98) and RR 1.096 (95% CI 0.68 to 1.69), respectively. CONCLUSIONS: ICU-acquired candidemia in critically ill patients is not associated with an increase in either ICU or hospital mortality. PMID:22698004
González de Molina, Francisco J; León, Cristóbal; Ruiz-Santana, Sergio; Saavedra, Pedro
Music is an ideal intervention to reduce anxiety and promote relaxation in critically ill patients. This article reviews the research studies on music-listening interventions to manage distressful symptoms in this population, and describes the development and implementation of the Music Assessment Tool (MAT) to assist professionals in ascertaining patients’ music preferences in the challenging, dynamic clinical environment of the intensive care unit (ICU). The MAT is easy to use with these patients who experience profound communication challenges due to fatigue and inability to speak because of endotracheal tube placement. The music therapist and ICU nursing staff are encouraged to work collaboratively to implement music in a personalized manner to ensure the greatest benefit for mechanically ventilated patients.
CHLAN, LINDA; HEIDERSCHEIT, ANNIE
This paper examines the role of selective serotonin reuptake inhibitors (SSRIs) in the treatment of hepatitis-C virus (HCV) patients who have developed interferon-? induced depression. A 2-year data analysis of HCV psychiatric liaison clinic has been undertaken. The diagnosis, treatment, and progress of those patients who were treated with interferon-? (INF-?) are reported. 53 of the 78 patients enrolled at the HCV Clinic and treated with INF-? were referred for psychiatric consultation. Six patients developed major depressive illness following INF therapy. They were all treated with SSRIs and they made full recovery. This is a significant observation and is concordant with other studies. Its biochemical ramifications are presented. It is concluded that INF-induced depression is fully reversible. A hypothesis is proposed that SSRIs modulate the neuro-protective neurotoxic ratio by possibly inhibiting the indole-2,3-dioxygenase induction of the kynurenine pathway.
Gupta, Ramesh K; Kumar, Rajeev; Bassett, Mark
This study compared the accuracy of an actuarial procedure for the prediction of community violence by patients with mental illness with the accuracy of clinicians' ratings of concern about patients' violence. Data came from a study in which patients were followed in the community for 6 months after having been seen in a psychiatric emergency room. Accuracy of actuarial prediction was estimated retrospectively, with a statistical correction for capitalization on chance. Actuarial prediction had lower rates of false-positive and false-negative errors than clinical prediction. The seriousness of the violence correctly identified by the actuarial predictor (the true positives) was similar to the seriousness identified by clinicians. Actuarial predictions based only on patients' histories of violence were more accurate than clinical predictions, as were actuarial predictions that did not use information about histories. PMID:8698955
Gardner, W; Lidz, C W; Mulvey, E P; Shaw, E C
Infectious diseases and impaired renal function often occur in critically ill patients, and delaying the start of appropriate empiric antimicrobial therapy or starting inappropriate therapy has been associated with poor outcomes. Our primary objective was to critically review and discuss the influence of chronic kidney disease (CKD) and acute kidney injury (AKI) on the clinical pharmacokinetic and pharmacodynamic properties of antimicrobial agents. The effect of continuous renal replacement therapies (CRRTs) and intermittent hemodialysis (IHD) on drug disposition in these two populations was also evaluated. Finally, proposed dosing strategies for selected antimicrobials in critically ill adult patients as well as those receiving CRRT or IHD have been compiled. We conducted a PubMed search (January 1980-March 2008) to identify all English-language literature published in which dosing recommendations were proposed for antimicrobials commonly used in critically ill patients, including those receiving CRRT or IHD. All pertinent reviews, selected studies, and associated references were evaluated to ensure their relevance. Forty antimicrobial, antifungal, and antiviral agents commonly used in critically ill patients were included for review. Dosage recommendations were synthesized from the 42 reviewed articles and peer-reviewed, evidence-based clinical drug databases to generate initial guidance for the determination of antimicrobial dosing strategies for critically ill adults. Because of the evolving process of critical illness, whether in patients with AKI or in those with CKD, prospective adaptation of these initial dosing recommendations to meet the needs of each individual patient will often rely on prospectively collected clinical and laboratory data. PMID:19397464
Heintz, Brett H; Matzke, Gary R; Dager, William E
Objective To identify scales that can establish a quantitative assessment of delirium symptoms in critically ill patients through a systematic review. Methods Studies that evaluated delirium stratification scales in patients hospitalized in intensive care units were selected in a search performed in the MedLine database. Validation studies of these scales and their target patient populations were analyzed, and we identified the examiner and the signs and symptoms evaluated. In addition, the duration of the application and the sensitivity and specificity of each scale were assessed. Results Six scales were identified: the Delirium Detection Score, the Cognitive Test of Delirium, the Memorial Delirium Assessment Scale, the Intensive Care Delirium Screening Checklist, The Neelon and Champagne Confusion Scale and the Delirium Rating Scale-Revised-98. Conclusion The scales identified allow the stratification and monitoring of critically ill patients with delirium. Among the six scales, the most studied and best suited for use in the intensive care units was the Intensive Care Delirium Screening Checklist.
Carvalho, Joao Pedro Lins Mendes; de Almeida, Antonio Raimundo Pinto; Gusmao-Flores, Dimitri
Objective Several factors including disease condition and different procedures could alter pharmacokinetic profile of drugs in critically ill patients. For optimizing patient's outcome, changing in dosing regimen is necessary. Extracorporeal Membrane Oxygenation (ECMO) is one of the procedures which could change pharmacokinetic parameters.The aim of this review was to evaluate the effect of ECMO support on pharmacokinetic parameters and subsequently pharmacotherapy. Method A systematic review was conducted by reviewing all papers found by searching following key words; extracorporeal membrane oxygenation, ECMO, pharmacokinetic and pharmacotherapy in bibliography database. Results Different drug classes have been studied; mostly antibiotics. Almost all of the studies have been performed in neonates (as a case series). ECMO support is associated with altered pharmacokinetic parameters that may result in acute changes in plasma concentrations with potentially unpredictable pharmacological effect. Altreation in volume of distribution, protein binding, renal or hepatic clearance and sequestration of drugs by ECMO circuit may result in higher or lower doses requirement during ECMO. As yet, definite dosing guideline is not available. ECMO is extensively used recently for therapy and as a procedure affects pharmacokinetics profile along with other factors in critically ill patients. For optimizing the pharmacodynamic response and outcome of patients, drug regimen should be individualized through therapeutic drug monitoring whenever possible.
Mousavi, S.; Levcovich, B; Mojtahedzadeh, M.
This study identified the needs of terminal cancer patients, investigated the factors associated with unmet needs, and assessed psychological and symptom distress associated with unsolved needs. Ninety-four patients were randomly selected from 324 patients admitted for palliative care in 13 Italian centers. Two self-administered questionnaires (the Symptom Distress Scale and the Psychological Distress Inventory) were administered to all the patients.
Gabriella Morasso; Marco Capelli; Paola Viterbori; Silvia Di Leo; Alessandra Alberisio; Massimo Costantini; Margherita Fiore; Denis Saccani; Gabriele Zeitler; Nilla Verzolatto; Walter Tirelli; Laura Lazzari; Manuela Partinico; Gianpiero Borzoni; Catia Savian; Enrico Obertino; Paola Zotti; Gian Paolo Ivaldi; Franco Henriquet
Background Uganda embraced the World Health Organization guidelines that recommend a universal 'test and treat' strategy for malaria, mainly by use of rapid diagnostic test (RDT) and microscopy. However, little is known how increased parasitological diagnosis for malaria influences antibiotic treatment among patients with febrile illness. Methods Data collection was carried out within a feasibility trial of presumptive diagnosis of malaria (control) and two diagnostic interventions (microscopy or RDT) in a district of low transmission intensity. Five primary level health centres (HCs) were randomized to each diagnostic arm (diagnostic method in a defined group of patients). All 52,116 outpatients (presumptive 16,971; microscopy 17,508; and RDT 17,638) aged 5 months to ninety five years presenting with fever (by statement or measured) were included. Information from outpatients and laboratory registers was extracted weekly from March 2010 to July 2011. The proportion of patients who were prescribed antibiotics was calculated among those not tested for malaria, those who tested positive and in those who tested negative. Results Seven thousand and forty (41.5%) patients in the presumptive arm were prescribed antibiotics. Of the patients not tested for malaria, 1,537 (23.9%) in microscopy arm and 810 (56.2%) in RDT arm were prescribed antibiotics. Among patients who tested positive for malaria, 845 (25.8%) were prescribed antibiotics in the RDT and 273(17.6%) in the microscopy arm. Among patients who tested negative for malaria, 7809 (61.4%) were prescribed antibiotics in the RDT and 3749 (39.3%) in the microscopy arm. Overall the prescription of antibiotics was more common for children less than five years of age 5,388 (63%) compared to those five years and above 16798 (38.6%). Conclusion Prescription of antibiotics in patients with febrile illness is high. Testing positive for malaria reduces antibiotic treatment but testing negative for malaria increases use of antibiotics. Trial Registration ClinicalTrials.gov: NCT00565071
Summary Background and objectives The fixed antibacterial combination of ampicillin and sulbactam is frequently used for various infections. Intact kidneys eliminate approximately 71% of ampicillin and 78% of sulbactam. Patients on thrice-weekly low-flux hemodialysis exhibit an ampicillin t1/2 of 2.3 hours on and 17.4 hours off dialysis. Despite its frequent use in intensive care units, there are no available dosing recommendations for patients with AKI undergoing renal replacement therapy. The aims of this study were to evaluate the pharmacokinetics of ampicillin/sulbactam in critically ill patients with AKI undergoing extended dialysis (ED) and to establish a dosing recommendation for this treatment method. Design, setting, participants, & measurements Twelve critically ill patients with anuric AKI being treated with ED were enrolled in a prospective, open-label, observational pharmacokinetic study. Pharmacokinetics after a single dose of ampicillin/sulbactam (2 g/1 g) was obtained in 12 patients. Multiple-dose pharmacokinetics after 4 days of twice-daily ampicillin/sulbactam (2 g/1 g) was obtained in three patients. Results The mean dialyzer clearance for ampicillin/sulbactam was 80.1±7.7/83.3±12.1 ml/min. The t1/2 of ampicillin and sulbactam in patients with AKI undergoing ED were 2.8±0.8 hours and 3.5±1.5 hours, respectively. There was no significant accumulation using a twice-daily dosage of 2 g/1 g ampicillin/sulbactam. Conclusions Our data suggest that in patients treated with ED using a high-flux dialyzer (polysulphone, 1.3 m2; blood and dialysate flow, 160 ml/min; treatment time, 480 minutes), a twice-daily dosing schedule of at least 2 g/1 g ampicillin/sulbactam, with one dose given after ED, should be used to avoid underdosing.
Lorenzen, Johan M.; Broll, Michael; Kaever, Volkhard; Burhenne, Heike; Hafer, Carsten; Clajus, Christian; Knitsch, Wolfgang; Burkhardt, Olaf
Aspergillus tracheobronchitis (ATB) is considered as an unusual form of invasive aspergillosis and has a fatal outcome. There is little current information on several aspects of chronic obstructive pulmonary diseases (COPD) complicated by ATB, the frequency of which is expected to increase in the coming years. In a prospective study of invasive bronchial-pulmonary aspergillosis (IBPA) in a critically ill COPD population, three proven cases of ATB were identified. The three new cases, combined with eight previously reported cases of COPD with ATB over a 30-year period (1983-2013), were analysed. Among 153 critically ill COPD patients admitted to the ICU, eight cases were complicated by ATB [23.5% of IBPA (8 of 34); and 5.2% of COPD (8 of 153)], and three cases were finally diagnosed as proven ATB by histopathological findings. Among the three new cases reported and the eight published cases, the overall mortality rate was 72.7% (8 of 11 cases), with a median of 11.5 days (range, 7-27 days) between admission to death. The mortality rate was significantly higher in patients with invasive pulmonary aspergillosis (IPA) [100% (8 of 8 patients)] than in patients without parenchyma invasion [0% (0 of 3 patient), P = 0.006]. Seven patients (77.8%) received systemic corticosteroid therapy and three patients (33.3%) inhaled corticosteroids before diagnosis with ATB. Dyspnoea resistant to corticosteroids (77.8%) was the most frequent symptom. The radiological manifestations progressed rapidly in three patients (75%) who had normal chest X-rays (CXRs) at admission. Pseudomembranous lesions were the most frequent form (54.5%) observed by bronchoscopy. Aspergillus fumigatus was the most frequently isolated pathogen (40%). ATB is an uncommon cause of exacerbation in approximately 5% of critically ill COPD patients admitted to the ICU, and may progress rapidly to IPA with a high mortality rate. Dyspnoea resistant to corticosteroids and appropriate antibiotics with a negative CXR should raise the suspicion of ATB. Early diagnosis of ATB is based on bronchoscopic examination and proven diagnosis maybe safely established with a bronchial mucous biopsy. PMID:24673772
He, Hangyong; Jiang, Shan; Zhang, Li; Sun, Bing; Li, Fang; Zhan, Qingyuan; Wang, Chen
We describe the illness perceptions of patients with low back pain, how they change over 6 months, and their associations with clinical outcome. Consecutive patients consulting eight general practices were eligible to take part in a prospective cohort study, providing data within 3 weeks of consultation and 6 months later. Illness perceptions were measured using the Revised Illness Perception Questionnaire
Nadine E. Foster; Annette Bishop; Elaine Thomas; Chris Main; Rob Horne; John Weinman; Elaine Hay
Electronic patient record (EPR) and picture archiving and communication systems (PACS) can be connected to wireless terminals which deliver information to the point of care. We present our experiences with mobile teleradiology using special type mobile phones: smartphones and personal digital assistants (PDA) with phone functions. According to the results, these terminals are feasible for emergency situations and mainly for
J. Reponen; J. Niinimäki; T. Kumpulainen; E. Ilkko; A. Karttunen; P. Jartti
Purpose This study aimed to investigate 2 dimensions of meaning in life—Presence of Meaning (i.e., the perception of your life as significant, purposeful, and valuable) and Search for Meaning (i.e., the strength, intensity, and activity of people's efforts to establish or increase their understanding of the meaning in their lives)—and their role for the well-being of chronically ill patients. Research design A sample of 481 chronically ill patients (M = 50 years, SD = 7.26) completed measures on meaning in life, life satisfaction, optimism, and acceptance. We hypothesized that Presence of Meaning and Search for Meaning will have specific relations with all 3 aspects of well-being. Results Cluster analysis was used to examine meaning in life profiles. Results supported 4 distinguishable profiles (High Presence High Search, Low Presence High Search, High Presence Low Search, and Low Presence Low Search) with specific patterns in relation to well-being and acceptance. Specifically, the 2 profiles in which meaning is present showed higher levels of well-being and acceptance, whereas the profiles in which meaning is absent are characterized by lower levels. Furthermore, the results provided some clarification on the nature of the Search for Meaning process by distinguishing between adaptive (the High Presence High Search cluster) and maladaptive (the Low Presence High Search cluster) searching for meaning in life. Conclusions The present study provides an initial glimpse in how meaning in life may be related to the well-being of chronically ill patients and the acceptance of their condition. Clinical implications are discussed.
Dezutter, Jessie; Casalin, Sara; Wachholtz, Amy; Luyckx, Koen; Hekking, Jessica; Vandewiele, Wim
Objectives: Obesity may alter the pharmacokinetics of ?-lactams. The goal of this study was to evaluate if and why serum concentrations are inadequate when standard ?-lactam regimens are administered to obese, non-critically ill patients. Subjects and methods: During first year, we consecutively included infected, obese patients (body mass index (BMI) ?30?kg?m?2) who received meropenem (MEM), piperacillin-tazobactam (TZP) or cefepime/ceftazidime (CEF). Patients with severe sepsis or septic shock, or those hospitalized in the intensive care unit were excluded. Serum drug concentrations were measured twice during the elimination phase by high-performance liquid chromatography. We evaluated whether free or total drug concentrations were >1 time (fT>minimal inhibition concentration (MIC)) or >4 times (T>4MIC) the clinical breakpoints for Pseudomonas aeruginosa during optimal periods of time: ?40% for MEM, ?50% for TZP and ?70% for CEF. Results: We included 56 patients (median BMI: 36?kg?m?2): 14 received MEM, 31 TZP and 11 CEF. The percentage of patients who attained target fT>MIC and T>4MIC were 93% and 21% for MEM, 68% and 19% for TZP, and 73% and 18% for CEF, respectively. High creatinine clearance (107 (range: 6–398) ml?min?1) was the only risk factor in univariate and multivariate analyses to predict insufficient serum concentrations. Conclusions: In obese, non-critically ill patients, standard drug regimens of TZP and CEF resulted in insufficient drug concentrations to treat infections due to less susceptible bacteria. Augmented renal clearance was responsible for these low serum concentrations. New dosage regimens need to be explored in this patient population (EUDRA-CT: 2011-004239-29).
Hites, M; Taccone, F S; Wolff, F; Maillart, E; Beumier, M; Surin, R; Cotton, F; Jacobs, F
Objectives:Obesity may alter the pharmacokinetics of ?-lactams. The goal of this study was to evaluate if and why serum concentrations are inadequate when standard ?-lactam regimens are administered to obese, non-critically ill patients.Subjects and methods:During first year, we consecutively included infected, obese patients (body mass index (BMI) ?30?kg?m(-2)) who received meropenem (MEM), piperacillin-tazobactam (TZP) or cefepime/ceftazidime (CEF). Patients with severe sepsis or septic shock, or those hospitalized in the intensive care unit were excluded. Serum drug concentrations were measured twice during the elimination phase by high-performance liquid chromatography. We evaluated whether free or total drug concentrations were >1 time (fT>minimal inhibition concentration (MIC)) or >4 times (T>4MIC) the clinical breakpoints for Pseudomonas aeruginosa during optimal periods of time: ?40% for MEM, ?50% for TZP and ?70% for CEF.Results:We included 56 patients (median BMI: 36?kg?m(-2)): 14 received MEM, 31 TZP and 11 CEF. The percentage of patients who attained target fT>MIC and T>4MIC were 93% and 21% for MEM, 68% and 19% for TZP, and 73% and 18% for CEF, respectively. High creatinine clearance (107 (range: 6-398) ml?min(-1)) was the only risk factor in univariate and multivariate analyses to predict insufficient serum concentrations.Conclusions:In obese, non-critically ill patients, standard drug regimens of TZP and CEF resulted in insufficient drug concentrations to treat infections due to less susceptible bacteria. Augmented renal clearance was responsible for these low serum concentrations. New dosage regimens need to be explored in this patient population (EUDRA-CT: 2011-004239-29). PMID:24956136
Hites, M; Taccone, F S; Wolff, F; Maillart, E; Beumier, M; Surin, R; Cotton, F; Jacobs, F
Acute kidney injury (AKI) is common in critically ill patients. Diuretics are used without any evidence demonstrating a beneficial effect on renal function. The objective of the present study is to determine the incidence of AKI in an intensive care unit (ICU) and if there is an association between the use of furosemide and the development of AKI. The study involved a hospital cohort in which 344 patients were consecutively enrolled from January 2010 to January 2011. A total of 132 patients (75 females and 57 males, average age 64 years) remained for analysis. Most exclusions were related to ICU discharge in the first 24?h. Laboratory, sociodemographic and clinical data were collected until the development of AKI, medical discharge or patient death. The incidence of AKI was 55% (95%CI = 46-64). The predictors of AKI found by univariate analysis were septic shock: OR = 3.12, 95%CI = 1.36-7.14; use of furosemide: OR = 3.27, 95%CI = 1.57-6.80, and age: OR = 1.02, 95%CI = 1.00-1.04. Analysis of the subgroup of patients with septic shock showed that the odds ratio of furosemide was 5.5 (95%CI = 1.16-26.02) for development of AKI. Age, use of furosemide, and septic shock were predictors of AKI in critically ill patients. Use of furosemide in the subgroup of patients with sepsis/septic shock increased (68.4%) the chance of development of AKI when compared to the sample as a whole (43.9%)
Levi, T.M.; Rocha, M.S.; Almeida, D.N.; Martins, R.T.C.; Silva, M.G.C.; Santana, N.C.P.; Sanjuan, I.T.; Cruz, C.M.S.
The number of people suffering with dementia is increasing in the general population and the trend is projected to continue as people live longer, especially in countries with developed economies. The most common cause of dementia (among the many other causes) is Alzheimer's dementia, which is considered a terminal illness. The disease could eventually lead to death, or death could occur as a consequence of co-morbid physical complications. The problem of end of life (EOL) care for patients suffering from dementia though spoken of and written about, does not get the attention and system support as for example patients suffering from cancer receive. Many reasons have been advanced for the current state of affairs where EOL issues for patients suffering from dementia are concerned. This article attempts to revisit the issues, and the reasons, that may contribute to this. Some guidelines on palliative management in cases of patients suffering from severe dementia exist; the evidence base for these guidelines though is relatively weak. The ethical and legal issues that may influence or impact on the decision to initiate the palliative care pathway in the management of EOL issues for dementia patients in the terminal or end stage of the illness is highlighted. Initiatives by the department of health in England and Wales, and other bodies with interest in dementia issues and palliative care in the United Kingdom to ensure good and acceptable EOL pathways for patients with dementia are mentioned. PMID:21665854
Coleman, Albert M E
Objectives. This study investigates the suitability, safety, and efficacy of vernakalant in critically ill patients with new onset atrial fibrillation (AF) after cardiac surgery. Methods. Patients were screened for inclusion and exclusion criteria according to the manufacturers' recommendations. Included patients were treated with 3?mg/kg of vernakalant over 10?min and, if unsuccessful, a second dose of 2?mg/kg. Blood pressure was measured continuously for 2 hours after treatment. Results. Of the 191 patients screened, 159 (83%) were excluded, most importantly due to hemodynamic instability (59%). Vernakalant was administered to 32 (17% of the screened) patients. Within 6 hours, 17 (53%) patients converted to sinus rhythm. Blood pressure did not decrease significantly 10, 30, 60, and 120 minutes after the vernakalant infusion. However, 11 patients (34%) experienced a transient decrease in mean arterial blood pressure <60?mmHg. Other adverse events included nausea (n = 1) and bradycardia (n = 2). Conclusions. Applying the strict inclusion and exclusion criteria provided by the manufacturer, only a minority of postoperative ICU patients with new onset AF qualified for vernakalant. Half of the treated patients converted to sinus rhythm. The drug was well tolerated, but close heart rate and blood pressure monitoring remains recommended.
Breitenstein, Alexander; Salzberg, Sacha P.; Bettex, Dominique
Congestive heart failure and left ventricular dysfunction in the setting of severe aortic stenosis are associated with a high mortality rate. Evidence on optimal medical therapy is scanty. Vasodilators were traditionally considered to be contraindicated in severe aortic stenosis, albeit this concept has recently been challenged. The use of levosimendan, which has positive inotropic, vasodilatory and cardioprotective properties seems attractive. We describe a small series of exceedingly ill patients with severe aortic stenosis and left ventricular dysfunction, in different clinical settings (acute heart failure, cardiogenic shock and difficult-to-wean ventilatory support), in which levosimendan was successfully used.
Mota, Paula; Barra, Sergio; Almeida, Ines; Botelho, Ana; Trigo, Joana; Marques, Antonio L