Kolva, Elissa; Rosenfeld, Barry; Pessin, Hayley; Breitbart, William; Brescia, Robert
Context Anxiety in terminal cancer is linked to diminished quality of life, yet overall it is poorly understood with regard to prevalence and relationship to other aspects of psychological distress. Objectives This study examines anxiety in terminally ill cancer patients, including the prevalence of anxiety symptoms, the relationship between anxiety and depression, differences in anxiety between participants receiving inpatient palliative care and those receiving outpatient care, and characteristics that distinguish highly anxious from less anxious patients. Methods Participants were 194 patients with terminal cancer. Approximately half (n = 103) were receiving inpatient care in a palliative care facility and half (n = 91) were receiving outpatient care in a tertiary care cancer center. The Hospital Anxiety and Depression Scale was used to assess anxiety and depression, and was administered along with measures of hopelessness, desire for hastened death, and social support. Results Moderately elevated anxiety symptoms were found in 18.6% of participants (n = 36) and 12.4% (n = 24) had clinically significant anxiety symptoms. Level of anxiety did not differ between the two treatment settings. However, participants receiving palliative care reported significantly higher levels of depression and desire for hastened death. A multivariate prediction model indicated that belief in an afterlife, social support, and anxiolytic and antidepressant use were unique, significant predictors of anxiety. Conclusion Severity of anxiety symptoms did not differ between the study sites, suggesting that anxiety may differ from depression and desire for hastened death in the course that it takes over the duration of terminal cancer. PMID:21565460
Osuna, E; Pérez-Cárceles, M D; Esteban, M A; Luna, A
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. PMID:9602997
Fraenkel, William A.
One clinical psychologist who worked with terminally ill, end-stage Acquired Immune Deficiency Syndrome (AIDS) patients in a hospice type setting experienced more than 150 deaths over an 18-month time period. Many of the patients denied that they had AIDS; some distinguished between having AIDS and testing positive for Human Immunodeficiency Virus…
Jarrett, William H.
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,…
Music's power to improve the 'human condition' has been acknowledged since ancient times. Something as counter-intuitive as weeping in response to music can ameliorate suffering for a time even for terminally ill patients. Several benefits-including catharsis, communication, and experiencing vitality-can be associated with grieving in response to "sad" music. In addressing the potential rewards of such an activity for terminally ill patients, this author combines concepts from philosopher Jerrold R. Levinson's article, entitled "Music and Negative Emotion," an illustration from a major motion picture, and supporting research from medical reports and aesthetic writings. Carefully offering this experience is recommended for patients who retain the capacity to express preference.
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 for use with terminally ill cancer patients. The 1st stage of measure development involved interviews with 13 palliative care experts and 30 terminally ill patients. Qualitative analysis of the patient interviews culminated in the development of a set of potential questionnaire items. In the 2nd study phase, we evaluated these preliminary items with a sample of 314 participants, using item response theory and classical test theory to identify optimal items and response format. These analyses generated an 8-item measure that we tested in a final study phase, using a 3rd sample (n = 228) to assess reliability and concurrent validity. These analyses demonstrated strong support for the Hopelessness Assessment in Illness Questionnaire providing greater explanatory power than existing measures of hopelessness and found little evidence that this assessment was confounded by illness-related variables (e.g., prognosis). In summary, these 3 studies suggest that this brief measure of hopelessness is particularly useful for palliative care settings. Further research is needed to assess the applicability of the measure to other populations and contexts. PMID:21443366
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…
Kelly, B; Burnett, P; Pelusi, D; Badger, S; Varghese, F; Robertson, M
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.
Granda-Cameron, Clara; Houldin, Arlene
The purpose of this concept analysis of good death was to examine the attributes of a good death and explore the changes of the concept over time and its impact on terminally ill patients. The method used for this analysis was the Rodgers' evolutionary method. A literature search was completed using Medline Ovid and Journal Storage (JSTOR).The findings describe the evolution of the good death concept over time from the prehistoric era followed by premodern, modern, and postmodern times. In addition, information is presented about surrogate terms, attributes, antecedents, and consequences associated with good death followed by analysis and discussion of the findings. General attributes of a good death include pain and symptom management, awareness of death, patient's dignity, family presence, family support, and communication among patient, family, and health care providers.
Ghio, P; Dell'Orco, L
The aim of this work is to be able to publish the information concerning communication with cancer patients as recommended in England. The observation and the study protocol during the stay abroad have been given the opportunity to stylize specific information on the methodology of communication of important information to terminally ill patients. It seems readily apparent as they characterized by both technical precision and sensivity to emotions and descriptions for the individual patient. How is shared by all chronic pain is predominantly complex emotion, a mix of additions and perceived physical and emotional pain - emotional. Because accurate information is beneficial to the patient and that really is not turned, so to speak, a "bullet" it is necessary that you have created, over time, a concrete "therapeutic alliance" between body physician, patient and possibly family. This arises, for sure, even at first accepted the patient during the clinical visit attentive to detail, is renewed in the definition of the common objective to be achieved, so analgesia and it is expressed in the certainty that the physician provides all the resources realistically available. It is then up to the sensitivity of the operator, doctor and/or nurse, described in the "take charge" find, from time to time, the words and manners, verbal and nonverbal, to respond fully to questions of the patient same.
The question of disclosing the diagnosis to terminally ill patients was investigated by means of a semi-standardized interview of 56 subjects who had been 'told the truth' about their condition. The effects and interdependence of the factors of age, personality structure (EPI neuroticism scale), duration of knowledge, social contact, and religiousness, on the patient's ability to cope with the information were examined. The process of adjustment was assessed according to the stages proposed by Kübler-Ross (1969). Using the statistical model of path analysis, it was possible to evaluate these individual factors and present linearly their interrelationships. These results can offer medical staff the following guidelines: Three factors (a) advanced years, (b) good social contact, and (c) optimally unneurotic personality structure, provide the optimum conditions for a positive adjustment to the disclosure of a diagnosis of fatal illness. If, however, only one or two of these factors are involved, or if they are evident only to a slight degree, then conditions for telling the truth are less positive. On the other hand, in the case of (a) youth, (b) restricted social contact, and (c) a more markedly neurotic person, particular caution is recommended, since the danger of a negative reaction, and indeed even of suicide, must be reckoned with.
Morita, Tatsuya; Murata, Hisayuki; Kishi, Emi; Miyashita, Mitsunori; Yamaguchi, Takuhiro; Uchitomi, Yosuke
, and the FACIT-Sp. The change ratio of each parameter ranged from 5.6% (willingness to help) to 37% for the helplessness score and 51% on the Confidence Scale. The percentages of nurses who evaluated this program as "useful" or "very useful" were 85% (to understand the conceptual framework in caring for terminally ill patients with meaninglessness), 80% (to foster nurses' personal values), and 88% (to know how to provide care for patients with meaninglessness). This educational intervention had a significant beneficial effect on nurse-perceived confidence, practice, and attitudes in providing care for patients feeling meaninglessness, in addition to the levels of burnout and spiritual well-being of nurses.
Loomis, Margaret T.; Williams, T. Franklin
Studied the quality of terminal care in 40 patients in an acute care facility and a chronic care facility. Minimial difficulty was observed in making the transition from active to comfort care. An evaluation method and a model of terminal care emphasizing improved communication and emotional support are proposed. (Author/JAC)
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.
Labus, Janet G.; Dambrot, Faye H.
Investigated differences between 28 hospice and 28 hospital patients who died. Comparison found that hospice patients were younger, had more people living in the home, and had shorter disease history. Age, number of people living in the home, and primary cancer site significantly discriminated between hospice and hospital patients and predicted…
Itzhaky, Haya; Lipschitz-Elhawi, Rachel
This article focuses on supervision of social workers who feel despair and hopelessness in treating terminally ill patients. The emotional difficulties that may lead to these feelings are discussed. A special model of supervision that relates to hope as a strategy to help social workers cope with such difficulties is presented. The model suggests…
Olokor, Christiana O.
The purpose of this study was to analyze the attitudes of terminally ill patients toward death and dying. Four hospitals in Nigeria were randomly selected: University College Hospital, Ibadan; University of Benin Teaching Hospital, Benin City; the Lagos University Teaching Hospital, Lagos; and Igbinedion Specialist Hospital, Okada, Benin City.…
Clayton, Josephine M; Hancock, Karen; Parker, Sharon; Butow, Phyllis N; Walder, Sharon; Carrick, Sue; Currow, David; Ghersi, Davina; Glare, Paul; Hagerty, Rebecca; Olver, Ian N; Tattersall, Martin H N
The aim of this systematic review was to examine studies that have investigated sustaining hope during prognostic and end-of-life issues discussions with terminally ill patients and their families. A comprehensive search of databases (MEDLINE, EMBASE, CINAHL, PsychINFO, Cochrane Central Register of Controlled Trials) and handsearching, from 1985 to June 2006, identified 27 studies. This review suggests that the issues surrounding hope in this context are complex. Despite the lack of unanimity among researchers regarding the definition of hope, findings suggest that balancing hope with honesty is an important skill for health professionals (HPs). Many patients seem to be able to maintain a sense of hope despite acknowledging the terminal nature of their illness. Patients and caregivers mostly preferred honest and accurate information, provided with empathy and understanding. Many different sources of hope were identified in this context in broad aspects of life, not just the medical situation. HPs need to recognize this spectrum of hope and appreciate that patients may simultaneously hope for 'cure' while acknowledging the terminal nature of their illness. HPs may help patients to cope with their terminal prognosis by exploring and fostering realistic forms of hope that are meaningful for the particular patient and their family.
Reljic, Tea; Kumar, Ambuj; Klocksieben, Farina A; Djulbegovic, Benjamin
Objective To assess the efficacy of active treatment targeted at underlying disease (TTD)/potentially curative treatments versus palliative care (PC) in improving overall survival (OS) in terminally ill patients. Design We performed a systematic review and meta-analysis of randomised controlled trials (RCT). Methodological quality of included RCTs was assessed using the Cochrane risk of bias tool. Data sources Medline and Cochrane databases were searched, with no language restriction, from inception to 19 October 2016. Eligibility criteria for selecting studies Any RCT assessing the efficacy of any active TTD versus PC in adult patients with terminal illness with a prognosis of <6-month survival were eligible for inclusion. Results Initial search identified 8252 citations of which 10 RCTs (15 comparisons, 1549 patients) met inclusion criteria. All RCTs included patients with cancer. OS was reported in 7 RCTs (8 comparisons, 1158 patients). The pooled results showed no statistically significant difference in OS between TTD and PC (HR (95% CI) 0.85 (0.71 to 1.02)). The heterogeneity between pooled studies was high (I2=62.1%). Overall rates of adverse events were higher in the TTD arm. Conclusions Our systematic review of available RCTs in patients with terminal illness due to cancer shows that TTD compared with PC did not demonstrably impact OS and is associated with increased toxicity. The results provide assurance to physicians, patients and family that the patients' survival will not be compromised by referral to hospice with focus on PC. PMID:28062473
Fischer, D.J.; Epstein, J.B.; Yao, Y.; Wilkie, D.J.
Purpose Oral conditions are established complications in terminally-ill cancer patients. Yet despite significant morbidity, the characteristics and impact of oral conditions in these patients are poorly documented. The study objective was to characterize oral conditions in terminally-ill cancer patients to determine the presence, severity, and the functional and social impact of these oral conditions. Methods This was an observational clinical study including terminally-ill cancer patients (2.5–3 week life expectancy). Data were obtained via the Oral Problems Scale (OPS) that measures the presence of subjective xerostomia, orofacial pain, taste change, and the functional/social impact of oral conditions and a demographic questionnaire. A standardized oral examination was used to assess objective salivary hypofunction, fungal infection, mucosal erythema, and ulceration. Regression analysis and t test investigated the associations between measures. Results Of 104 participants, most were ≥50 years of age, female, and high-school educated; 45% were African American, 43% Caucasian, and 37% married. Oral conditions frequencies were: salivary hypofunction (98%), mucosal erythema (50%), ulceration (20%), fungal infection (36%), and other oral problems (46%). Xerostomia, taste change, and orofacial pain all had significant functional impact; p<.001, p=.042 and p<.001, respectively. Orofacial pain also had a significant social impact (p<.001). Patients with oral ulcerations had significantly more orofacial pain with a social impact than patients without ulcers (p=.003). Erythema was significantly associated with fungal infection and with mucosal ulceration (p<.001). Conclusions Oral conditions significantly affect functional and social activities in terminally-ill cancer patients. Identification and management of oral conditions in these patients should therefore be an important clinical consideration. PMID:24232310
Onishi, Hideki; Kawanishi, Chiaki; Onose, Masanari; Yamada, Tomoki; Saito, Hideyuki; Yoshida, Akira; Noda, Kazumasa
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 delirium. Two of the three patients did not show the classical triad of Wernicke encephalopathy. Common clinical symptoms were delirium and poor nutritional status. Intravenous thiamine administration dramatically improved the symptoms of delirium in all three patients. In terminally ill cancer patients, clinicians must remain aware of the possibility of Wernicke encephalopathy when patients with a poor nutritional status present with unexplained delirium. Early intervention may correct the symptoms and prevent irreversible brain damage and the quality of life for the patient may improve.
Existential Psychological Theory was employed as a conceptual and theoretical foundation for the use of hypnotically facilitated therapy in the management of intractable pain, nausea, and vomiting in 3 end-stage, terminally ill cancer patients. The existential principles of death anxiety, existential isolation, and existential meaninglessness were addressed with a combination of classic and Ericksonian techniques. The intractable nature of the presenting physical symptoms was conceptualized as a possible manifestation of the impact of the terminal prognosis. Direct hypnotic suggestions for the management of pain, nausea and vomiting were avoided. It was hypothesized that, as the existential conflicts associated with the patients' terminal status resolved, the physiological symptoms would become responsive to medication. After 6 sessions grounded in the principles of Existential Psychotherapy, the intractable status of the physical symptomatology remitted, and the patients responded to medical management. This paper addresses the usefulness of Existential Psychotherapy in hypnotic interventions for mediating somatic and psychosomatic symptomatology.
Royal, Kenneth D; Elahi, Fereshte
Research conducted with the terminally ill population in relation to death anxiety is rare and mostly outdated. The purpose of this study was to evaluate the psychometric properties of the widely used Death Anxiety Scale (DAS) on a sample of terminal cancer patients.Additionally, validation studies of the DAS have exclusively used traditional statistical methods for analysis. The current study utilized an item response theory technique (IRT), namely the Rasch Rating Scale model for data analysis. The methodology employed may be useful for other researchers conducting validation studies from an IRT perspective.
The medical approach as summarized by Leibowitz--"We must treat the person, not just the disease"--highlights the importance of treating the sick person and not only the illness' pathology. This approach calls for healing not only the physical side, but also--and mainly--the mental aspect of the patient. One of the goals of this article is to turn physicians' attention towards the compassion necessary in treating a person with a severe or chronic illness, or a person who is dying--precisely because sometimes there is no medical cure for the physical state of such a patient. Therefore, physicians' attention does need to be directed to providing emotional assistance to such a patient. Sometimes, the emotional strength the patient draws from the medical team that is treating him can change his view of, and approach to, the illness, and can enable his body to muster the emotional strength necessary to deal with his situation. Buddhism's approach enables the sick patient to experience his illness in a different way, by making peace with one's situation and, sometimes, even viewing the situation differently--viewing the illness as a type of renewal. Buddhism, therefore, enables a sick person to choose a different point of view when his energy is exhausted and he loses hope, providing quality of life to patients. In such a situation, a sick person finds emotional strength in the knowledge that the end of his life is actually a renewal somewhere else. The limited life expectancy of the terminally ill patient demands that he be able to spend his time with minimal concerns and worries, and does not leave much time for treating the emotional side--the patient's fear. In light of this fact, the patient's ability to look ahead and grasp at hope is the most important issue. As much as possible, this is accomplished in an atmosphere of acceptance and with the absence, or reduction, of fear. The freedom to decide for oneself how to behave, according to one's own approach, is what
Sasaki, Tsubasa; Kawagoe, Izumi
Since the launch of pure oxycodone injections in May 2012, it has been possible to use oxycodone without opioid rotation. Although an extremely important step showing progress, very few studies regarding the use of pure oxycodone injections have been performed. In this study, we evaluated the safety and efficacy of pure oxycodone injections in 31 terminally ill cancer patients receiving home care. The difficulty in oral oxycodone intake was the main reason for changing to pure oxycodone injections. The mean administered period of subcutaneous pure oxycodone was 5.6 ± 6.7 days. One out of 5 patients receiving pure oxycodone injections complained of worsening sleepiness. However, other symptoms improved. In addition, in cases wherein pure oxycodone injection was the initiating opioid, 1 out of 6 patients showed no improvement of respiratory discomfort, while other symptoms improved. It was difficult to evaluate more patients because of the short period for administration. Although 5 patients experienced skin problems, they were successfully managed by changing the injection site. Of these 5 patients, 2 patients had sensitive skin, with a previous history of alcohol rash. In conclusion, our study suggests that pure oxycodone injections are beneficial over oral oxycodone treatment for terminally ill cancer patients. However, further evaluation of skin problems associated with pure oxycodone injections is required by performing larger studies.
Morita, Tatsuya; Murata, Hisayuki; Hirai, Kei; Tamura, Keiko; Kataoka, Jun; Ohnishi, Hideki; Akizuki, Nobuya; Kurihara, Yukie; Akechi, Tatsuo; Uchitomi, Yosuke
Recent empirical studies revealed that fostering patients' perception of meaning in their life is an essential task for palliative care clinicians. However, few studies have reported the effects of training programs for nurses specifically aimed at improving skills to relieve the meaninglessness of terminally ill cancer patients, and we have had no specific measurement instruments. The primary aims of this study were 1) to validate measurement tools to quantify nurses' self-reported practice and attitudes toward caring for terminally ill cancer patients feeling meaninglessness and 2) to explore the effects of the five-hour educational workshop focusing on meaninglessness on nurses' self-reported practice, attitudes toward caring for such patients, confidence, burnout, death anxiety, and meaning of life. A quasi-experimental pre-post questionnaire survey was performed on 147 nurses. The questionnaire was distributed before the intervention workshop and one and six months after. The workshop consisted of lecture, role-play, and the exercise of assessment and care planning based on two vignette verbatim records. First, using the first questionnaire sample and an additional sample of 20 nurses for the test-retest examination, we validated a six-item Self-Reported Practice scale, and an eight-item Attitudes Toward Caring for Patients Feeling Meaninglessness scale with three subscales (Willingness to Help, Positive Appraisal, and Helplessness). The nurses also completed a scale to assess confidence in caring for terminally ill patients with meaninglessness, the Maslach Burnout Inventory, the Death Attitude Inventory, the Frommelt Attitudes Toward Care of the Dying scale, the Self-Reported Practice Score in General Communication, and the three pain-related items from the Palliative Care Quiz for Nursing. For the Self-Reported Practice scale and the subscales of the Attitudes Toward Caring for Patients Feeling Meaninglessness scale, the Cronbach's alpha coefficients were 0
Gil-Herrera, Eleazar; Yalcin, Ali; Tsalatsanis, Athanasios; Barnes, Laura E; Djulbegovic, Benjamin
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.
Morita, T; Tsunoda, J; Inoue, S; Chihara, S
To determine an underlying factorial structure of existential distress in Japanese terminally ill cancer patients, a principal components analysis was performed on 162 Japanese hospice inpatients. Existential distress commonly identified was dependency (39%), meaninglessness in present life (37%), hopelessness (37%), burden on others (34%), loss of social role functioning (29%), and feeling emotionally irrelevant (28%). By a factor analysis, three primary components accounted for 66% of the variance. 'Dependency' and 'loss of social role functioning' loaded highly on the first factor, which was interpreted as 'loss of autonomy'. 'Burden on others' and 'feeling emotionally irrelevant' loaded highly on the second component interpreted as 'lowered self-esteem', while 'hopelessness' loaded highly on the third factor. On the other hand, 'meaninglessness in present life' loaded equally on all three components, and was significantly associated with other distress. In conclusion, existential suffering of Japanese terminally ill cancer patients has three principal components: loss of autonomy, lowered self-esteem, and hopelessness. It is also suggested that meaninglessness in present life would be an underlying theme in patients' spirituality.
Rosenfeld, Barry; Pessin, Hayley; Marziliano, Allison; Jacobson, Coleen; Sorger, Brooke; Abbey, Jennifer; Olden, Megan; Brescia, Robert; Breitbart, William
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 who 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
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.
Pledger, Carolyn Brastow
Examines Kubler-Ross' five stages of grief (denial, anger, bargaining, depression, acceptance) as they are experienced not by terminally ill persons, but by 20 criminal offenders and their families during incarceration. Concludes that shock of arrest and incarceration stimulates reactions similar to those of persons coping with terminal diagnosis.…
TITLE: Proposal for Development of EBM-CDSS (Evidence-based Clinical Decision Support System) to Aid Prognostication in Terminally Ill Patients...SUBTITLE Proposal for development of EBM-CDSS (Evidence-based Clinical Decision Support System) to aid prognostication in terminally ill patients 5a...to improve prognostication of the life expectancy of terminally ill patients to improve referral of patients to hospice. In addition, the EBM-CDSS
Chao, Co-Shi Chantal
The purpose of this study was to survey physicians attitudes toward DNR of terminally ill cancer patients in Taiwan. A total of 7626 structured questionnaires were sent by mail to physicians who were members of the Taiwan Society of Internal Medicine and the Surgical Association of Taiwan, and 1328 valid responses were received. The response rate was 17.6%. The instrument, a structured questionnaire, was composed of one scenario and six questions. A majority (77.6%) of the physicians under investigation would tell a terminally ill cancer patient or his family about the possibility of DNR and ask them to consider signing a consent form. Over one half of the physicians (58.4%) did not know whether the Medical Law in Taiwan permits natural death, and 96.1% of the subjects felt they would need legal protection for agreeing patient s autonomy to decide DNR. Unfortunately, 41.2% of the respondent admitted that they did not have a formal Informed Consent Form that could be used for DNR. Even of those who had such a form, only 27.4% had clear guidelines given by their institutions. Among 623 physicians whose institutions had an formal Informed Consent Form for DNR, 63.7% agreed that it was reasonably used. Surprisingly, 67.9% of the physicians had used Slow Codes. The findings of this study served as a solid base. The investigator and other colleagues used it to convince legislators to pass a Natural Death Act in Taiwan. Since some legislators disliked the term death and the main promotes were people engaged in hospice palliative care, the new law entitled Hospice Palliative Act was passed on May 23, 2000. The DNR order finally gained its legal base for medical practice. The limitation of this study was the low response rate. However, since the subjects, physicians, had a busy work load, this was still an acceptable response rate.
Matsuo, Naoki; Yomiya, Kinomi
Steroids are commonly used for fatigue relief in terminally ill cancer patients. However, steroid-induced adverse effects including depression, myopathy, and hyperglycemia may contribute to fatigue. We report our experiences with aggravation of fatigue with steroid use in three cases. Case 1 was a 65-year-old man with advanced gastric cancer. He was started on betamethasone (2 mg/d) for fatigue, but the fatigue worsened due to steroid-induced depression. Discontinuation of steroids and initiation of an antidepressant ameliorated the fatigue. Case 2 was a 68-year-old man with advanced lung cancer. He complained of fatigue. Betamethasone (1 mg/d) was started and alleviated the fatigue. However, when the betamethasone dose was increased to 2 mg/d, the fatigue, with muscle weakness and myalgia, worsened due to steroid-induced myopathy. We therefore switched from betamethasone (2 mg/d) to prednisolone (10 mg /d). The fatigue resolved and the patient returned to his previous condition. Case 3 was a 73-year-old man with recurrent bile duct cancer. He also had diabetes mellitus. He developed fatigue, anorexia and fever. We started betamethasone (1.5 mg/d) for these symptoms, but the fatigue and anorexia worsened due to steroid-induced hyperglycemia. Blood glucose rose to 532 mg/dL. Therefore, insulin therapy was started, and the dose of betamethasone was reduced to 0.5 mg/d. His glucose level decreased to less than 320 mg/dL and he recovered from the fatigue while achieving moderate oral intake. In conclusion, the possibility of steroid-induced secondary fatigue in terminally ill cancer patients should be taken into consideration.
Parpa, Efi; Mystakidou, Kyriaki; Tsilika, Eleni; Sakkas, Pavlos; Patiraki, Elisabeth; Pistevou-Gombaki, Kyriaki; Galanos, Antonis; Vlahos, Lambros
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.
Victoria, Kitty; Patel, Sarita
Background: Studies have shown that over 50% of end-of-life discussions take place for the first time in the hospital and that terminally ill patients often have unrealistic views regarding the possible scope of treatment. The Palliative Care information Act (PCIA) was passed in an attempt to address the lack of access for terminally ill patients to palliative care services. A multi-database systematic review was performed on published studies from 2010 to present, and there were none found measuring the effectiveness of the PCIA. Objectives: We aimed to study the effect of the PCIA on access to palliative care services. Methods: We conducted a retrospective chart review of all terminally ill patients who died at Kingsbrook Jewish Medical Center from January 2010 to August 2013 in relation to passing of the PCIA. Results: Prelaw (prior to the law passing), 12.3% of the terminal patients received palliative care consults, 25% during the transition period (time between passing of law and when it came into effect) and 37.7% postlaw (after coming into effect) (P < 0.001). Conclusions: Legislation can have a significant effect on terminally ill patient's access to palliative care services and can change the culture of a hospital to be more pro-palliative for the appropriate populations. PMID:27803564
Lascaratos, J; Poulakou-Rebelakou, E; Marketos, S
Our research on the texts of the Byzantine historians and chroniclers revealed an apparently curious phenomenon, namely, the abandonment of terminally ill emperors by their physicians when the latter realised that they could not offer any further treatment. This attitude tallies with the mentality of the ancient Greek physicians, who even in Hippocratic times thought the treatment and care of the terminally ill to be a challenge to nature and hubris to the gods. Nevertheless, it is a very curious attitude in the light of the concepts of the Christian Byzantine physicians who, according to the doctrines of the Christian religion, should have been imbued with the spirit of philanthropy and love for their fellowmen. The meticulous analysis of three examples of abandonment of Byzantine emperors, and especially that of Alexius I Comnenus, by their physicians reveals that this custom, following ancient pagan ethics, in those times took on a ritualised form without any significant or real content. PMID:10390682
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…
Classroom teachers of terminally ill children face potentially difficult, challenging, rewarding and professionally expanding experiences which require an understanding of the basic needs of the dying. Strategies for teaching such children include literature, writing, role playing, magic circle discussions, play therapy, art therapy, counseling,…
Gerson, S N
Corporate America's healthcare cost crisis and the country's budget deficit are forcing limits on the resources used to finance healthcare, including mental healthcare. At the same time, the 1990 Americans with Disabilities Act bars discrimination against patients with chronic illnesses, including chronic mental illness. Therefore, corporate benefits managers need guidance on how to ethically and rationally allocate scarce clinical resources to those high-morbidity insureds who utilize disproportionate amounts of these resources. In particular, how should we define the public/private interface: When do patients who repeatedly fail to respond to treatment fall out of the private sector's responsibility? The author, medical director for a leading behavioral healthcare utilization management company, offers the following guidelines recommending reasonable and practical limitations on trials of treatment for seven common categories of difficult psychiatric patients.
Nagi, Mostafa H.; Lazerine, Neil G.
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…
Dobríková, Patricia; Pčolková, Dušana; AlTurabi, Layla Khalil; West, Daniel J
This study examines the effect of 2 indicators on quality of life (QOL): social support and meaning of life for terminally ill patients. These 2 indicators are very important from a psychological and spiritual point of view. The findings suggest that there is a statistically significant correlation between meaning of life and QOL (r = .610, P < .001). Results have also demonstrated that more frequent patient visits increase the sense of life fulfillment for dying patients. A significant relationship exists in survival of life meaningfulness and satisfaction with social support. In conclusion, experiencing one's life as meaningful is positively related to the well-being for dying patients. Social support provided by a close relative had a positive influence on the patient's meaning of life and overall life satisfaction.
Miyao, Y; Tonouchi, A; Yokoyama, H
Karuizawa Hospital is a rural, small town municipal hospital with 60 beds, located in Nagano Prefecture in central Japan. The terminal stages of patients who were treated in our department of surgery but later died of cancer are reviewed. In the five year period extending from April, 1994 through March, 1999 sixty patients died from cancer. Of them, 34 people died in their own home and 26 in our hospital. The annual ratio of patients who died at home to those who died in the hospital are analyzed, as well as whether these ratios differed according to the location of the patient's cancer. The identity of the patients' main home caregiver was sought, as well as how many days the patients resided at home until they passed away, and how frequently doctors or nurses visited their home. Some of the doctors' attempts to gain informed consent are described. Based on the findings, the authors recommend an end to the practice of first revealing the name and details of a patient's disease to his/her family. It was also found that documented information is useful in order to promote smooth relationships among patients, family members, and the doctor.
Morita, Tatsuya; Sakaguchi, Yukihiro; Hirai, Kei; Tsuneto, Satoru; Shima, Yasuo
A desire for death and requests to hasten death are major topics in recent medical literature. The aim of this study was to clarify the bereaved family-reported incidence and reasons for desiring death and requests to hasten death during the whole course of terminally ill cancer patients receiving specialized palliative care in Japan. A nationwide questionnaire survey of 500 primary caregivers yielded a total of 290 responses (effective response rate, 62%). Sixty-two (21%) families reported that the patients had expressed a desire to die, and 29 (10%) families reported that the patients had requested that death be hastened. The major reasons for desiring death and requests to hasten death were: burden on others, dependency, meaninglessness, unable to pursue pleasurable activities, general malaise, pain, dyspnea, concerns about future distress, and wish to control the time of death. No intolerable physical symptoms were reported in 32% and 28% of the patients who desired death and those who requested to hasten death, respectively. Concerns about future distress and wishes to control the time of death were significantly more likely to be listed as major reasons for desiring death in patients who requested that death be hastened than those who did not. A desire for death and requests to hasten death are not uncommon in terminally ill cancer patients receiving specialized inpatient palliative care in Japan. More intensive strategies for general malaise, pain, and dyspnea near the end of life, and for feelings of being a burden, meaninglessness, and concerns about future distress would alleviate the serious suffering of patients with a desire for death. However, some patients with a strong wish to control the time of death might not receive benefit from conventional palliative care.
Yeung, E W; French, P; Leung, A O
This study explored the expectations and experiences of patients with terminal cancer in a hospice inpatient environment in an attempt to evaluate their quality of life and the impact of the care and services provided. A total of 52 patients terminally ill with cancer from 11 hospice units in Hong Kong participated in the study. Data were collected from patients by devising a Hospice Care Performance Inventory (HCPI), which was an interview schedule consisting of 25 items. The HCPI was developed after a review of the literature on the quality of life experienced by patients with advanced cancer and the aims of hospice units in Hong Kong. Each item was rated by the patient on a Likert scale in terms of its importance and the perceived effectiveness of the care provided. The study identified six issues in which expectations did not seem to match effectiveness. These issues indicated areas in which improvement could be attempted to enhance the quality of life for the patients. The most important was maximizing self-care and mobility. Two issues were identified in which effectiveness was high and importance to the patient relatively low. One of these issues was pain management, and the other was spiritual care.
Kim, Sunghee; Shin, Gisoo
The purpose of this study was to develop a simulation-based training program for people living with HIV (PLWH) as peer caregivers who would take care of terminally ill, HIV-infected patients. We used qualitative research methods and standardized patients to explore the meaning of caring for patients as peer caregivers. Study participants included 32 patients registered as PLWH at the South Korea Federation for HIV/AIDS. The meanings of peer caregiving were categorized into four dimensions: physical, psychological, relational, and economic. Our study had benefits in knowledge acquisition for caregivers as well as care recipients, empathy with HIV-infected care recipients, improvement in self-esteem and social participation, and financial self-sufficiency to enable independent living for caregivers. The simulation training program for PLWH peer caregivers for terminally ill HIV-infected patients demonstrated value, for both PLWH caregivers and terminally ill HIV-infected patients in South Korea, to improve the quality of care.
Khanna, R.; Singh, R.P.N.
SUMMARY A study of 50 terminally ill cancer patients revealed that 52% were uninformed regarding their diagnosis and prognosis. In almost all cases the relatives had been adequately informed. No less than 82% of the terminally ill patients showed an awareness of the fatal prognosis. Most of the patients found the communication with the doctor and the relatives as unsatisfactory. Comparing this group with another group of non-terminal medically ill patients showed striking differences between the two groups. The findings are compared with those reported from the West and the implications of the above observations discussed. PMID:21927320
Maltoni, Marco; Miceli, Rosalba; Mariani, Luigi; Caraceni, Augusto; Amadori, Dino; Nanni, Oriana
Purpose. An existing and validated palliative prognostic (PaP) score predicts survival in terminally ill cancer patients based on dyspnea, anorexia, Karnofsky performance status score, clinical prediction of survival, total WBC, and lymphocyte percentage. The PaP score assigns patients to three different risk groups according to a 30-day survival probability—group A, >70%; group B, 30%–70%; group C, <30%. The impact of delirium is known but was not incorporated into the PaP score. Materials and Methods. Our aim was to incorporate information on delirium into the PaP score based on a retrospective series of 361 terminally ill cancer patients. We followed the approach of “validation by calibration,” proposed by van Houwelingen and later adapted by Miceli for achieving score revision with inclusion of a new variable. The discriminating performance of the scores was estimated using the K statistic. Results. The prognostic contribution of delirium was confirmed as statistically significant (p < .001) and the variable was accordingly incorporated into the PaP score (D-PaP score). Following this revision, 30-day survival estimates in groups A, B, and C were 83%, 50%, and 9% for the D-PaP score and 87%, 51%, and 16% for the PaP score, respectively. The overall performance of the D-PaP score was better than that of the PaP score. Conclusion. The revision of the PaP score was carried out by modifying the cutoff values used for prognostic grouping without, however, affecting the partial scores of the original tool. The performance of the D-PaP score was better than that of the PaP score and its key feature of simplicity was maintained. PMID:22042788
Peng, Meng-Ting; Liu, Chien-Ting; Hung, Yu-Shin; Kao, Chen-Yi; Chang, Pei-Hung; Yeh, Kun-Yun; Wang, Hung-Ming; Lin, Yung-Chang; Chou, Wen-Chi
This study aimed to assess the utility of the Eastern Cooperative Oncology Group (ECOG) performance scale assessments on days 1 and 8 of palliative care, as well as scale change between these assessments, as prognostic tools for patients with terminally ill cancer. A total of 2392 patients with terminally ill cancer who received palliative care between January 2006 and December 2011 at a single medical center were analyzed. Our study showed that the ECOG scale is a useful prognostic tool to predict life expectancy in patients with terminally ill cancer. The ECOG scale assessments at different time points under palliative care were independent predictors for overall survival. The combined ECOG scale assessments on days 1 and 8 predicted survival more precisely than using day 1 ECOG scale assessment alone.
The classification of a patient as terminally ill is based on an expert diagnosis of a severe and irreversible disease and the absence of an effective available treatment, according to present medical knowledge. Terminal diseases must not be confused with severe ones, since the latter may be reversible with an adequate and timely treatment. The physician assumes a great responsibility at the moment of diagnosing a patient as terminally ill. The professional must assume his care until the moment of death. This care must be oriented to the alleviation of symptoms and to provide the best possible quality of life. Also, help must be provided to deal with personal, legal and religious issues that may concern the patient.
Harrison, A; al-Saadi, A M; al-Kaabi, A S; al-Kaabi, M R; al-Bedwawi, S S; al-Kaabi, S O; al-Neaimi, S B
OBJECTIVES: To study the opinions of nationals (Emiratis) and doctors practising in the United Arab Emirates (UAE) with regard to informing terminally ill patients. DESIGN: Structured questionnaires administered during January 1995. SETTING: The UAE, a federation of small, rich, developing Arabian Gulf states. PARTICIPANTS: Convenience samples of 100 Emiratis (minimum age 15 years) and of 50 doctors practising in government hospitals and clinics. RESULTS: Doctors emerged as consistently less in favour of informing than the Emiratis were, whether the patient was described as almost certain to die during the next six months or as having a 50% chance of surviving, and even when it was specified that the patient was requesting information. In the latter situation, a third of doctors maintained that the patient should not be told. Increasing survival odds reduced the number of doctors selecting to inform; but it had no significant impact on Emiratis' choices. When Emiratis were asked whether they would personally want to be informed if they had only a short time to live, less than half responded in the way they had done to the in principle question. CONCLUSIONS: The doctors' responses are of concern because of the lack of reference to ethical principles or dilemmas, the disregard of patients' wishes and dependency on survival odds. The heterogeneity of Emiratis' responses calls into question the usefulness of invoking norms to explain inter-society differences. In the current study, people's in principle choices did not provide a useful guide to how they said they would personally wish to be treated. PMID:9134491
To clarify the prevalence and the characteristics of patients who received palliative sedation therapy for psycho-existential suffering, a questionnaire was sent to 105 responsible physicians at all certified palliative care units in Japan. The participants were requested to report the number of patients who received continuous deep sedation for refractory psycho-existential suffering during the past year, and to provide details of the 2 most recent patients. A total of 81 physicians returned questionnaires (response rate, 80%). Twenty-nine physicians (36%) reported clinical experience in continuous deep sedation for psycho-existential suffering. The overall prevalence of continuous deep sedation was calculated as 1.0% (90 cases/8,661 total patient deaths), and a total of 46 patient histories were collected. Performance status just before sedation was 3 or 4 in 96%, and predicted survival was 3 weeks or less in 94%. The suffering requiring sedation was feeling of meaninglessness/worthlessness (61%), burden on others/dependency/inability to take care of oneself (48%), death anxiety/fear/panic (33%), wish to control the time of death by oneself (24%), and isolation/lack of social support (22%). Before sedation, intermittent sedation and specialized psychiatric, psychological, and/or religious care had been performed in 94% and 59%, respectively; 89% of 26 depressed patients had received antidepressant medications. All competent patients (n=37) expressed explicit requests for sedation, and family consent was obtained in all cases where family members were available (n=45). Palliative sedation for psycho-existential suffering was performed in exceptional cases in specialized palliative care units in Japan. The patient condition was generally very poor, and the suffering was refractory to intermittent sedation and specialized psychiatric, psychological, and/or religious care. Sedation was performed on the basis of patient and family consent. These findings suggest that
... or to society (e.g., stealing to get money for the drugs). In a study of over 11,000 patients ... also have a somewhat exaggerated fear that government drug enforcement agencies may ... Research and Quality, the National Comprehensive Cancer Network, the ...
Tardy, B; Picard, S; Guirimand, F; Chapelle, C; Danel Delerue, M; Celarier, T; Ciais, J-F; Vassal, P; Salas, S; Filbet, M; Gomas, J-M; Guillot, A; Gaultier, J-B; Merah, A; Richard, A; Laporte, S; Bertoletti, L
Essentials Bleeding incidence as hemorrhagic risk factors are unknown in palliative care inpatients. We conducted a multicenter observational study (22 Palliative Care Units, 1199 patients). At three months, the cumulative incidence of clinically relevant bleeding was 9.8%. Cancer, recent bleeding, thromboprophylaxis and antiplatelet therapy were independent risk factors.
Stephens, Ronald L.; Grady, Rosemary
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…
Downey, Lois; Engelberg, Ruth A; Standish, Leanna J; Kozak, Leila; Lafferty, William E
Improving end-of-life care is a priority in the United States, but assigning priorities for standard care services requires evaluations using appropriate study design and appropriate outcome indicators. A recent randomized controlled trial with terminally ill patients produced no evidence of benefit from massage or guided meditation, when evaluated with measures of global quality of life or pain distress over the course of patient participation. However, reanalysis using a more targeted outcome, surrogates' assessment of patients' benefit from the study intervention, suggested significant gains from massage-the treatment patients gave their highest preassignment preference ratings. The authors conclude that adding a menu of complementary therapies as part of standard end-of-life care may yield significant benefit, that patient preference is an important predictor of outcome, and that modifications in trial design may be appropriate for end-of-life studies.
Daneault, Serge; Lussier, Véronique; Mongeau, Suzanne; Yelle, Louise; Côté, Andréanne; Sicotte, Claude; Paillé, Pierre; Dion, Dominique; Coulombe, Manon
Objective To better understand the role of hope among terminally ill cancer patients. Design Qualitative analysis. Setting A tertiary specialized cancer centre in Canada. Participants Cancer patients in palliative care with an estimated remaining life expectancy of 12 months or less (N = 12) and their loved ones (N = 12) and treating physicians (N = 12). Methods Each patient underwent up to 3 interviews and identified a loved one who participated in 1 interview. Treating physicians were also interviewed. All interviews were fully transcribed and analyzed by at least 2 investigators. Interviews were collected until saturation occurred. Main findings Seven attributes describe the experiences of palliative cancer patients and their caregivers: hope as an irrational phenomenon that is a deeply rooted, affect-based response to adversity; initial hope for miraculous healing; hope as a phenomenon that changes over time, evolving in different ways depending on circumstances; hope for prolonged life when there is no further hope for cure; hope for a good quality of life when the possibility of prolonging life becomes limited; a lack of hope for some when treatments are no longer effective in curbing illness progression; and for others hope as enjoying the present moment and preparing for the end of life. Conclusion Approaches aimed at sustaining hope need to reflect that patients’ reactions might fluctuate between despair and a form of acceptance that leads to a certain serenity. Clinicians need to maintain some degree of hope while remaining as realistic as possible. The findings also raise questions about how hope influences patients’ perceptions and acceptance of their treatments. PMID:27521394
Miyashita, Mitsunori; Morita, Tatsuya; Shima, Yasuo; Kimura, Rieko; Takahashi, Mikako; Adachi, Isamu
We evaluated nurse views on the adequacy of decision-making discussion among nurses and physicians regarding artificial hydration for terminally ill cancer patients and nurse distress arising from artificial hydration issues, as well as factors related to this distress. A self-administered questionnaire consisting of 4 questions about nurse views of discussions regarding artificial hydration and 6 questions about nurse distress arising from artificial hydration issues was distributed in participating institutions in October 2002 and returned by mail. A total of 3328 responses (79%) were analyzed. Almost half of the nurses felt that discussion of terminal hydration issues was insufficient. Among responses, 39% of oncology nurses and 78% of palliative care unit (PCU) nurses agreed that patients and medical practitioners discuss the issue of artificial hydration adequately, and 49% and 79%, respectively, agreed that medical practitioners discuss the issue of artificial hydration with other physicians adequately. As for distress on behalf of patients and families who refuse artificial hydration, 44% of oncology nurses and 57% of PCU nurses experienced such distress for patients, and 19% and 28% did so for families, respectively. Furthermore, 48% of oncology nurses and 47% of PCU nurses experienced distress arising from disagreements among medical practitioners about withholding artificial hydration, whereas 44% and 43% experienced distress about medical practitioners refusing artificial hydration, respectively. Discussion among care providers regarding artificial hydration is insufficient, particularly in general wards. Medical practitioners caring for terminally ill cancer patients should engage in greater discussion among patient-centered teams and facilitate individualized decision making.
Levy, Michael H.
Two main goals in the care of the terminally ill are to optimize the quality of their remaining life and to alleviate the distress of their survivors. Pain control research has contributed significantly to meeting those goals, but continued progress is needed in both basic studies and expanded applications of new techniques. (Author/NB)
Morita, T; Tsunoda, J; Inoue, S; Chihara, S; Oka, K
Although valid measurement of the severity of terminal delirium is of great importance in palliative care settings, existing instruments have considerable limitations. In order to quantify patients' communication capacity and agitated behaviour, two new operational observer-rating scales, the Communication Capacity Scale (Communication Scale) and Agitation Distress Scale (Agitation Scale), were validated. Thirty terminally ill cancer patients diagnosed with delirium were evaluated simultaneously by two palliative care physicians blinded to each other's coding using the Communication Scale and Agitation Scale. In addition, the Memorial Delirium Assessment Scale (MDAS), Delirium Rating Scale (DRS) and Sedation Scale were rated by one researcher. Both scales achieved high internal consistency and inter-rater reliability with Cronbach's alpha coefficients of 0.91 and 0.96, and Cohen's kappa values on each item of 0.72-1.00. The principal components analysis resulted in the emergence of only one component for each scale. The total score on the Communication Scale was highly associated with that of the MDAS (rho = 0.78), Sedation Scale (rho = 0.86), and cognitive items from the MDAS and DRS (rho = 0.83). The whole score on the Agitation Scale was significantly correlated with that of the DRS (rho = 0.61) and agitation items from the MDAS and DRS (rho = 0.61). In conclusion, the Communication Scale and Agitation Scale have acceptable reliability and validity to quantify patients' communication capacity and agitation symptoms of terminally ill cancer patients with delirium.
Sorkness, Christine A.
More than 4.5 million people worldwide live with an implanted pacemaker, including >3 million in the USA alone. Also, >0.8 million people in the USA have an implantable cardioverter defibrillator (ICD). Knowing the principles of managing these devices towards the end of life is important, as the interruption of their function may have serious consequences. This article provides health care providers who are not specialized in cardiac electrophysiology with an introduction to the general principles of management of pacemakers or ICD devices towards the end of life, with a suggested algorithm for approaching this process. Also discussed are pertinent ethical and practical considerations in deciding on and implementing a management strategy for these devices during terminal illnesses.
Wenrich, Marjorie D; Curtis, J Randall; Ambrozy, Donna A; Carline, Jan D; Shannon, Sarah E; Ramsey, Paul G
This study addressed the emotional and personal needs of dying patients and the ways physicians help or hinder these needs. Twenty focus groups were held with 137 individuals, including patients with chronic and terminal illnesses, family members, health care workers, and physicians. Content analyses were performed based on grounded theory. Emotional support and personalization were 2 of the 12 domains identified as important in end-of-life care. Components of emotional support were compassion, responsiveness to emotional needs, maintaining hope and a positive attitude, and providing comfort through touch. Components of personalization were treating the whole person and not just the disease, making the patient feel unique and special, and considering the patient's social situation. Although the levels of emotional support and personalization varied, there was a minimal level, defined by compassion and treating the whole person and not just the disease, that physicians should strive to meet in caring for all dying patients. Participants also identified intermediate and advanced levels of physician behavior that provide emotional and personal support.
Librach, S. L.
Pain control is still a prime concern in managing patients with terminal illnesses, such as AIDS and cancer. I review some special issues that confront family physicians providing such care. Issues include common blocks to good pain management, understanding different types of pain, and the appropriate use of adjunct analgesic drugs and therapies. PMID:7539651
In trying to comprehend a culture and its ways of structuring the world, much can be learned from addressing the manner in which intimate family relationships are ordered and family crises channeled toward care. A family's experience with illness cannot be considered in isolation from the cultural milieu in which it occurs. Family adaptation to cancer diagnosis is a continuous motion between many critical strata--a fragile oscillation between hope and desperation. Processes for optimal functioning and the well-being of members are seen to vary over time, as challenges unfold and families evolve across the life cycle and illness trajectory. The manner in which the healthcare system and family manage illness and terminal care is a particularly helpful window into the cultural, religious and traditional values of every family in a particular society.
... htm Talking with a child about a parent's terminal illness To use the sharing features on this ... soon after you find out your cancer is terminal. Being included in this difficult transition can help ...
Healthy Lifestyle End of life When terminal illness affects a loved one, it isn't always easy to know how to react. Find out how to offer support and ... support to a loved one who has a terminal illness can be challenging. What can you say ...
the prognosis ! that no reasonable possibility exists of the patient’s return to a cognitive, sapient state. These committees should not be composed of...possi- bility that he will return to a cognitive sapient state or is mentally incapacitated, and: (1) It is determined by the attending physician that
Parry, Ruth; Land, Victoria; Faull, Christina; Feathers, Luke; Seymour, Jane
Objective To examine how palliative medicine doctors engage patients in end-of-life (hereon, EoL) talk. To examine whether the practice of “eliciting and responding to cues”, which has been widely advocated in the EoL care literature, promotes EoL talk. Design Conversation analysis of video- and audio-recorded consultations. Participants Unselected terminally ill patients and their companions in consultation with experienced palliative medicine doctors. Setting Outpatient clinic, day therapy clinic, and inpatient unit of a single English hospice. Results Doctors most commonly promoted EoL talk through open elaboration solicitations; these created opportunities for patients to introduce–then later further articulate–EoL considerations in such a way that doctors did not overtly ask about EoL matters. Importantly, the wording of elaboration solicitations avoided assuming that patients had EoL concerns. If a patient responded to open elaboration solicitations without introducing EoL considerations, doctors sometimes pursued EoL talk by switching to a less participatory and more presumptive type of solicitation, which suggested the patient might have EoL concerns. These more overt solicitations were used only later in consultations, which indicates that doctors give precedence to patients volunteering EoL considerations, and offer them opportunities to take the lead in initiating EoL talk. There is evidence that doctors treat elaboration of patients’ talk as a resource for engaging them in EoL conversations. However, there are limitations associated with labelling that talk as “cues” as is common in EoL communication contexts. We examine these limitations and propose “possible EoL considerations” as a descriptively more accurate term. Conclusions Through communicating–via open elaboration solicitations–in ways that create opportunities for patients to volunteer EoL considerations, doctors navigate a core dilemma in promoting EoL talk: giving
Parrillo, J.E.; Masur, H. )
This book discusses the papers on the diagnosis and management of immunosuppressed patient. Some of the topics are: life-threatening organ failure in immunosuppressed patients; diagnosis and therapy of respiratory disease in the immunosuppressed patient; CNS complication of immunosuppression; infections; antineoplastic therapy of immunosuppressed patient; radiation therapy-issues in critically ill patient; AIDS; and management of bone marrow transplant patients.
Meyers, Allan R.; And Others
A review of 85 patients who received home care for terminal illness showed that a small proportion of patients use a relatively high volume of both in-patient and home care services. Data suggest that there are two dimensions of service utilization: a medical dimension and a social dimension. (Author/RC)
Heller, Kathryn Wolff; Coleman, Mari Beth; Best, Sherwood J.; Emerson, Judith
This study examined teachers' knowledge and support when working with students with terminal illness or having experienced a student death. One hundred and ninety teachers of students with physical or multiple disabilities responded to a 40 item questionnaire that was distributed nationally. Results indicated that teachers have greater knowledge…
Bolton, C F; Gilbert, J J; Hahn, A F; Sibbald, W J
Five patients developed a severe motor and sensory polyneuropathy at the peak of critical illness (sepsis and multiorgan dysfunction complicating a variety of primary illnesses). Difficulties in weaning from the ventilator as the critical illness subsided and the development of flaccid and areflexic limbs were early clinical signs. However, electrophysiological studies, especially needle electrode examination of skeletal muscle, provided the definite evidence of polyneuropathy. The cause is uncertain, but the electrophysiological and morphological features indicate a primary axonal polyneuropathy with sparing of the central nervous system. Nutritional factors may have played a role, since the polyneuropathy improved in all five patients after total parenteral nutrition had been started, including the three patients who later died of unrelated causes. The features allow diagnosis during life, and encourage continued intensive management since recovery from the polyneuropathy may occur. Images PMID:6094735
Fraser, S.; Walters, J.
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 PMID:10786323
Chochinov, Harvey Max; Kristjanson, Linda J.; Breitbart, William; McClement, Susan; Hack, Thomas F; Hassard, Tom; Harlos, Mike
Objectives Dignity Therapy is a unique, individualized, brief psychotherapy, developed for patients (and their families) living with life threatening or life limiting illness. The purpose of this study was to determine if Dignity Therapy could mitigate distress and/or bolster end-of-life experience for patients nearing death. Trial Design Multi-site randomized controlled trial, with patients assigned to Dignity Therapy, Client Centred Care or Standard Palliative Care. Study arm assignment was based on a computer-generated table of random numbers. Blinding was achieved using opaque sealed envelopes, containing allocations that were only opened once consent had been obtained. Participants Patients receiving hospital or community (hospice or home) based palliative care, in Winnipeg, New York, or Perth, randomly assigned to, Dignity Therapy [n=108], Client Centered Care [n=107] and Standard Palliative Care (n=111). Main Outcome Measures The primary outcome measures included the FACIT Spiritual Well-Being Scale, the Patient Dignity Inventory, the Hospital Anxiety and Depression Scale; items from the Structured Interview for Symptoms and Concerns, the Quality of Life Scale and a modified Edmonton Symptom Assessment Scale. Mean changes between baseline and end of intervention ratings were determined. Secondary outcomes, examining self-report end-of-life experience, consisted of a post-study survey administered across all study arms. Intervention Dignity Therapy, a novel, brief psychotherapy, provides patients with life threatening and life limiting illnesses an opportunity to speak about things that matter most to them. These recorded conversations form the basis of a generativity document, which patients can bequeath to individuals of their choosing. Client Centred Care is a supportive psychotherapeutic approach, in which research nurse/therapists guide patients through discussions focusing on here and now issues. Findings No significant differences across study arms
Slooter, A J C; Van De Leur, R R; Zaal, I J
Delirium is common in critically ill patients and associated with increased length of stay in the intensive care unit (ICU) and long-term cognitive impairment. The pathophysiology of delirium has been explained by neuroinflammation, an aberrant stress response, neurotransmitter imbalances, and neuronal network alterations. Delirium develops mostly in vulnerable patients (e.g., elderly and cognitively impaired) in the throes of a critical illness. Delirium is by definition due to an underlying condition and can be identified at ICU admission using prediction models. Treatment of delirium can be improved with frequent monitoring, as early detection and subsequent treatment of the underlying condition can improve outcome. Cautious use or avoidance of benzodiazepines may reduce the likelihood of developing delirium. Nonpharmacologic strategies with early mobilization, reducing causes for sleep deprivation, and reorientation measures may be effective in the prevention of delirium. Antipsychotics are effective in treating hallucinations and agitation, but do not reduce the duration of delirium. Combined pain, agitation, and delirium protocols seem to improve the outcome of critically ill patients and may reduce delirium incidence.
Namasivayam, Pathmavathy; Orb, Angélica; O'Connor, Margaret
Caring for families of the terminally ill is an important aspect of nursing care as nurses are considered the main health care professionals who are closest to families. This paper describes the experience of seven registered nurses caring for families of the terminally ill in Western Australia. Five of the nurses worked in an acute area at a public hospital; the other two nurses worked at long-term care settings at a private hospital. Descriptive phenomenology as described by Husserl (1970) was used to describe and explore nurses' lived experience. Data were collected through in depth interviews and analysed using the Colaizzi method. Four major themes are reported in this paper: 1) walking a journey together; 2) dealing with intense emotions; 3) working as a team; and 4) balancing the dimension of care. Nurses' lived experiences of caring for families of terminally ill patients revealed that nurses are confronted by families' emotions and at the same time needed to manage their own emotions. The findings further indicated that nurses play a significant role in caring for families of the terminally ill. The family's fear of losing their loved ones often resulted in conflicts, which required extra time from nurses. Moreover, some of the major barriers identified were time constraints and excessive workloads. Finally, some implications of the findings for registered nurses are discussed.
Kayser-Jones, Jeanie; Kris, Alison E; Lim, Kyung-Choon; Walent, Ronald J; Halifax, Elizabeth; Paul, Steven M
The purpose of this prospective, anthropological study was to describe and analyze the experiences and care of terminally ill nursing home residents who were admitted with or acquired pressure ulcers (PUs) after admission. Data were collected in two proprietary nursing homes. Participant observation, in-depth interviews, event analysis, and chart review were used to obtain data. A total of 64 (54.7%) of the 117 terminally ill residents in the study had PUs; 52 (81.3%) of whom died with PUs. The findings disclosed that the absence of family advocacy, inability to speak English, and inadequate staffing and lack of supervision, along with other previously reported risk factors, contributed to the development of PUs. Specifically, inadequate staffing and lack of supervision led to inadequate assistance at mealtime, infrequent repositioning, and inadequate continence care, which in turn led to weight loss, unrelieved pressure on bony prominences, and moist, irritated skin. The outcome was a high rate of residents dying with PUs. Knowledge of and attention to these risk factors can guide nurses in the prevention and management of PUs.
Carrier, Paul; Debette-Gratien, Marilyne; Girard, Murielle; Jacques, Jérémie; Nubukpo, Philippe; Loustaud-Ratti, Véronique
Patients with psychiatric disorders are usually more exposed to multiple somatic illnesses, including liver diseases. Specific links are established between psychiatric disorders and alcohol hepatitis, hepatitis B, and hepatitis C in the population as a whole, and specifically in drug abusers. Metabolic syndrome criteria, and associated steatosis or non-alcoholic steato-hepatitis (NASH) are frequent in patients with chronic psychiatric disorders under psychotropic drugs, and should be screened. Some psychiatric medications, such as neuroleptics, mood stabilizers, and a few antidepressants, are often associated with drug-induced liver injury (DILI). In patients with advanced chronic liver diseases, the prescription of some specific psychiatric treatments should be avoided. Psychiatric disorders can be a limiting factor in the decision-making and following up for liver transplantation. PMID:28123443
Lindley, Lisa C
Within the Patient Protection and Affordable Care Act of 2010 or health care reform, is a relatively small provision about concurrent curative care that significantly affects terminally ill children. Effective on March 23, 2010, terminally ill children, who are enrolled in a Medicaid or state Children's Health Insurance Plans (CHIP) hospice benefit, may concurrently receive curative care related to their terminal health condition. The purpose of this article was to conduct a policy analysis of the concurrent curative care legislation by examining the intended goals of the policy to improve access to care and enhance quality of end of life care for terminally ill children. In addition, the policy analysis explored the political feasibility of implementing concurrent curative care at the state-level. Based on this policy analysis, the federal policy of concurrent curative care for children would generally achieve its intended goals. However, important policy omissions focus attention on the need for further federal end of life care legislation for children. These findings have implications nurses.
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…
therapy, pain medication, nutritional and psychological support, thoracocentesis and/or tube thorascopy.”44 Three studies described supportive care... gestalt survival expectation is presented without loss of contradictory information. This increases the transparency and traceability of the...and/ or psychological damages to the patient. Specifically, a patient may suffer harms due to a treatment strategy (e. g. adverse effects) or
Waldrop, Deborah P.
Caregivers experience multiple losses during the downhill trajectory of a loved one's terminal illness. Using mixed methods, this two-stage study explored caregiver grief during a terminal illness and after the care recipient's death. Caregiver grief was a state of heightened responsiveness during end-stage care: anxiety, hostility, depression,…
Manis, Amie A.; Bodenhorn, Nancy
This article presents a review of the literature on counseling adults with terminal illness, particularly the literature on the nature of preparation that counselors and other professionals who attend to the needs of adults with a terminal illness require. The authors review information and findings from philosophical, psychological, practical,…
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…
staff greatly determine the social context in which dying occurs. 2 0 The work of Elizateth Kubler -Ross on death and dying, and the subsequent...of the patient. 47 SELECTED BIBLIOGRAPHY Socks Allen, George R. The Graduate Students’ Guide to Thesis and Dissertations. California: Jossey-Bass, Inc...Medicine. 2nd Ed. 1982, Lea & Feteger, Philadelphia. Kubler -Ross, Elisabeth. On Death and Dying. New York: Macmillian Publishing Co., Inc., 1969
regarding continuation of life-sustaining vs. palliative care . Finally, using regret DCA, the optimal decision for the specific patient is suggested...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...Analysis and Regret theory to compare multiple decision strategies based on the decision maker’s personal attitudes towards each strategy
Delgado Sevilla, David; Juarez Vela, Raúl; Pellicer García, Begoña; Redondo Castán, Luis Carlos; Ramón Arbués, Enrique; López Martín, Inmaculada; De Blas Gómez, Irene; Alburquerque Medina, Eulalia
Palliative care is a group of actions performed by nurses in order to increase the comfort and well-being of patients with terminal illnesses. The World Health Organization (WHO) defines this term as: An approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual . Cicely Mary Strode Saunders is considered as the precursor of the palliative care, who explained the need to change the Palliative Care Units in order to improve the quality of life of patients with terminal illnesses. Palliative care is necessary for patients with a terminal illness. In such cases, the life expectancy is less than six months. Human being is considered a biopsychosocial model. For this reason, the nurse must take into account all the requirements arising from these three dimensions of the human being. In this essay, we deal with palliative care in patients with terminal illnesses, considering the role of the nurse as an important reference when teaching palliative care to the main carer.
Namendys-Silva, Silvio A; Hernández-Garay, Marisol; García-Guillén, Francisco J; Correa-García, Paulina; Herrera Gómez, Angel; Meneses-García, Abelardo
Severe metabolic alterations frequently occur in critically ill cancer patients; hypercalcemia, hypocalcemia, hyponatremia, tumor lysis syndrome, metabolic complications of renal failure and lactic acidosis. Cancer patients with metabolic emergencies should be treated in a medical oncology department or an intensive care unit. Most metabolic emergencies can be treated properly when they are identified early. The clinician should consider that the prognosis of critically ill cancer patients depends on their primary disease, comorbidities and organ failure.
Duba, Jill D.; Magenta, Mary
End-of-life care is continuously becoming an issue of paramount importance given an increase in medical advances, the aging of the population, and the movement toward contributing toward a quality of life among terminally ill patients. However, there is a dearth in literature related to this topic specifically in terms of preparing counselors to…
Vassalo, Juliana; Spector, Nelson; de Meis, Ernesto; Soares, Márcio; Salluh, Jorge Ibrain Figueira
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. PMID:25028953
Wood, Felicity Juliette
Terminally ill prison inmates have a right to all aspects of health care including palliative care provision. However, there are numerous difficulties in providing palliative care to high-security prisoners in the UK. Local community hospices may be reluctant to admit terminally ill prisoners and therefore initiatives must be established to provide appropriate palliative care within the prison itself. Dying prisoners need companionship and to be shown respect and compassion to avoid feelings of loneliness and hopelessness. Inmate volunteers can provide an invaluable source of support and friendship for the terminally ill prisoner, helping to improve quality of life.
McCandless, N J; Conner, F P
While sexism and ageism in the health care system have been systematically documented, nowhere is the treatment of aging women more androcentric than in the care for the terminally ill. In fact, a terminally ill older woman is too often disadvantaged by a health care system which excludes her from decision-making and renders her powerless. In response, we propose a feminist approach to health care for terminally ill older women and argue that it is this approach which will not only put knowledge and power into the hands of women, but will change the fundamental ways in which women approach death.
Krychtiuk, Konstantin A.; Honeder, Maria C.; Lenz, Max; Maurer, Gerald; Wojta, Johann; Heinz, Gottfried; Huber, Kurt; Speidl, Walter S.
Background Critically ill patients admitted to a medical intensive care unit exhibit a high mortality rate irrespective of the cause of admission. Besides its role in fluid and electrolyte balance, vasopressin has been described as a stress hormone. Copeptin, the C-terminal portion of provasopressin mirrors vasopressin levels and has been described as a reliable biomarker for the individual’s stress level and was associated with outcome in various disease entities. The aim of this study was to analyze whether circulating levels of copeptin at ICU admission are associated with 30-day mortality. Methods In this single-center prospective observational study including 225 consecutive patients admitted to a tertiary medical ICU at a university hospital, blood was taken at ICU admission and copeptin levels were measured using a commercially available automated sandwich immunofluorescent assay. Results Median acute physiology and chronic health evaluation II score was 20 and 30-day mortality was 25%. Median copeptin admission levels were significantly higher in non-survivors as compared with survivors (77.6 IQR 30.7–179.3 pmol/L versus 45.6 IQR 19.6–109.6 pmol/L; p = 0.025). Patients with serum levels of copeptin in the third tertile at admission had a 2.4-fold (95% CI 1.2–4.6; p = 0.01) increased mortality risk as compared to patients in the first tertile. When analyzing patients according to cause of admission, copeptin was only predictive of 30-day mortality in patients admitted due to medical causes as opposed to those admitted after cardiac surgery, as medical patients with levels of copeptin in the highest tertile had a 3.3-fold (95% CI 1.66.8, p = 0.002) risk of dying independent from APACHE II score, primary diagnosis, vasopressor use and need for mechanical ventilation. Conclusion Circulating levels of copeptin at ICU admission independently predict 30-day mortality in patients admitted to a medical ICU. PMID:28118414
Longley, Alison J; Doyle, Patricia E
Virtually every oral health care practice includes patients with mental illness. This continuing education (CE) course gives a practical overview of common psychiatric disorders, their effects on oral and dental health, and conditions associated with mental illness that affect oral health treatment. Following a brief description of mental illnesses, information on conducting a mental health interview and making a psychiatric referral are provided. Oral health problems associated with mental illness and factors affecting treatment delivery are discussed, as well as ideas for avoiding potentially dangerous medication interactions and working with fearful, suspicious, or cognitively impaired patients. Ways in which dental hygienists can work with case managers to provide much needed oral health care to patients whose illness is severe or chronic are covered. Examples are given of work with clients illustrating principles described in the text. The purpose of this course is to provide oral health personnel the information they need to knowledgeably care for patients who have mental illness. Successful completion will be assessed with a post-test to be completed after reading the article in its entirety, including figures and case-reports. Two continuing education course credit hours will be awarded following successful completion of the post-test.
Casaroto, Eduardo; Mohovic, Tatiana; Pinto, Lilian Moreira; de Lara, Tais Rodrigues
ABSTRACT The echocardiography has become a vital tool in the diagnosis of critically ill patients. The use of echocardiography by intensivists has been increasing since the 1990’s. This tool has become a common procedure for the cardiovascular assessment of critically ill patients, especially because it is non-invasive and can be applied in fast and guided manner at the bedside. Physicians with basic training in echocardiography, both from intensive care unit or emergency department, can assess the left ventricle function properly with good accuracy compared with assessment made by cardiologists. The change of treatment approach based on echocardiographic findings is commonly seen after examination of unstable patient. This brief review focuses on growing importance of echocardiography as an useful tool for management of critically ill patients in the intensive care setting along with the cardiac output assessment using this resource. PMID:26761560
Velissaris, Dimitrios; Karamouzos, Vassilios; Pierrakos, Charalampos; Aretha, Diamanto; Karanikolas, Menelaos
Magnesium (Mg), also known as "the forgotten electrolyte", is the fourth most abundant cation overall and the second most abundant intracellular cation in the body. Mg deficiency has been implicated in the pathophysiology of many diseases. This article is a review of the literature regarding Mg abnormalities with emphasis on the implications of hypomagnesemia in critical illness and on treatment options for hypomagnesemia in critically ill patients with sepsis. Hypomagnesemia is common in critically ill patients, and there is strong, consistent clinical evidence, largely from observational studies, showing that hypomagnesemia is significantly associated with increased need for mechanical ventilation, prolonged ICU stay and increased mortality. Although the mechanism linking hypomagnesemia with poor clinical outcomes is not known, experimental data suggest mechanisms contributing to such outcomes. However, at the present time, there is no clear evidence that magnesium supplementation improves outcomes in critically ill patients with hypomagnesemia. Large, well-designed clinical trials are needed to evaluate the role of magnesium therapy for improving outcomes in critically ill patients with sepsis.
Suárez, J C; López, P; Mancebo, J; Zapata, L
Left ventricular diastolic dysfunction is a common finding in critically ill patients. It is characterized by a progressive deterioration of the relaxation and the compliance of the left ventricle. Two-dimensional and Doppler echocardiography is a cornerstone in its diagnosis. Acute pulmonary edema associated with hypertensive crisis is the most frequent presentation of diastolic dysfunction critically ill patients. Myocardial ischemia, sepsis and weaning failure from mechanical ventilation also may be associated with diastolic dysfunction. The treatment is based on the reduction of pulmonary congestion and left ventricular filling pressures. Some studies have found a prognostic role of diastolic dysfunction in some diseases such as sepsis. The present review aims to analyze thoroughly the echocardiographic diagnosis and the most frequent scenarios in critically ill patients in whom diastolic dysfunction plays a key role.
Silva-Perez, Livier Josefina; Benitez-Lopez, Mario Alberto; Varon, Joseph; Surani, Salim
Disorders of glucose homeostasis, such as stress-induced hypoglycemia and hyperglycemia, are common complications in patients in the intensive care unit. Patients with preexisting diabetes mellitus (DM) are more susceptible to hyperglycemia, as well as a higher risk from glucose overcorrection, that may results in severe hypoglycemia. In critically ill patients with DM, it is recommended to maintain a blood glucose range between 140-180 mg/dL. In neurological patients and surgical patients, tighter glycemic control (i.e., 110-140 mg/d) is recommended if hypoglycemia can be properly avoided. There is limited evidence that shows that critically ill diabetic patients with a glycosylated hemoglobin levels above 7% may benefit from looser glycemic control, in order to reduce the risk of hypoglycemia and significant glycemic variability. PMID:28344751
Psychoneuroimmunology is the study of the interactions among behavior, neural, and endocrine functions and the immune system. The purpose of this review is to briefly summarize the evidence concerning interactions among behavior, the neuroendocrine system, and the immune system, and to show how this evidence relates to critical care patients. It has been shown that the immune function of many patients in the intensive care unit is suppressed as a result of trauma, sepsis, or profound physiologic and psychological stress. Three of the most common stressors among patients in the intensive care unit are pain, sleep deprivation, and fear or anxiety. Findings have shown each of these stressors to be associated with decreased immune functioning. Nurses have an important responsibility to protect their patients from infection and promote their ability to heal. Several actions are suggested that can help the nurse achieve these goals. It is hoped that nurses would keep these interactions in mind while caring for their patients in the intensive care unit.
Noh, Hyunjin; Schroepfer, Tracy A
The underuse of hospice care by terminally ill African American elders suggests they are suffering when hospice care could offer quality end of life care. Guided by the Behavioral Model for Vulnerable Populations, this study sought understanding of structural barriers faced when seeking access to hospice care and reasons for using it when access is possible. Data was collected through interviews with 28 African American hospice patients. Themes from directed content analysis provide insights into strategies used to overcome access barriers posed by income, health insurance and administrative procedure, as well as the role religion, family, information and health beliefs played in using it. Distributing educational materials and addressing spiritual/religious concerns in choosing hospice care are key in promoting African Americans' use of hospice care.
Burgos Peláez, Rosa; Escudero Álvarez, Elena; García Almeida, Jose Manuel; García de Lorenzo, Abelardo; García Luna, Pedro Pablo; Gil Hernández, Angel; Matos Adames, Alfredo; Molina Soria, Juan Bautista; Montejo González, Juan Carlos; Sánchez Alvarez, Carmen; Perez de la Cruz, Antonio
"Pharmaconutrient" is a term applicable to those compounds which. in addition to their nutritional function, play a role as aids in the treatment of patients with severe pathologies, including sepsis, trauma, burns and major surgery, In general, enrichment of enteral an parenteral formulas with pharmaconutrients contribute to positively modulate the inflammatory response, infection and controlling the internal milieu, which in turn can be evaluated through lower mortality, hospital and intensive care units stay, days of mechanical ventilation and other parameters allowing to asses their effects. Arginine, glutamine, nucleotides, omega-3 fatty acids and antioxidant micronutrients, make up the nucleus of pharmaconutrients used with that aim, usually as mixtures of them. In the present review current evidence about the effects, indications, limitations, doses, potential adverse risks and even counter-indications is analysed.
Young, Sam; Speare, Rick; Berger, Lee; Skerratt, Lee F
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.
Stillman, A E; Braitman, L E; Grant, R J
Our goal was to determine whether critically ill older patients are treated differently than middle-aged patients. If so, what factors besides age contribute to that difference? Internal medicine residents (n = 46) and practicing internists (n = 41) received 8 clinical vignettes of 4 critically ill 85-year-old patients and 4 critically ill 50-year-old patients. Each patient had a distinct premorbid mental and physical state. Each respondent selected from 4 levels of therapeutic aggressiveness for each patient. The main outcome measure was the proportion of physicians who intended to treat the older of each matched pair of patients less aggressively than the younger one (that is, downgraded for age). Eight physicians (9%) treated a previously unimpaired 85-year-old patient less aggressively than a comparable 50-year-old patient. When the matched patients were either premorbidly mentally or physically impaired (but not both), about 20% of physicians downgraded for age. Most downgraded for age in matched patients who were premorbidly both mentally and physically impaired. We conclude that age alone does not engender much therapeutic bias against older patients as long as they are physically and mentally intact before the onset of their acute illness. As premorbid disabilities multiply, older patients may be treated less aggressively than younger ones with similar impairments and clinical presentations. PMID:9771155
Fliers, Eric; Bianco, Antonio C; Langouche, Lies; Boelen, Anita
Patients in the intensive care unit (ICU) typically present with decreased concentrations of plasma tri-iodothyronine, low thyroxine, and normal range or slightly decreased concentration of thyroid-stimulating hormone. This ensemble of changes is collectively known as non-thyroidal illness syndrome (NTIS). The extent of NTIS is associated with prognosis, but no proof exists for causality of this association. Initially, NTIS is a consequence of the acute phase response to systemic illness and macronutrient restriction, which might be beneficial. Pathogenesis of NTIS in long-term critical illness is more complex and includes suppression of hypothalamic thyrotropin-releasing hormone, accounting for persistently reduced secretion of thyroid-stimulating hormone despite low plasma thyroid hormone. In some cases distinguishing between NTIS and severe hypothyroidism, which is a rare primary cause for admission to the ICU, can be difficult. Infusion of hypothalamic-releasing factors can reactivate the thyroid axis in patients with NTIS, inducing an anabolic response. Whether this approach has a clinical benefit in terms of outcome is unknown. In this Series paper, we discuss diagnostic aspects, pathogenesis, and implications of NTIS as well as its distinction from severe, primary thyroid disorders in patients in the ICU.
Melson, S J; Rynearson, E K
In our psychiatric practice in Seattle, we have found several cases of complicated bereavement in which the patient has been unable to accept the death of her mother for an unusually long time and, consequently, continues to complain of physical symptoms similar to those of her mother. These patients initially sought medical care from primary care physicians, who tried to treat the symptoms without considering the cause. In some instances, needless medical and even surgical procedures were pursued to no avail. We believe that such patients usually require only referral for psychiatric care, which unfortunately often is palliative but not curative.
... signature on the certification or recertification form, the physician must also sign immediately following... contain check boxes or standard language used for all patients. (v) The narrative associated with the...
Undurraga F, Juan P; González, Matías; Calderón, Jorge
During the last decades we have witnessed a progressive aging of the general population and a higher prevalence of chronic disease. This fact along with the appearance of infectious diseases like AIDS, anticipates that more patients will benefit from comprehensive palliative care. The objective of this article is to propose a simple, integral and effective method of emotional support to the patient, family and health team in palliative care (PC). PC receives little attention in medical schools, despite the great impact it has on standard health practice and quality of life of patients and their families. Our proposed method, counselling, has been empirically studied and proven to be an effective therapeutic tool in promoting behavioural changes that favour the outcome of many conditions. We believe that it facilitates PC practice, promoting direct conversation and identifying issues that can potentially cause suffering to the patients. It is based on the patient's autonomy, considers his multiple dimensions, uses and stimulates patient's own resources and coping strategies, to improve quality of life
Rossi Ferrario, Silvia; Giorgi, Ines; Baiardi, Paola; Giuntoli, Laura; Balestroni, Gianluigi; Cerutti, Paola; Manera, Marina; Gabanelli, Paola; Solara, Valentina; Fornara, Roberta; Luisetti, Michela; Omarini, Pierangela; Omarini, Giovanna; Vidotto, Giulio
Purpose Interest in assessing denial is still present, despite the criticisms concerning its definition and measurement. We tried to develop a questionnaire (Illness Denial Questionnaire, IDQ) assessing patients’ and caregivers’ denial in relation to their illness/disturbance. Patients and methods After a preliminary study, a final version of 24 dichotomous items (true/false) was selected. We hypothesized a theoretical model with three dimensions: denial of negative emotions, resistance to change, and conscious avoidance, the first two composing the actual Denial and the last representing an independent component of the illness denial behavior. The IDQ was administered to 400 subjects (219 patients and 181 caregivers) together with the Anxiety–Depression Questionnaire – Reduced form (AD-R), in order to assess concurrent validity. Confirmatory factor analysis (CFA), internal consistency indices (Cronbach’s α and McDonald’s ω), and test–retest analysis were performed. Results CFA and internal consistency indices (Cronbach’s α: 0.87–0.96) indicated a clear and meaningful three-factor structure of IDQ, for both patients and caregivers. Further analyses showed good concurrent validity, with Denial and its subscale negatively associated with anxiety and depression and avoidance positively associated with anxiety and depression. The IDQ also showed a good stability (r from 0.71 to 0.87). Conclusion The IDQ demonstrated good psychometric properties. Denial of negative emotions and resistance to change seem to contribute to a real expression of denial, and conscious avoidance seems to constitute a further step in the process of cognitive–affective elaboration of the illness. PMID:28356745
McCarley, Tracey H.
The dying patient reacts emotionally to the problems encountered in the terminal period according to his established pattern of response to stress. The nature of this pattern will play a part in his experience of pain. Some of the types of reaction include the bizarre misinterpretation of bodily sensation of the psychotic, the development of conversion symptoms, the increase in pain through muscle tension in the anxious but overcontrolled person, and the stoical acceptance by guilt-ridden patients. Physicians are sometimes reluctant to devote full attention to the care of the terminally ill for a number of reasons, including the attitude that “curing” is the only worthwhile activity of a doctor of medicine. Observers have found that the physician's attention to the day to day anxieties of the patient in a terminal stage may contribute substantially to his comfort. PMID:18732651
Kuzmanovska, Biljana; Cvetkovska, Emilija; Kuzmanovski, Igor; Jankulovski, Nikola; Shosholcheva, Mirjana; Kartalov, Andrijan; Spirovska, Tatjana
Introduction: Rhabdomyolysis is a syndrome of injury of skeletal muscles associated with myoglobinuria, muscle weakness, electrolyte imbalance and often, acute kidney injury as severe complication. The aim: of this study is to detect the incidence of rhabdomyolysis in critically ill patients in the surgical intensive care unit (ICU), and to raise awareness of this medical condition and its treatment among the clinicians. Material and methods: A retrospective review of all surgical and trauma patients admitted to surgical ICU of the University Surgical Clinic “Mother Teresa” in Skopje, Macedonia, from January 1st till December 31st 2015 was performed. Patients medical records were screened for available serum creatine kinase (CK) with levels > 200 U/l, presence of myoglobin in the serum in levels > 80 ng/ml, or if they had a clinical diagnosis of rhabdomyolysis by an attending doctor. Descriptive statistical methods were used to analyze the collected data. Results: Out of totally 1084 patients hospitalized in the ICU, 93 were diagnosed with rhabdomyolysis during the course of one year. 82(88%) patients were trauma patients, while 11(12%) were surgical non trauma patients. 7(7.5%) patients diagnosed with rhabdomyolysis developed acute kidney injury (AKI) that required dialysis. Average values of serum myoglobin levels were 230 ng/ml, with highest values of > 5000 ng/ml. Patients who developed AKI had serum myoglobin levels above 2000 ng/ml. Average values of serum CK levels were 400 U/l, with highest value of 21600 U/l. Patients who developed AKI had serum CK levels above 3000 U/l. Conclusion: Regular monitoring and early detection of elevated serum CK and myoglobin levels in critically ill surgical and trauma patients is recommended in order to recognize and treat rhabdomyolysis in timely manner and thus prevent development of AKI. PMID:27703296
Kurt, Layla J.; Piazza, Nick J.
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).
Sauer, Michael Paul
The purpose of this dialogical qualitative research study was to gain insight into the process of storytelling with adults diagnosed with terminal illness as a way of making meaning of their experiences and lives. The study was informed by the conceptual frameworks of story, storytelling, and story listening which are grounded in the theory of…
Rice, Craig J.; Gourley, Junean Krajewski
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)
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.
... include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months... clinical findings of the face-to-face encounter support a life expectancy of 6 months or less. (4) The... must have a face-to-face encounter with each hospice patient whose total stay across all hospices...
... include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months... clinical findings of the face-to-face encounter support a life expectancy of 6 months or less. (4) The... must have a face-to-face encounter with each hospice patient whose total stay across all hospices...
... include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months... clinical findings of the face-to-face encounter support a life expectancy of 6 months or less. (4) The... must have a face-to-face encounter with each hospice patient whose total stay across all hospices...
O'Brien, Mary R; Clark, David
Stories about illness have proven invaluable in helping health professionals understand illness experiences. Such narratives have traditionally been solicited by researchers through interviews and the collection of personal writings, including diaries. These approaches are, however, researcher driven; the impetus for the creation of the story comes from the researcher and not the narrator. In recent years there has been exponential growth in illness narratives created by individuals, of their own volition, and made available for others to read in print or as Internet accounts. We sought to determine whether it was possible to identify such material for use as research data to explore the subject of living with the terminal illness amyotrophic lateral sclerosis/motor neuron disease--the contention being that these accounts are narrator driven and therefore focus on issues of greatest importance to the affected person. We encountered and sought to overcome a number of methodological and ethical challenges, which is our focus here.
Cotta, M O; Roberts, J A; Lipman, J
The judicious use of existing antibiotics is essential for preserving their activity against infections. In the era of multi-drug resistance, this is of particular importance in clinical areas characterized by high antibiotic use, such as the ICU. Antibiotic dose optimization in critically ill patients requires sound knowledge not only of the altered physiology in serious infections - including severe sepsis, septic shock and ventilator-associated pneumonia - but also of the pathogen-drug exposure relationship (i.e. pharmacokinetic/pharmacodynamic index). An important consideration is the fact that extreme shifts in organ function, such as those seen in hyperdynamic patients or those with multiple organ dysfunction syndrome, can have an impact upon drug exposure, and constant vigilance is required when reviewing antibiotic dosing regimens in the critically ill. The use of continuous renal replacement therapy and extracorporeal membrane oxygenation remain important interventions in these patients; however, both of these treatments can have a profound effect on antibiotic exposure. We suggest placing emphasis on the use of therapeutic drug monitoring and dose individualization when optimizing therapy in these settings.
Vitrat, Virginie; Hautefeuille, Serge; Janssen, Cécile; Bougon, David; Sirodot, Michel; Pagani, Leonardo
Critically ill patients with infection in the intensive care unit (ICU) would certainly benefit from timely bacterial identification and effective antimicrobial treatment. Diagnostic techniques have clearly improved in the last years and allow earlier identification of bacterial strains in some cases, but these techniques are still quite expensive and not readily available in all institutions. Moreover, the ever increasing rates of resistance to antimicrobials, especially in Gram-negative pathogens, are threatening the outcome for such patients because of the lack of effective medical treatment; ICU physicians are therefore resorting to combination therapies to overcome resistance, with the direct consequence of promoting further resistance. A more appropriate use of available antimicrobials in the ICU should be pursued, and adjustments in doses and dosing through pharmacokinetics and pharmacodynamics have recently shown promising results in improving outcomes and reducing antimicrobial resistance. The aim of multidisciplinary antimicrobial stewardship programs is to improve antimicrobial prescription, and in this review we analyze the available experiences of such programs carried out in ICUs, with emphasis on results, challenges, and pitfalls. Any effective intervention aimed at improving antibiotic usage in ICUs must be brought about at the present time; otherwise, we will face the challenge of intractable infections in critically ill patients in the near future. PMID:25349478
Nowicka-Sauer, Katarzyna; Banaszkiewicz, Dorota; Staśkiewicz, Izabela; Kopczyński, Piotr; Hajduk, Adam; Czuszyńska, Zenobia; Ejdys, Mariola; Szostakiewicz, Małgorzata; Sablińska, Agnieszka; Kałużna, Anna; Tomaszewska, Magda; Siebert, Janusz
The study evaluates the psychometric properties of a Polish translation of the Brief Illness Perception Questionnaire. A total of 276 patients with chronic conditions (58.7% women) completed the Brief Illness Perception Questionnaire and the Hospital Anxiety and Depression Scale. The internal consistency of the Polish Brief Illness Perception Questionnaire measured with Cronbach's alpha was satisfactory (α = 0.74). Structural validity was demonstrated by significant inter-correlations between the Brief Illness Perception Questionnaire components. Discriminant validity was supported by the fact that the Brief Illness Perception Questionnaire enables patients with various conditions to be differentiated. Significant correlations were found between Brief Illness Perception Questionnaire and depression and anxiety levels. The Polish Brief Illness Perception Questionnaire thus evaluated is a reliable and valid tool.
Dickerson, Roland N.
Critically ill older patients with sarcopenia experience greater morbidity and mortality than younger patients. It is anticipated that unabated protein catabolism would be detrimental for the critically ill older patient. Healthy older subjects experience a diminished response to protein supplementation when compared to their younger counterparts, but this anabolic resistance can be overcome by increasing protein intake. Preliminary evidence suggests that older patients may respond differently to protein intake than younger patients during critical illness as well. If sufficient protein intake is given, older patients can achieve a similar nitrogen accretion response as younger patients even during critical illness. However, there is concern among some clinicians that increasing protein intake in older patients during critical illness may lead to azotemia due to decreased renal functional reserve which may augment the propensity towards worsened renal function and worsened clinical outcomes. Current evidence regarding protein requirements, nitrogen balance, ureagenesis, and clinical outcomes during nutritional therapy for critically ill older patients is reviewed. PMID:27096868
Moliner Velázquez, S; Rubio Haro, R; De Andrés Serrano, C; De Andrés Ibáñez, J
Regional analgesia intrinsically, based on its physiological effects, is routinely used for the perioperative treatment of pain associated with surgical procedures. However, in other areas such as the non-surgical treatment of acute pain for patients in a critical condition, it has not been subjected to specific prospective studies. If we confine ourselves to the physiological effects of the nerve block, in a situation of stress, the indications for regional anaesthesia in this group of patients extend to the management of a wide variety of medical as well as postsurgical conditions, of trauma patients and of other painful procedures performed in the patient's bed. The critical patient certainly must be analyzed individually as their own primary conditions is of vital importance, as well as any associated conditions they have developed that can potentially increase the risk of systemic toxicity or morbidity, such as, coagulopathies, infection, immunosuppressive states, sedation and problems associated with mechanical ventilation. This review aims to assess the role of regional analgesia in critically ill patients, placing it within the algorithm decision tree of the professional responsible for patients in critical care units, all based on the evidence of potential benefits according to the published literature.
Hejazi, Najmeh; Mazloom, Zohreh; Zand, Farid; Rezaianzadeh, Abbas; Amini, Afshin
Background: Malnutrition is an important factor in the survival of critically ill patients. The purpose of the present study was to assess the nutritional status of patients in the intensive care unit (ICU) on the days of admission and discharge via a detailed nutritional assessment. Methods: Totally, 125 patients were followed up from admission to discharge at 8ICUs in Shiraz, Iran. The patients’ nutritional status was assessed using subjective global assessment (SGA), anthropometric measurements, biochemical indices, and body composition indicators. Diet prescription and intake was also evaluated. Results: Malnutrition prevalence significantly increased on the day of discharge (58.62%) compared to the day of admission (28.8%) according to SGA (P<0.001). The patients’ weight, mid-upper-arm circumference, mid-arm muscle circumference, triceps skinfold thickness, and calf circumference decreased significantly as well (P<0.001). Lean mass weight and body cell mass also decreased significantly (P<0.001). Biochemical indices showed no notable changes except for magnesium, which decreased significantly (P=0.013). A negative significant correlation was observed between malnutrition on discharge day and anthropometric measurements. Positive and significant correlations were observed between the number of days without enteral feeding, days delayed from ICU admission to the commencement of enteral feeding, and the length of ICU stay and malnutrition on discharge day. Energy and protein intakes were significantly less than the prescribed diet (26.26% and 26.48%, respectively). Conclusion: Malnutrition on discharge day increased in the patients in the ICU according to SGA. Anthropometric measurements were better predictors of the nutritional outcome of our critically ill patients than were biochemical tests. PMID:27217600
Nelson, William A.
The dying and death component of the psychiatry clerkship at Dartmouth Medical School is described. The educational objectives and instructional methods were developed to enhance the student's understanding of what terminal patients experience in psychosocial needs and to explore his role and skill in caring for patients in terminal situations.…
Hidalgo, F; Mas, D; Rubio, M; Garcia-Hierro, P
Severe burn patients are one subset of critically patients in which the burn injury increases the risk of infection, systemic inflammatory response and sepsis. The infections are usually related to devices and to the burn wound. Most infections, as in other critically ill patients, are preceded by colonization of the digestive tract and the preventative measures include selective digestive decontamination and hygienic measures. Early excision of deep burn wound and appropriate use of topical antimicrobials and dressings are considered of paramount importance in the treatment of burns. Severe burn patients usually have some level of systemic inflammation. The difficulty to differentiate inflammation from sepsis is relevant since therapy differs between patients with and those without sepsis. The delay in prescribing antimicrobials increases morbidity and mortality. Moreover, the widespread use of antibiotics for all such patients is likely to increase antibiotic resistance, and costs. Unfortunately the clinical usefulness of biomarkers for differential diagnosis between inflammation and sepsis has not been yet properly evaluated. Severe burn injury induces physiological response that significantly alters drug pharmacokinetics and pharmacodynamics. These alterations impact antimicrobials distribution and excretion. Nevertheless the current available literature shows that there is a paucity of information to support routine dose recommendations.
Holliday, R L; Doris, P 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. PMID:115566
Legal aspects of end-of-life decisions in Italy: the penal relevance of the limitation of treatment in the terminally ill and the problem of causality by omission. The legal puzzle of end-of-life care in Italy: is therapeutic limitation in the terminally ill patients a crime of omission liable to prosecution?
Fabris, E P; Piccinni, M
The interruption of life support poses different problems for he who interrogates himself regarding the possible juridical role of omissible behaviour or activities by part of the physician when dealing with end-of-life interventions within the boundary of life and death. The present contribution proposes to trace the coordinates necessary to answer the main query regarding the obligations which may be incumbent on the physician. For this reason, the necessity to interpret the legal sanctions in a technical key is highlighted. This is performed in sight of a progressive and inevitable adaptation to problems which are the result of a social evolution, and to the conception of values which constitute an object responsibility, as renewed by the constitution. The laws that discipline crimes against life and individual integrity must be interpreted while keeping in mind that the objective of maintaining the patient in life must be integrated with the control of suffering and the guarantee of a dignified death. When identifying the principles which have to inspire the decisions during 'borderline or boundary situations', it is highlighted the way the physician has to resort to a just equilibrium between benefit, which can be reasonably expected, and sacrifice, which should be imposed, taking into consideration the criteria of good clinical practice, among which attention to the patient's will must be taken into consideration.
Koekkoek, Bauke; van Tilburg, Willem
This case report offers a different perspective on a patient with a long-term non-psychotic psychiatric disorder that was difficult to specify. The patient, a man in his 50s, was unable to profit from outpatient treatment and became increasingly dependent on mental healthcare - which could not be understood based on his history and psychiatric symptoms alone. By separating symptoms from illness behaviour, the negative course of this patient's treatment is analysed. Focusing on ineffective chronic illness behaviour by the patient, and mutual ineffective treatment behaviour by the clinicians, it becomes clear that basic requirements of effective treatment were unmet. By making a proper diagnosis, clarifying expectations and offering a suitable therapy, ineffective illness behaviour was diminished and this 'difficult' case became much easier for both patient and clinicians. The illness behaviour framework offers a useful, systematic tool to analyse difficulties between patients and clinicians beyond psychiatric symptoms or explanations.
Liddy, Clare; Dusseault, Joanne J.; Dahrouge, Simone; Hogg, William; Lemelin, Jacques; Humber, Jennie
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
Kames, L D; Naliboff, B D; Heinrich, R L; Schag, C C
Two studies are presented which describe the development of a problem-oriented psychosocial screening instrument for use in health care settings. Reliability and validity data are presented on the Chronic Illness Problem Inventory (CIPI) which demonstrate its ability to document accurately patient's specific problems in areas of physical limitations, psychosocial functioning, health care behaviors and marital adjustment. A study is also presented which compares the problems of patients with three distinct chronic illnesses: pain, obesity, and respiratory ailments. Results indicate a significantly greater severity of problems for pain patients and especially patients with multiple pain complaints. Problem areas common to all three illness groups are discussed in the context of providing better comprehensive treatment for chronically ill patients.
LiPuma, Samuel H; DeMarco, Joseph P
As currently practiced, the use of continuous sedation until death (CSD) is controlled by clinicians in a way that may deny patients a key choice in controlling their dying process. Ethical guidelines from the American Medical Association and the American Academy of Pain Medicine describe CSD as a "last resort," and a position statement from the American Academy of Hospice and Palliative Medicine describe it as "an intervention reserved for extreme situations." Accordingly, patients must progress to unremitting pain and suffering and reach a last-resort stage before the option to pursue CSD is considered. Alternatively, we present and defend a new guideline in which decisionally capable, terminally ill patients who have a life expectancy of less than six months may request CSD before being subjected to the refractory suffering of a treatment of "last resort."
Bachner, Yaacov G.; O'Rourke, Norm; Carmel, Sara
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…
Glebocka, A; Gawor, A; Ostrowski, F
Euthanasia is an issue that generates an extensive social debate. Euthanasia is generally classified as either active or passive. The former is usually defined as taking specific steps to cause the patient's death, while the latter is described as withdrawal of medical treatment with the deliberate intention of bringing the patient's life to an end. The dispute on euthanasia involves a multitude of aspects including religious, legal, cultural, ethical, medical, and spiritual issues. The purpose of the present study was to examine the views of medical professionals toward the highly controversial issue of euthanasia. Accordingly, the research has been conducted among a group of Polish nurses and physicians working in Intensive Care and Oncology Units. Their views have been compared to those of the control group, which included the members of the general public, who do not work in medical profession. It was expected that the education and training and the day-to-day exposure to vegetative patients might influence the views of medical personnel concerning euthanasia. The research demonstrated that the members of all groups supported liberal views. Conservative views were not popular among the respondents. The physicians turned out to be the least conservative group. The survey has also demonstrated that there is a broad consensus that informational and psychological support should be provided to terminally ill patients and their relatives. The attitude toward the passive form of euthanasia seems to have broad support. In particular doctors tend to approve this form of bringing a terminally ill patient's life to an end. The active euthanasia is regarded with much less favor and physicians, in particular, appear to disapprove of it.
Reeve, Joanne; Lloyd-Williams, Mari; Payne, Sheila; Dowrick, Christopher
Biographical accounts of illness offer useful insights into the social and adaptive processes of living with chronic illness. Yet there are concerns that the underlying theoretical assumptions of a reflexive self seeking to maintain meaning may not reflect the lived experience of individuals. A narrative emphasis may neglect the importance of emotional/felt experiences; while an analytical focus on disruptive processes may not adequately reflect the totality of actual events. In this study, we explored how well biographical theory supports understanding of individual lived experience. Narratives from 19 individuals identified from General Practice lists with a terminal diagnosis of cancer were analysed using the holistic-form approach described by Lieblich. Participants described an ongoing process of living their life, 'managing' disruptive events and maintaining an overall sense of well-being (narrative form = biographical flow). For a minority, continuity was lost when people's capacity to continue living their everyday lives was overwhelmed (narrative form = fracture). The identified emphasis was on individual creative capacity in the face of terminal illness, highlighting the importance of embodied experience in understanding outcome and need. Maintaining continuity was draining: exhaustion precipitated fracture and thus need for external help to restore continuity. By focusing on feelings associated with overall narrative form, rather than individual disruptive events, we highlight the context in which disruptive events are experienced, and individual perceptions of their relative importance. We conclude that combining narrative and emotion offers new insights into the value of understanding of biographical accounts of illness in the context of individual creative capacity. We discuss the possibilities for new approaches to clinical assessment and management of need.
Hamdan-Mansour, Ayman M; Wardam, Lina A
The purpose of this study was to examine Jordanian mental health nurses' attitudes toward mental illness and patients with mental illness. A descriptive correlational design was utilized to collect data from 92 mental health nurses in Jordan. Data was collected on nurses' attitudes toward mental illness and patients with mental disorder and their satisfaction with nursing care delivery. The Jordanian mental health nurses who participated in this study had negative attitudes toward mental illness and toward patients with mental disorders. About 60% of the mental health nurses had perceived patients with mental illness to be dangerous, immature, dirty, cold hearted, harmful, and pessimistic. In only two descriptions-being polite and adult-did nurses have positive perception about patients with mental illness. Mental health nurse were not satisfied with nursing care delivery. More than 70% of nurses were proud to be a mental health nurse. Age and gender were significant influential factors in forming the nurses' attitudes or satisfaction. Immediate intervention is needed to improve the quality of patient care provided by mental health nurses.
Wedel, Kenneth R.
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)
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
Cheng, Ju-Fen; Lin, Ya-Ching; Huang, Pai-Ho; Wei, Chih-Hsin; Sun, Jia-Ling
Providing spiritual care to patients with advanced cancer may improve the quality of life of these patients and help them experience a good death. Cancer patients are eager for additional spiritual care and for a sense of peace at the end of their life. However, spirituality is an abstract concept. The literature on spiritual care focuses primarily on elaborations of spirituality theory. Thus, first-line medical care professionals lack clear guidelines for managing the spiritual needs of terminal cancer patients. The purposes of this article were to: 1) introduce a spiritual care model based on the concept of repair and recovery of relationships that addresses the relationship between the self and God, others, id, and objects and 2) set out a four-step strategy for this model that consists of understanding, empathizing, guiding, and growing. This article provides operational guidelines for the spiritual care of terminal cancer patients.
Echarte, Luis E.; Bernacer, Javier; Larrivee, Denis; Oron, J. V.; Grijalba-Uche, Miguel
A substantial minority of patients with terminal illness hold unrealistically hopeful beliefs about the severity of their disease or the nature of its treatment, considering therapy as curative rather than palliative. We propose that this attitude may be understood as self-deception, following the current psychological theories about this topic. In this article we suggest that the reason these patients deceive themselves is to preserve their belief systems. According to some philosophical accounts, the human belief system (HBS) is constituted as a web with a few stable central nodes – deep-seated beliefs – intimately related with the self. We hypothesize that the mind may possess defensive mechanisms, mostly non-conscious, that reject certain sensory inputs (e.g., a fatal diagnosis) that may undermine deep-seated beliefs. This interpretation is in line with the theory of cognitive dissonance. Following this reasoning, we also propose that HBS-related self-deception would entail a lower cognitive load than that associated with confronting the truth: whereas the latter would engage a myriad of high cognitive functions to re-configure crucial aspects of the self, including the setting of plans, goals, or even a behavioral output, the former would be mostly non-conscious. Overall, we believe that our research supports the hypothesis that in cases of terminal illness, (self-)deceiving requires less effort than accepting the truth. PMID:26903921
The study represents a completely new criminological phenomenon among homicide offenses: the killing of many very old terminally or incurably ill patients in hospitals and sometimes nursing homes. These homicides are a worldwide phenomenon. Six distinguishing indications of this phenomenon are differentiated from the traditional homicide criminology. Some statistical data of 11 nurses are presented, sentenced between 1976 and 1993 in the Federal Republic of Germany, Austria, Norway, the Netherlands, and in the United States of America. Centerpiece of this description is the differentiation of ten important characteristics of these homicidal acts. It is not possible to discuss the motives of this crime in detail.
Aoun, Samar M.; Breen, Lauren J.; Howting, Denise
Context: The number of terminally ill people who live alone at home and without a caregiver is growing and exerting pressure on the stretched resources of home-based palliative care services. Objectives: We aimed to highlight the unmet support needs of terminally ill people who live alone at home and have no primary caregiver and identify specific models of care that have been used to address these gaps. Methods: We conducted a narrative review of empirical research published in peer-reviewed journals in English using a systematic approach, searching databases 2002–2013. This review identified 547 abstracts as being potentially relevant. Of these, 95 were retrieved and assessed, with 37 studies finally reviewed. Results: Majority of the studies highlighted the reduced likelihood of this group to be cared for and die at home and the experiences of more psychosocial distress and more hospital admissions than people with a primary caregiver. Few studies reported on the development of models of care but showed that the challenges faced by this group may be mitigated by interventions tailored to meet their specific needs. Conclusion: This is the first review to highlight the growing challenges facing community palliative care services in supporting the increasing number of people living alone who require care. There is a need for more studies to examine the effectiveness of informal support networks and suitable models of care and to provide directions that will inform service planning for this growing and challenging group. PMID:25750828
Aoun, Samar M; Breen, Lauren J; Howting, Denise
Context: The number of terminally ill people who live alone at home and without a caregiver is growing and exerting pressure on the stretched resources of home-based palliative care services. Objectives: We aimed to highlight the unmet support needs of terminally ill people who live alone at home and have no primary caregiver and identify specific models of care that have been used to address these gaps. Methods: We conducted a narrative review of empirical research published in peer-reviewed journals in English using a systematic approach, searching databases 2002-2013. This review identified 547 abstracts as being potentially relevant. Of these, 95 were retrieved and assessed, with 37 studies finally reviewed. Results: Majority of the studies highlighted the reduced likelihood of this group to be cared for and die at home and the experiences of more psychosocial distress and more hospital admissions than people with a primary caregiver. Few studies reported on the development of models of care but showed that the challenges faced by this group may be mitigated by interventions tailored to meet their specific needs. Conclusion: This is the first review to highlight the growing challenges facing community palliative care services in supporting the increasing number of people living alone who require care. There is a need for more studies to examine the effectiveness of informal support networks and suitable models of care and to provide directions that will inform service planning for this growing and challenging group.
Bello, G; Paliani, G; Annetta, M G; Pontecorvi, A; Antonelli, M
The nonthyroidal illness syndrome (NTIS) is a clinical condition of abnormal thyroid function tests observed in patients with acute or chronic systemic illnesses. The laboratory parameters of NTIS usually include low serum levels of triiodothyronine, with normal or low levels of thyroxine and normal or low levels of thyroid-stimulating hormone. It is still a matter of controversy whether the NTIS represents a protective adaptation of the organism to a stressful event or a maladaptive response to illness that needs correction. Multiple studies have investigated the effect of thyroid hormone replacement therapy in certain clinical situations, such as caloric restriction, cardiac disease, acute renal failure, brain-dead potential donors, and burn patients. Treating patients with NTIS seems not to be harmful, but there is no persuasive evidence that it is beneficial. The administration of hypothalamic releasing factors in patients with NTIS appears to be safe and effective in improving metabolism and restoring the anterior pituitary pulsatile secretion in the chronic phase of critical illness. However, also this promising strategy needs to be explored further. Anyhow, an extremely prudent approach is needed if treatment is given. Much of the data appearing in the literature on the treatment of NTIS encourage further randomized controlled trials on large number of patients. At present, however, we believe that there is no indication for treating thyroid hormone abnormalities in critically ill patients until convincing proof of efficacy and safety is provided.
Chernow, B. )
This book contains papers addressing the pharmacologic approach to the critically ill patient. Chapter topics include: Radiation injury; Red cell substitutes: a current appraisal; and Psychopharmacology in the ICU.
The author proposes the training of physicians in the use of a protocol to help a patient draw up a Living Will. The successful use of such a training protocol could begin to meet the existing need for a more structured education in the care of the terminally ill and to minimize uncertainty by achieving standards of uniformity in this aspect of…
Hamrell, Burt B
A finding in the autopsy of John Paul Jones, the American Revolutionary War naval hero, may explain his terminal illness. During his last 2 years, he had a persistent productive cough and dyspnea. Ten days before death, he developed rapidly progressive dependent edema and ascites. He died in France in 1792. His body, preserved in alcohol in a lead coffin, was, in 1905, removed to the United States. Glomerulonephritis was noted on an autopsy, performed in France, but there was no comment then or since about ventricular wall thickness being the same in both ventricles at 5-6 mm. Hypertrophy and dilatation with biventricular failure followed by tissue shrinkage during 113 years in alcohol could have resulted in these ventricular wall findings. Systemic hypertension and left ventricular failure are consistent with his respiratory symptoms complicated perhaps by pulmonary emboli, right ventricular failure with tricuspid regurgitation, peripheral congestion, and jaundice.
Kunschitz, E; Friedrich, O; Schöppl, Ch; Maitz, J; Sipötz, J
The purpose of this study is to identify patterns of illness perception in patients with angiografically verified Coronary Artery Disease. A total of 166 patients (age: 64.4 ± 12.1, 80.7% male) were recruited after angiography. Cluster analysis on the items of the Brief Illness Perception Questionnaire was used to identify patterns of illness perception. The resulting groups were characterized with regard to Quality of Life (MacNew), anxiety and depression (GAD-7 and PHQ-9) and resilience (RS-13). The analysis revealed 4 distinct groups differing with regard to the items covering the perception of the physical and emotional impact of disease. Stronger perceptions in these domains were associated with lower Health Related Quality of Life and higher levels of emotional distress. Group 1 (33.1%) reported the strongest perceptions of the physical and emotional impact of disease and expressed low treatment control, high chronic timeline and significantly higher levels of depression than the other groups. Group 2 (27.7%) was characterized by more moderate perceptions of the emotional and physical impact of disease together with low scores on illness coherence and chronic timeline. Groups 3 (25.3%) and 4 (13.9%) reported smaller physical and emotional impact of illness but differed in chronic timeline. Our results correspond largely to recent findings in patients with other chronic diseases. Further research is needed to explore if stratification of patients according patterns of illness perception can help to inform patient-physician communication strategies.
Zhang, Yun-yun; Xu, Fan; Chu, Ming; Bi, Li-qing
Objective: To assess the incidence, possible risk factors and prognosis of pulmonary arterial hypertension (PAH) in critically ill elderly patients. Methods: We selected 122 cases admitted to the ICU, ages 60–93 years old. An echocardiography examination was performed within four days after admission to the ICU. PAH is usually suspected if the patient’s pulmonary artery systolic pressure ≥ 40 mmHg. We collected echocardiography data, relevant clinical data and routine laboratory data; we then used a statistical method to analyze the risk factors for PAH in critically ill elderly patients and examined its impact on the prognosis. Results: Total 51 patients were diagnosed with PAH. The prevalence of critically ill elderly patients with PAH was 41.8%. The ANOVA analysis showed that if patients had COPD (P = 0.031) and/or respiratory failure (P = 0.021), they were more prone to PAH. An enlarged left atrium (P = 0.038) and/or right ventricle (P = 0.029), a declining left ventricle fractional shortening rate (P = 0.038), and an elevated amount of the brain natriuretic peptides (P = 0.046) were all associated with the occurrence of PAH. Multivariate regression analysis showed that the left atrial diameter (P = 0.045) was the risk factor in critically ill elderly patients with PAH. The 30-day mortality rate was 33.3% for elderly patients with PAH, which is statistically significant (P = 0.035) when compared with the mortality rate of patients with normal pulmonary artery pressure. Our multivariate regression analysis also showed that, for critically ill elderly patients admitted in the ICU, PAH (P = 0.039) is risk factor for increased mortality. Conclusions: A higher incidence of PAH occurs in critically ill elderly patients. PAH is more likely to occur in patients with an enlarged left atrium, and these problems adversely impact the prognosis. PMID:28367167
Kyriaki, M; Eleni, T; Efi, P; Ourania, K; Vassilios, S; Lambros, V
In 1986, the European Organization for Research and Treatment (EORTC) initiated a research program to develop an integrated, modular approach for evaluating the quality of life of patients participating in international clinical trials. The questionnaire was designed to measure cancer patients' physical, psychological and social functions. The questionnaire is composed of 5 multiitem scales (physical, role, social, emotional and cognitive functioning) and 9 single items (pain, fatigue, financial impact, appetite loss, nausea/vomiting, diarrhea, constipation, sleep disturbance and quality of life). It was administered to the patients before the initiation of palliative treatment and then once again during the treatment. The validation of the questionnaire took place at Areteion Hospital, while the translation was conducted by the EORTC bureau. The final validation sample consisted of 120 cancer patients. The clinical variable assessed was the performance status. The aim of our study was to assess the applicability of this quality of life measurement on a Hellenic sample of cancer patients receiving palliative care. The results showed that the questionnaire was well accepted in the present patient population. In addition, the questionnaire was found to be useful in detecting the effectiveness of palliative treatment over time. The scale reliability was very good (pretreatment from 0.57-0.79, ontreatment from 0.56-0.75), especially for the functioning scale. In addition, very good validity was found in all the approaches used. Moreover, the factor analysis results in a 6-factor solution that satisfies the criteria of reproducibility, interpretability and confirmatory setting. Performance status showed an improvement (p < 0.0025) during the studied period. These results support that the QLQ-C30 (version 3.0) has proven to be a reliable and valid measure of the quality of life in Greek cancer patients receiving palliative care treatment.
Some people whom the health care manager encounters--employees as well as patients--seem to find their significance in being ill, partaking of the supposed benefits of being sick. For a variety of reasons, even the attention garnered in this manner may not be enough to meet an individual's needs so the behavior continues and intensifies. There are, however, several reasonable strategies available for dealing with persons who pursue illness for the underlying purpose of gaining attention.
The shift towards providing critical care in general wards has changed the way acutely ill patients are identified, treated and managed in hospital. This requires the expertise of knowledgeable, informed and capable staff. Effective education and appropriate knowledge and skills are required to aid identification of the deteriorating patient and provide prompt, timely and appropriate intervention to prevent further deterioration and possibly death. This article provides information about a systematic approach that will enable healthcare professionals to intervene to prevent deterioration in acutely ill patients.
Hartley, N A
Music therapists are constantly called upon to justify their work through research projects and evaluation processes. Rarely do we get the opportunity to talk personally about our work, the effects it has on us as music therapists, indeed, as human beings. This paper traces my own journey as a music therapist working with the terminally ill. Using audio extracts of music improvised with patients at the end of their lives, the concept of "attention" in music is addressed and explored. The paper will investigate: a) What is the difference between the quality of attention that is available to ourselves and our patients "in" music, as opposed to other ways of being together?; b) What does musical experience, particularly when achieved through improvisation, enable us and our patients to be that we cannot achieve in other ways?; c) Can "being in music" with another person fulfill a sense of longing that is evident in people at the end of their lives? In her book Waiting For God, Simone Weil suggests, "Those who are unhappy have no need for anything else in this world other than people capable of giving them their attention..." (1). Can the improvisation of music offer a unique and uncomplicated medium for being close?
Baiardini, I; Braido, F; Menoni, S; Bellandi, G; Savi, E; Canonica, G W; Macchia, D
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.
Bonnet, Caroline; Gagnayre, Remi; d'Ivernois, Jean Francois
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,…
The concept of careers has an extensive history in the sociology of health and illness. Among other things, the notion of a career has been used to describe the changing identities of patients diagnosed with mental illness, to identify distinct stages in the progression of various illnesses, and to recognize the cooperative efforts of hospitalized patients. However, the career concept may be reanalyzed as part of an analytical metaphor that makes salient both the agency of people with illnesses and the social structures in which they are enmeshed. This metaphor, ILLNESS IS WORK, can valorize and aid understanding of the identity work and actions of patients with chronic illnesses, particularly illnesses with a low degree of social recognition and medical prestige such as myalgic encephalopathy and chronic fatigue syndrome.
Hashem, Mohamed D; Parker, Ann M; Needham, Dale M
Neuromuscular disorders are increasingly recognized as a cause of both short- and long-term physical morbidity in survivors of critical illness. This recognition has given rise to research aimed at better understanding the risk factors and mechanisms associated with neuromuscular dysfunction and physical impairment associated with critical illness, as well as possible interventions to prevent or treat these issues. Among potential risk factors, bed rest is an important modifiable risk factor. Early mobilization and rehabilitation of patients who are critically ill may help prevent or mitigate the sequelae of bed rest and improve patient outcomes. Research studies and quality improvement projects have demonstrated that early mobilization and rehabilitation are safe and feasible in patients who are critically ill, with potential benefits including improved physical functioning and decreased duration of mechanical ventilation, intensive care, and hospital stay. Despite these findings, early mobilization and rehabilitation are still uncommon in routine clinical practice, with many perceived barriers. This review summarizes potential risk factors for neuromuscular dysfunction and physical impairment associated with critical illness, highlights the potential role of early mobilization and rehabilitation in improving patient outcomes, and discusses some of the commonly perceived barriers to early mobilization and strategies for overcoming them.
Farina, Nicholas; Smithburger, Pamela
Delirium is highly prevalent in the critically ill population and has been associated with numerous negative outcomes including increased mortality. The presentation of a delirious patient in the intensive care unit (ICU) is characterized by a fluctuating cognitive status and inattention that varies dramatically among patients. Delirium can present in 3 different motoric subtypes: hyperactive, hypoactive, and mixed. Two tools, the Intensive Care Delirium Screening Checklist and Confusion Assessment ICU, are validated and recommended for the detection of delirium in critically ill patients. The identification of delirium in a critically ill patient should be facilitated using one of these tools. An intermediate form of delirium known as subsyndromal delirium also exists, although the significance of this syndrome is largely unknown. Another phenomenon known as sedation-related delirium has been recently described, although more research is needed to understand its significance. Patients in the ICU are exposed to many risk factors for developing delirium; controlling these risk factors is essential for preventing delirium development in critically ill patients. Nonpharmacologic interventions have been shown to prevent patients from developing delirium. Prevention is crucial because once delirium develops pharmacologic therapy is limited. PMID:26715799
McCanny, Peter; Colreavy, Frances
Cardiac tamponade should be considered in a critically ill patient in whom the cause of haemodynamic shock is unclear. When considering tamponade, transthoracic echocardiography plays an essential role and is the initial investigation of choice. Diagnostic sensitivity of transthoracic echocardiography is dependent on image quality, and in some cases a transoesophageal approach may be required to confirm the diagnosis. Knowledge of the pathophysiology and echocardiographic features of cardiac tamponade are essential for the practicing Intensivist. This review presents an approach to the recognition, diagnosis, and treatment of cardiac tamponade in critically ill patients.
Carter, Chris; Snell, David
Critical illness in the developing world is a substantial burden for individuals, families, communities and healthcare services. The management of these patients will depend on the resources available. Simple conditions such as a fractured leg or a strangulated hernia can have devastating effects on individuals, families and communities. The recent Lancet Commission on Global Surgery and the World Health Organization promise to strengthen emergency and essential care will increase the focus on surgical services within the developing world. This article provides an overview of nursing the critically ill surgical patient in Zambia, a lower middle income country (LMIC) in sub-Saharan Africa.
Rondi, Céline; Berney, Alexandre
The use of social media as a communication tool is rapidly growing in the community, and more specifically in patients, through illness blogs. This has been true for several years in North America, but is becoming a reality in Europe as well. We report here the first results of studies on the putative psychological benefits and risks of illness blogs for their authors. We also explore the possible impact of blogging on the patient-caregiver relationship. Social media are expected to have a growing influence in certain areas of health care. Physicians should therefore stay informed about them, take advantage of their benefits, and anticipate their risks.
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.
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. PMID:23097280
Felton, TW; McCalman, K; Malagon, I; Isalska, B; Whalley, S; Goodwin, J; Bentley, AM; Hope, WW
Pulmonary infections in critically ill patients are common and associated with high morbidity and mortality. Piperacillin-tazobactam is a frequently used therapy in critically ill patients with pulmonary infection. Antibiotic concentrations in the lung reflect target site antibiotic concentrations in patients with pneumonia. The aim of this study was to assess the plasma and intra-pulmonary pharmacokinetics (PK) of piperacillin-tazobactam in critically ill patients administered standard piperacillin-tazobactam regimens. A population PK model was developed to describe plasma and intra-pulmonary piperacillin and tazobactam concentrations. The probability of piperacillin exposures reaching pharmacodynamic endpoints and the impact of pulmonary permeability on piperacillin and tazobactam pulmonary penetration was explored. The median piperacillin and tazobactam pulmonary penetration ratio was 49.3% and 121.2%, respectively. Pulmonary piperacillin and tazobactam concentration were unpredictable and negatively correlated to pulmonary permeability. Current piperacillin-tazobactam regimens may be insufficient to treat pneumonia caused by piperacillin-tazobactam susceptible organisms in some critically ill patients. PMID:24926779
Azoulay, Elie; Pène, Frédéric; Darmon, Michael; Lengliné, Etienne; Benoit, Dominique; Soares, Marcio; Vincent, Francois; Bruneel, Fabrice; Perez, Pierre; Lemiale, Virginie; Mokart, Djamel
The number of patients living with hematological malignancies (HMs) has increased steadily over time. This is the result of intensive and effective treatments that also increase the probability of infiltrative, infectious or toxic life threatening event. Over the last two decades, the number of patients with HMs admitted to the ICU increased and their mortality has dropped sharply. ICU patients with HMs require an extensive diagnostic workup and the optimal use of ICU treatments to identify the reason for ICU admission and the nature of the complication that explains organ dysfunctions. Mortality of ARDS or septic shock is up to 50%, respectively. In this review, the authors share their experience with managing critically ill patients with HMs. They discuss the main aspects of the diagnostic and therapeutic management of critically ill patients with HMs and argue that outcomes have improved over time and that many classic determinants of mortality have become irrelevant.
Bluman, Rabbi Olga F.; Klein, Linda; Thomas, Jay; Ferrell, Betty
Providing biopsychosocial/spiritual care for patients facing a life threatening illness can be complex, and this complexity can be amplified when a patient identifies as Jewish. A common but incorrect assumption is that a person who identifies him or herself as Jewish abides by the tenets of the Jewish religion. However, many Jews consider themselves Jewish in an ethnic or cultural sense rather than connected to a religion or belief in God. This case report presents an ethnic/cultural Jew with a life threatening illness of advanced lung cancer. Despite evidence of spiritual/existential suffering, this patient declined spiritual care. From an analysis of this case and clinical experience, we suggest exploratory questions that clinicians can use in response to common questions or statements made by such patients. This exploration may lead to a chaplain referral and we highlight interventions that chaplains and clinicians may find helpful as they come alongside Jewish patients. PMID:23614173
Godinjak, Amina; Iglica, Amer; Burekovic, Azra; Jusufovic, Selma; Ajanovic, Anes; Tancica, Ira; Kukuljac, Adis
Introduction: Hyperglycemia is a common complication of critical illness. Patients in intensive care unit with stress hyperglycemia have significantly higher mortality (31%) compared to patients with previously confirmed diabetes (10%) or normoglycemia (11.3%). Stress hyperglycemia is associated with increased risk of critical illness polyneuropathy (CIP) and prolonged mechanical ventilation. Intensive monitoring and insulin therapy according to the protocol are an important part of the treatment of critically ill patients. Objective: To evaluate the incidence of stress hyperglycemia, complications and outcome in critically ill patients in our Medical intensive care unit. Materials and methods: This study included 100 patients hospitalized in Medical intensive care unit during the period January 2014–March 2015 which were divided into three groups: Diabetes mellitus, stress-hyperglycemia and normoglycemia. During the retrospective-prospective observational clinical investigation the following data was obtained: age, gender, SAPS, admission diagnosis, average daily blood glucose, highest blood glucose level, glycemic variability, vasopressor and corticosteroid therapy, days on mechanical ventilation, total days of hospitalization in Medical intensive care unit, and outcome. Results: Patients with DM treated with a continuous insulin infusion did not have significantly more complications than patients with normoglycemia, unlike patients with stress hyperglycemia, which had more severe prognosis. There was a significant difference between the maximum level of blood glucose in recovered and patients with adverse outcome (p = 0.0277). Glycemic variability (difference between max. and min. blood glucose) was the strongest predictor of adverse outcome. The difference in glycemic variability between the stress-hyperglycemia and normoglycemic group was statistically significant (p = 0.0066). There was no statistically significant difference in duration of mechanical
Artificial nutrition (AN) is necessary to meet the nutritional requirements of critically ill patients at nutrition risk because undernutrition determines a poorer prognosis in these patients. There is debate over which route of delivery of AN provides better outcomes and lesser complications. This review describes the management of parenteral nutrition (PN) in critically ill patients. The first aim is to discuss what should be done in order that the PN is safe. The second aim is to dispel “myths” about PN-related complications and show how prevention and monitoring are able to reach the goal of “near zero” PN complications. Finally, in this review is discussed the controversial issue of the route for delivering AN in critically ill patients. The fighting against PN complications should consider: (1) an appropriate blood glucose control; (2) the use of olive oil- and fish oil-based lipid emulsions alternative to soybean oil-based ones; (3) the adoption of insertion and care bundles for central venous access devices; and (4) the implementation of a policy of targeting “near zero” catheter-related bloodstream infections. Adopting all these strategies, the goal of “near zero” PN complications is achievable. If accurately managed, PN can be safely provided for most critically ill patients without expecting a relevant incidence of PN-related complications. Moreover, the use of protocols for the management of nutritional support and the presence of nutrition support teams may decrease PN-related complications. In conclusion, the key messages about the management of PN in critically ill patients are two. First, the dangers of PN-related complications have been exaggerated because complications are uncommon; moreover, infectious complications, as mechanical complications, are more properly catheter-related and not PN-related complications. Second, when enteral nutrition is not feasible or tolerated, PN is as effective and safe as enteral nutrition. PMID
Hsiao, Chih-Yin; Chang, Chueh; Chen, Chih-Dao
Successful blood pressure (BP) control requires good adherence to medication and specific health-related behaviors. However, the BP control rate is not optimal, and limited research has focused on the patient's perspective. This study aimed at investigating the illness perceptions of hypertensive patients and how they relate to drug adherence. One hundred and seventeen hypertensive patients enrolled in this study, and data were collected in a family physician clinic of a medical center located in northern Taiwan. The Illness Perception Questionnaire was administered, and medication adherence and demographic data were also collected. Results showed the patients' perceptions of their hypertension, that it was a chronically severe but stable disease, and the patients were confident in the effectiveness of medical treatments and their ability to control their disease. The participants were divided into three clusters by cluster analysis. There were 46.15% participants in the first cluster; they had less negative belief in their illness consequence and less negative emotional responses, but a low personal sense of control. The second cluster (11.97%) had more negative emotional responses and more negative beliefs in their illness consequence, but these individuals scored highly on their personal sense of control and treatment control beliefs. The third cluster (41.88%) had scores between clusters 1 and 2. Cluster 1 had the best drug adherence, and cluster 2 had the worst drug adherence (χ(2) = 7.67, p < 0.05). It may be beneficial for clinical physicians to pay attention to patients' illness perceptions, including their negative emotional response and symptoms, in order to improve their drug adherence.
Artificial nutrition (AN) is necessary to meet the nutritional requirements of critically ill patients at nutrition risk because undernutrition determines a poorer prognosis in these patients. There is debate over which route of delivery of AN provides better outcomes and lesser complications. This review describes the management of parenteral nutrition (PN) in critically ill patients. The first aim is to discuss what should be done in order that the PN is safe. The second aim is to dispel "myths" about PN-related complications and show how prevention and monitoring are able to reach the goal of "near zero" PN complications. Finally, in this review is discussed the controversial issue of the route for delivering AN in critically ill patients. The fighting against PN complications should consider: (1) an appropriate blood glucose control; (2) the use of olive oil- and fish oil-based lipid emulsions alternative to soybean oil-based ones; (3) the adoption of insertion and care bundles for central venous access devices; and (4) the implementation of a policy of targeting "near zero" catheter-related bloodstream infections. Adopting all these strategies, the goal of "near zero" PN complications is achievable. If accurately managed, PN can be safely provided for most critically ill patients without expecting a relevant incidence of PN-related complications. Moreover, the use of protocols for the management of nutritional support and the presence of nutrition support teams may decrease PN-related complications. In conclusion, the key messages about the management of PN in critically ill patients are two. First, the dangers of PN-related complications have been exaggerated because complications are uncommon; moreover, infectious complications, as mechanical complications, are more properly catheter-related and not PN-related complications. Second, when enteral nutrition is not feasible or tolerated, PN is as effective and safe as enteral nutrition.
Lee, Woo Kyung; Hwang, Sena; Kim, Daham; Lee, Seul Gi; Jeong, Seonhyang; Seol, Mi-Youn; Kim, Hyunji; Ku, Cheol Ryong; Shin, Dong Yeop; Chung, Woong Youn; Lee, Eun Jig; Lee, Jandee; Jo, Young Suk
Abstract Nonthyroidal illness (NTI), often observed in critically ill patients, arises through diverse alterations in the hypothalamus-pituitary-thyroid (HPT) axis. However, the causal relationship between underlying disease and NTI diversity in critically ill patients is poorly understood. The aim of this study was to examine NTI severity and adverse outcomes in critically ill patients with respect to their underlying disease(s). The medical records of 616 patients admitted to the intensive care unit (ICU) between January 2009 and October 2014 were retrospectively reviewed. Patients with known diseases or taking medications that affect thyroid function were excluded. All-cause mortality (ACM) and length of stay (LOS) in the ICU were assessed as adverse outcomes. The enrolled patients (n = 213) were divided into the following 4 groups according to the severity of NTI at the nadir of their thyroid function test (TFT): normal (n = 11, 5.2%), mild NTI (n = 113, 53.1%), moderate NTI (n = 78, 36.6%), and severe NTI (n = 11, 5.2%). There was no significant difference between the groups in terms of age and gender. NTI severity showed a significantly strong association with ACM (P < 0.0001) and a significant positive association with LOS in the ICU (P = 0.031). After adjusting for age, gender, and current medications affecting TFT, increasing NTI severity led to increased ACM (odds ratio = 3.101; 95% confidence interval = 1.711–5.618; P < 0.0001). Notably, the prevalence of moderate-to-severe NTI was markedly higher in patients with infectious disease than in those with noninfectious disease (P = 0.012). Consistent with this, serum C-reactive protein levels were higher in patients with moderate-to-severe NTI (P = 0.016). NTI severity is associated with increased ACM, LOS, and underlying infectious disease. Future studies will focus on the biological and clinical implications of infectious disease on the HPT axis. PMID
Bion, J F; Abrusci, T; Hibbert, P
Unreliable delivery of best practice care is a major component of medical error. Critically ill patients are particularly susceptible to error and unreliable care. Human factors analysis, widely used in industry, provides insights into how interactions between organizations, tasks, and the individual worker impact on human behaviour and affect systems reliability. We adopt a human factors approach to examine determinants of clinical reliability in the management of critically ill patients. We conducted a narrative review based on a Medline search (1950-March 2010) combining intensive/critical care (units) with medical errors, patient safety, or delivery of healthcare; keyword and Internet search 'human factors' or 'ergonomics'. Critical illness represents a high-risk, complex system spanning speciality and geographical boundaries. Substantial opportunities exist for improving the safety and reliability of care of critically ill patients at the level of the task, the individual healthcare provider, and the organization or system. Task standardization (best practice guidelines) and simplification (bundling or checklists) should be implemented where scientific evidence is strong, or adopted subject to further research ('dynamic standardization'). Technical interventions should be embedded in everyday practice by the adjunctive use of non-technical (behavioural) interventions. These include executive 'adoption' of clinical areas, systematic methods for identifying hazards and reflective learning from error, and a range of techniques for improving teamworking and communication. Human factors analysis provides a useful framework for understanding and rectifying the causes of error and unreliability, particularly in complex systems such as critical care.
Litch, C. Scott; Liggett, Martha L.
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.…
Kamkar, Mohammad Zaman; Sanagoo, Akram; Zargarani, Fatemeh; Jouybari, Leila; Marjani, Abdoljalal
Background: Metabolic syndrome is commonly associated with cardiovascular diseases and psychiatric mental illness. Hence, we aimed to assess the metabolic syndrome among severe mental illness (SMI). Materials and Methods: The study included 267 patients who were referred to the psychiatric unit at 5th Azar Education Hospital of Golestan University of Medical Sciences in Gorgan, Iran. Results: The mean waist circumference, systolic and diastolic blood pressure, triglyceride and fasting blood glucose levels were significantly higher in the SMI with metabolic syndrome, but the high density lipoprotein (HDL)-cholesterol was significantly lower. The prevalence of metabolic syndrome in SMI patients was 20.60%. There were significant differences in the mean of waist circumference, systolic (except for women) and diastolic blood pressure, triglyceride, HDL-cholesterol and fasting blood glucose in men and women with metabolic syndrome when compared with subjects without metabolic syndrome. The prevalence of metabolic syndrome in SMI women was higher than men. The most age distribution was in range of 30-39 years old. The most prevalence of metabolic syndrome was in age groups 50-59 years old. The prevalence of metabolic syndrome was increased from 30 to 59 years old. Conclusion: The prevalence of metabolic syndrome in patients with SMI in Gorgan is almost similar to those observed in Asian countries. The prevalence of metabolic syndrome was lower than western countries. These observations may be due to cultural differences in the region. It should be mention that the families of mental illness subjects in our country believe that their patients must be cared better than people without mental illness. These findings of this study suggest that mental illness patients are at risk of metabolic syndrome. According to our results, risk factors such as age and gender differences may play an important role in the presence of metabolic syndrome. In our country, women do less
Casino, Francesco Gaetano
Acute kidney injury affects about 35% of intensive care unit patients. Renal replacement therapy is required in about 5% of such patients and is associated with a mortality rate as high as 50% to 80%. The latter is likely more related to the failure of extrarenal organs than to an insufficient dialysis dose. This could explain, at least in part, the findings of 2 recent trials (VA/ NIH and RENAL) where the expected dose-outcome relationship was not confirmed. These results cannot be taken to infer that assessing the dialysis dose is no longer required. The contrary is true, in that the common finding of large differences between prescribed and delivered doses calls for accurate dose assessment, at least to avoid underdialysis. The minimum adequate levels are now a Kt/V urea of 1.2 to 1.4 three times a week (3x/wk) on intermittent hemodialysis (IHD), and an effluent of 20 mL/kg/h for 85% of the time on continuous renal replacement therapy (CRTT). Both these parameters can be easily measured but are far from ideal indices because they account neither for residual renal function nor for irregular dose delivery. The equivalent renal urea clearance (EKRjc), by expressing the averaged renal+dialytic urea clearance over the whole treatment period, is able to account for the above factors. Although assessing EKRjc is quite complex, for regular 3x/wk IHD one could use the formula EKRjc=10 Kt/V+1 to compute that a Kt/V of 1.2 and 1.4 corresponds to an EKRjc of 13 and 15 mL/min, respectively. On the other hand, the hourly effluent per kg is numerically similar to EKRjc. On this basis it can be calculated that in non-prediluted really continuous treatment, the recommended CRRT dose (EKRjc=20 mL/min) is 33% higher than the EKRjc of 15 mL/min, corresponding to the recommended Kt/V of 1.4 on 3x/wk IHD.
Soussi, Sabri; Ferry, Axelle; Chaussard, Maité; Legrand, Matthieu
Crystalloids have become the fluid of choice in critically ill patients and in the operating room both for fluid resuscitation and fluid maintenance. Among crystalloids, NaCl 0.9% has been the most widely used fluid. However, emerging evidence suggests that administration of 0.9% saline could be harmful mainly through high chloride content and that the use of fluid with low chloride content may be preferable in major surgery and intensive care patients. Administration of NaCl 0.9% is the leading cause of metabolic hyperchloraemic acidosis in critically ill patients and side effects might target coagulation, renal function, and ultimately increase mortality. More balanced solutions therefore may be used especially when large amount of fluids are administered in high-risk patients. In this review, we discuss physiological background favouring the use of balanced solutions as well as the most recent clinical data regarding the use of crystalloid solutions in critically ill patients and patients undergoing major surgery.
Dehkordi, Leila Mardanian; Babashahi, Monireh; Irajpour, Alireza
Background: Decision-making about patients with critical condition transfer from Intensive Care Unit to the general wards be delegated to their families. The aim of the study was explaining the experiences of family caregiver's about care of chronic critically ill patient. Methods: This study was conducted with a qualitative content analysis using unstructured interview. Participants were selected purposively from May 2014 to May 2015 and data collection continued until data saturation. Analysis was based on conventional content analysis. Results: Participants’ experiences classified into three main categories as following: nonprofessional care, enhancing factors of care, and inhibiting factors of care. Conclusions: Finding of the current study showed different aspects of care. Care of chronic critically ill patients is a long-term process that affected by different factors. It seems that the exploration of caregivers needs and planning supportive interventions based on their needs improve the quality of care. PMID:28028426
Hoogerwerf, M A; Ninaber, M K; Willems, L N A; Kaptein, A A
Given the high degree of psychosocial problems in patients with lung cancer, quality medical care would benefit from exploring and addressing and providing potential solutions for these problems. Patients with recently diagnosed non-small-cell lung cancer filled out a questionnaire that assessed illness perceptions and made a drawing of how they perceived their diseased lungs look. They also participated in an interview about the impact of lung cancer in their lives. Scores on the Brief Illness Perception Questionnaire indicated that patients score low on 'concern', 'emotional response' and 'timeline', indicating they hope to be cured from lung cancer. Patients drew the tumor larger than it is on the chest radiograph. The drawings are moderately accurate representations of the patients' lungs. In the interviews patients often expressed their hopes of being cured and how thinking positively would help. Patients who made a more accurate drawing of their lungs had less optimistic views about their prognosis. These views are more in line with the prognosis their physician would give them. However, few patients made an accurate drawing. This study contributes to a better insight into what patients believe and feel about their disease. Suggestions for taking patient perceptions into account are provided.
Fernández, Javier; Aracil, Carles; Solà, Elsa; Soriano, Germán; Cinta Cardona, Maria; Coll, Susanna; Genescà, Joan; Hombrados, Manoli; Morillas, Rosa; Martín-Llahí, Marta; Pardo, Albert; Sánchez, Jordi; Vargas, Victor; Xiol, Xavier; Ginès, Pere
Cirrhotic patients often develop severe complications requiring ICU admission. Grade III-IV hepatic encephalopathy, septic shock, acute-on-chronic liver failure and variceal bleeding are clinical decompensations that need a specific therapeutic approach in cirrhosis. The increased effectiveness of the treatments currently used in this setting and the spread of liver transplantation programs have substantially improved the prognosis of critically ill cirrhotic patients, which has facilitated their admission to critical care units. However, gastroenterologists and intensivists have limited knowledge of the pathogenesis, diagnosis and treatment of these complications and of the prognostic evaluation of critically ill cirrhotic patients. Cirrhotic patients present alterations in systemic and splanchnic hemodynamics, coagulation and immune dysfunction what further increase the complexity of the treatment, the risk of developing new complications and mortality in comparison with the general population. These differential characteristics have important diagnostic and therapeutic implications that must be known by general intensivists. In this context, the Catalan Society of Gastroenterology and Hepatology requested a group of experts to draft a position paper on the assessment and treatment of critically ill cirrhotic patients. This article describes the recommendations agreed upon at the consensus meetings and their main conclusions.
Hunsucker, S; Flannery, J; Frank, D
This study explored the coping strategies of families of critically ill patients in a rural Southern Appalachian setting. A convenience sample of 30 family members of 22 critically ill patients in two rural hospitals completed the Jaloweic Coping Scale. The five most frequently used coping methods were helping, thinking positively, worrying about the problem, trying to find out more about the problem and trying to handle things one step at a time. The five most effective coping strategies were talking the problem over with friends, praying, thinking about the good things in life, trying to handle things one step at a time and trying to see the good side of the situation. Findings contradicted many of the more "negative" descriptions of Appalachian people in the literature. Similarities outweighed differences when comparing the coping styles of rural and urban populations. Findings suggest that coping strategies must be considered for positive outcomes in the delivery of care to such a rural population.
Williams, Jane; Phillips, Catherine; Byrd, Hollie Marie
Simple Summary Cancer is as common amongst pets as it in humans. Chemotherapy can be integrated into treatment regimes for terminally ill pets to attempt to shrink tumours to extend life expectancy, but it does not cure cancer and it can have negative side effects including vomiting, depression and behavioral changes. To date, little research has been undertaken to explore owners’ decisions whether or not to treat their animals with chemotherapy. Seventy-eight dog and cat owners completed an online questionnaire to determine if they would opt for chemotherapy if their pet was diagnosed with cancer, and asked how they thought their pet’s quality of life would be affected. Fifty-eight percent of respondents would not use chemotherapy largely due to their previous experience of it. Seventy-two percent over estimated pet survival time post chemotherapy, with most people believing it would lead to remission or a cure. Owners expected their pets to be less active, sleep more and play less, reducing their quality of life. Common side effects associated with chemotherapy were not rated as acceptable. The results suggest pet owners would benefit from an increased understanding of the positive and negative impacts of chemotherapy when initially discussing treatment options with the veterinary team. Abstract Chemotherapy is a commonly integrated treatment option within human and animal oncology regimes. Limited research has investigated pet owners’ treatment decision-making in animals diagnosed with malignant neoplasia. Dog and cat owners were asked to complete an online questionnaire to elucidate factors which are key to the decision making process. Seventy-eight respondents completed the questionnaire in full. Fifty-eight percent of pet owners would not elect to treat pets with chemotherapy due to the negative impact of the associated side effects. Seventy-two percent of respondents over estimated pet survival time post chemotherapy, indicating a general perception
von Plessen, Christian; Nielsen, Thyge L; Steffensen, Ida E; Larsen, Shuruk Al-Halwai; Taudorf, Ebbe
Terminal chronic obstructive pulmonary disease (COPD) and advanced cancer have similar prognosis and symptom burden. However, palliative care of patients with terminal COPD has been neglected in Denmark. We describe the symptoms of terminal COPD and suggest criteria for defining the palliative phase of the disease. Furthermore we discuss the prognostic and ethical challenges for patients, their families and their caregivers. Finally, we summarize the current evidence for palliative treatment of dyspnoea and ways to evaluate response to treatment.
Popov, Nadia; Heruti, Irit; Levy, Sigal; Lulav-Grinwald, Doron; Bar-Sela, Gil
Illness perception influences health and illness behaviors. This study was designed to estimate illness perception differences between Russian-speaking and Hebrew-speaking Israeli oncology patients. Changes in illness perception associated with time spent in Israel among Russian-speaking patients were also evaluated. Additionally, we evaluated differences in illness perception of patients exposed to Chernobyl's consequences. A total of 144 oncology patients (77 Hebrew-speaking, 67 Russian-speaking) completed personal data questionnaires and The illness perception questionnaire revised, translated into Russian for this study. Significantly more Russian-speaking oncology patients perceived their illness as chronic and having negative consequences on life (p < .01). Russian-speaking oncology patients tend to have a more negative perception of cancer compared to Hebrew-speaking patients. Time spent in Israel may create more positive perceptions of cancer among these patients. No illness perception differences were found concerning Chernobyl consequences.
Dexheimer Neto, Felippe Leopoldo; Dalcin, Paulo de Tarso Roth; Teixeira, Cassiano; Beltrami, Flávia Gabe
The evaluation of critically ill patients using lung ultrasound, even if performed by nonspecialists, has recently garnered greater interest. Because lung ultrasound is based on the fact that every acute illness reduces lung aeration, it can provide information that complements the physical examination and clinical impression, the main advantage being that it is a bedside tool. The objective of this review was to evaluate the clinical applications of lung ultrasound by searching the PubMed and the Brazilian Virtual Library of Health databases. We used the following search terms (in Portuguese and English): ultrasound; lung; and critical care. In addition to the most relevant articles, we also reviewed specialized textbooks. The data show that lung ultrasound is useful in the differential diagnosis of pulmonary infiltrates, having good accuracy in identifying consolidations and interstitial syndrome. In addition, lung ultrasound has been widely used in the evaluation and treatment of pleural effusions, as well as in the identification of pneumothorax. This technique can also be useful in the immediate evaluation of patients with dyspnea or acute respiratory failure. Other described applications include monitoring treatment response and increasing the safety of invasive procedures. Although specific criteria regarding training and certification are still lacking, lung ultrasound is a fast, inexpensive, and widely available tool. This technique should progressively come to be more widely incorporated into the care of critically ill patients.
Fliers, Eric; Bianco, Antonio C; Langouche, Lies; Boelen, Anita
Patients in the intensive care unit (ICU) typically present with decreased concentrations of plasma tri-iodothyronine, low thyroxine, and normal range or slightly decreased concentration of thyroid-stimulating hormone. This ensemble of changes is collectively known as non-thyroidal illness syndrome (NTIS). The extent of NTIS is associated with prognosis, but no proof exists for causality of this association. Initially, NTIS is a consequence of the acute phase response to systemic illness and macronutrient restriction, which might be beneficial. Pathogenesis of NTIS in long-term critical illness is more complex and includes suppression of hypothalamic thyrotropin-releasing hormone, accounting for persistently reduced secretion of thyroid-stimulating hormone despite low plasma thyroid hormone. In some cases distinguishing between NTIS and severe hypothyroidism, which is a rare primary cause for admission to the ICU, can be difficult. Infusion of hypothalamic-releasing factors can reactivate the thyroid axis in patients with NTIS, inducing an anabolic response. Whether this approach has a clinical benefit in terms of outcome is unknown. In this Series paper, we discuss diagnostic aspects, pathogenesis, and implications of NTIS as well as its distinction from severe, primary thyroid disorders in patients in the ICU. PMID:26071885
Mechanic, D; Meyer, S
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.
Lavrentieva, Athina; Kontakiotis, Theodore; Bitzani, Militsa
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.
Flordelís Lasierra, J L; Pérez-Vela, J L; Montejo González, J C
The benefit of enteral nutrition in critically ill patients has been demonstrated by several studies, especially when it is started early, in the first 24-48h of stay in the Intensive Care Unit, and this practice is currently advised by the main clinical guidelines. The start of enteral nutrition is controversial in patients with hemodynamic failure, since it may trigger intestinal ischemia. However, there are data from experimental studies in animals, as well as from observational studies in humans that allow for hypotheses regarding its beneficial effect and safety. Interventional clinical trials are needed to confirm these findings.
Hajsadeghi, Shokoufeh; Khamseh, Mohammad Ebrahim; Gholami, Saeid; Kerman, Scott Reza Jafarian; Gohardehi, Golnar; Moghadam, Negar Seifi; Sabet, Azade Shafiee; Moradi, Masoud; Mollahoseini, Reza; Najafi, Mehri; Keramati, Mohammad Reza
BACKGROUND: Insulin-like growth factor 1 (IGF-I) is an anabolic growth factor that affects nitrogen balance and its changing trend is not clearly understood in critically ill patients. This study was carried out to evaluate the association between serum IGF-I levels and its changing trend in critically ill patients. METHODS: In this nested case-control study, all consecutive patients admitted to the medical ICU of Rasoul-e-Akram and Firuzgar hospital (Tehran, Iran) from January through October 2008 were included. IGF1 concentration was measured within the first 24h of ICU admission and the fourth, seventh and tenth day since admission. Patients were followed until discharge from ICU or expiration. RESULTS: The study population consisted of 90 patients (mean age: 58.01 ± 22.56), 31 (34.4%) of who died and 59 (65.6%) were discharged. On admission, 43 patients (47.7%) had low IGF-I levels, whereas 47 (52.3%) had normal or high levels. The concentration of IGF-I was not significantly different in every 4 measurements between expired and discharged patients. Significant decrease was seen between first to fourth day IGF-I concentration (p = 0.005). Changing trend was not statistically different in two groups of patients. CONCLUSIONS: There was no relation between low IGF-I concentration on admission day and increased adverse outcome, but overall these patients had lower IGF1. No clear association was found between changing trend of IGF1 and mortality. Stress on admission time may cause decreasing pattern of IGF-I in the first 4 days of admission. PMID:22091227
Cotogni, Paolo; Pittiruti, Mauro
Venous access devices are of pivotal importance for an increasing number of critically ill patients in a variety of disease states and in a variety of clinical settings (emergency, intensive care, surgery) and for different purposes (fluids or drugs infusions, parenteral nutrition, antibiotic therapy, hemodynamic monitoring, procedures of dialysis/apheresis). However, healthcare professionals are commonly worried about the possible consequences that may result using a central venous access device (CVAD) (mainly, bloodstream infections and thrombosis), both peripherally inserted central catheters (PICCs) and centrally inserted central catheters (CICCs). This review aims to discuss indications, insertion techniques, and care of PICCs in critically ill patients. PICCs have many advantages over standard CICCs. First of all, their insertion is easy and safe -due to their placement into peripheral veins of the arm- and the advantage of a central location of catheter tip suitable for all osmolarity and pH solutions. Using the ultrasound-guidance for the PICC insertion, the risk of hemothorax and pneumothorax can be avoided, as well as the possibility of primary malposition is very low. PICC placement is also appropriate to avoid post-procedural hemorrhage in patients with an abnormal coagulative state who need a CVAD. Some limits previously ascribed to PICCs (i.e., low flow rates, difficult central venous pressure monitoring, lack of safety for radio-diagnostic procedures, single-lumen) have delayed their start up in the intensive care units as common practice. Though, the recent development of power-injectable PICCs overcomes these technical limitations and PICCs have started to spread in critical care settings. Two important take-home messages may be drawn from this review. First, the incidence of complications varies depending on venous accesses and healthcare professionals should be aware of the different clinical performance as well as of the different risks
Richardson, Amy E; Morton, Randall; Broadbent, Elizabeth
This study investigated the contribution of patient and caregiver illness perceptions to the quality of life of head and neck cancer (HNC) patients. Ninety-eight patients and their caregivers (n = 80) completed questionnaires at diagnosis. Caregivers' illness perceptions were significantly more negative than patients with respect to consequences, timeline, treatment, concern, and the emotional impact of HNC. The interaction between some patient and caregiver illness perceptions explained additional variance in patient quality of life, above and beyond patients' own illness perceptions. These findings suggest that caregivers should be included in psychological interventions to improve HNC patient quality of life.
Introduction Inter-hospital transport of critically ill patients is increasing. When performed by specialized retrieval teams there are less adverse events compared to transport by ambulance. These transports are performed with technical equipment also used in an Intensive Care Unit (ICU). As a consequence technical problems may arise and have to be dealt with on the road. In this study, all technical problems encountered while transporting patients with our mobile intensive care unit service (MICU) were evaluated. Methods From March 2009 until August 2011 all transports were reviewed for technical problems. The cause, solution and, where relevant, its influence on protocol were stated. Results In this period of 30 months, 353 patients were transported. In total 55 technical problems were encountered. We provide examples of how they influenced transport and how they may be resolved. Conclusion The use of technical equipment is part of intensive care medicine. Wherever this kind of equipment is used, technical problems will occur. During inter-hospital transports, without extra personnel or technical assistance, the transport team is dependent on its own ability to resolve these problems. Therefore, we emphasize the importance of having some technical understanding of the equipment used and the importance of training to anticipate, prevent and resolve technical problems. Being an outstanding intensivist on the ICU does not necessarily mean being qualified for transporting the critically ill as well. Although these are lessons derived from inter-hospital transport, they may also apply to intra-hospital transport. PMID:22326110
Oksan, Derinoz; Ayfer, Keles
We reviewed the charts of 25 patients who underwent powered intraosseous line insertion between July 1, 2008 and August 31, 2010 to determine its users, indications, procedural details, success rates, and complications. Intraosseous (IO) line was inserted in the anteromedial aspect of the proximal tibia in all patients. The first attempt was successful in 80%, and the median duration for insertion of the IO line was 4 hours. Extravasation was the most common complication. Ninety-six percent of the physicians had undergone prior training in IO insertion. Because of its high success and short procedure time, IO access should be the first alternative to failed vascular access in critically ill children. Training in IO should be extended to all who care for pediatric patients in inpatient as well as in prehospital and emergency department settings.
Vargas, Nicola; Tibullo, Loredana; Landi, Emanuela; Carifi, Giovanni; Pirone, Alfonso; Pippo, Antonio; Alviggi, Immacolata; Tizzano, Renato; Salsano, Elisa; Di Grezia, Francesco; Vargas, Maria
Despite technological advances, the mortality rate for critically ill oldest old patients remains high. The intensive caring should be able to combine technology and a deep humanity considering that the patients are living the last part of their lives. In addition to the traditional goals of ICU of reducing morbidity and mortality, of maintaining organ functions and restoring health, caring for seriously oldest old patients should take into account their end-of-life preferences, the advance or proxy directives if available, the prognosis, the communication, their life expectancy and the impact of multimorbidity. The aim of this review was to focus on all these aspects with an emphasis on some intensive procedures such as mechanical ventilation, noninvasive mechanical ventilation, cardiopulmonary resuscitation, renal replacement therapy, hemodynamic support, evaluation of delirium and malnutrition in this heterogeneous frail ICU population.
Lorente, J A; Amaya-Villar, R
The management of critically ill burn patients is challenging. These patients have to be managed in specialized centers, where the expertise of physicians and nursing personnel guarantees the best treatment. Mortality of burn patients has improved over the past decades due to a better understanding of burn shock pathophysiology, optimal surgical management, infection control and nutritional support. Indeed, a more aggressive resuscitation, early excision and grafting, the judicious use of topical antibiotics, and the provision of an adequate calorie and protein intake are key to attain best survival results. General advances in critical care have also to be implemented, including protective ventilation, glycemic control, selective decontamination of the digestive tract, and implementation of sedation protocols.
Romero-Bermejo, Francisco J; Ruiz-Bailén, Manuel; Guerrero-De-Mier, Manuel; López-Álvaro, Julián
Echocardiography has shown to be an essential diagnostic tool in the critically ill patient's assessment. In this scenario the initial fluid therapy, such as it is recommended in the actual clinical guidelines, not always provides the desired results and maintains a considerable incidence of cardiorrespiratory insufficiency. Echocardiography can council us on these patients' clinical handling, not only the initial fluid therapy but also on the best-suited election of the vasoactive/inotropic treatment and the early detection of complications. It contributes as well to improving the etiological diagnosis, allowing one to know the heart performance with more precision. The objective of this manuscript is to review the more important parameters that can assist the intensivist in theragnosis of hemodynamically unstable patients. PMID:22758613
Laudański, Krzysztof; Nowak, Zbigniew; Wańkowicz, Zofia
The aim of the paper was to evaluate the mood and attitude to the illness-related stress and correlations between them among patients treated with haemodialysis (HD) or continuous ambulatory peritoneal dialysis (CAPD). The following psychological questionnaires were used: the Cognitive Stress Appreciation Questionnaire (CSAQ), the Social Appreciation Questionnaire and the Profile of Mood States. The total of 26 HD (17M, 9F) and 28 CAPD (17M, 11F) patients were studied. The control group (CONTR) consisted of 48 (26M, 22F) healthy volunteers who filled the questionnaires as if they had a "bad cold". The dispositional attitude to the stress was similar in the studied groups. The dialysed patients evaluated their disease-related stress mainly as a threat as compared to the healthy volunteers (p < 0.01). Additionally, HD patients evaluated their disease as a loss as compared to the CAPD group and CONTR group (p < 0.05). In HD and CAPD patients Confusion-Bewilderment had significantly higher values in comparison to the healthy group (p < 0.01), whereas only HD group had higher values of Fatigue-Inertia as compared to CAPD and control groups (p < 0.01). Additionally our results showed a significant correlation between evaluation of renal disease as a loss and Fatigue--Inertia emotion in the HD group (r = 0.89; p < 0.01). From the psychological point of view CAPD seems to be better than HD, since the patients treated by this method evaluated better their mood and illness-related stress, similarly as the healthy volunteers suffering from acute infectious disease.
Schultz, Marcus J; de Graaff, Mart J; Royakkers, Annic A N M; van Braam Houckgeest, Floris; van der Sluijs, Johannes P; Kieft, Hans; Spronk, Peter E
Blood glucose control aiming at normoglycemia, frequently referred to as "strict glycemic control", decreases mortality and morbidity of critically ill patients. We searched the medical literature for export opinions, surveys, and clinical reports on blood glucose control in intensive care medicine. While strict glycemic control has been recommended standard of care for critically ill patients, the risk of severe hypoglycemia with strict glycemic control is frequently mentioned by experts. Some rationalize this risk, though others strongly point out the high incidence of hypoglycemia to be (one) reason not to perform strict glycemic control. Implementation of strict glycemic control is far from complete in intensive care units across the world. Frequently local guidelines accept higher blood glucose levels than those with strict glycemic control. Only a minority of retrieved manuscripts are on blood glucose regimens with the lower targets as with strict glycemic control. Hypoglycemia certainly is encountered with blood glucose control, in particular with strict glycemic control. Reports show intensive care-nurses can adequately and safely perform strict glycemic control. Implementation of strict glycemic control is far from complete, at least in part because of the feared risks of hypoglycemia. The preference for hyperglycemia over intermittent hypoglycemia is irrational, however, because there is causal evidence of harm for the former but only associative evidence of harm for the latter. For several reasons it is wise to have strict glycemic control being a nurse-based strategy.
Bangash, Mansoor N; Kong, Ming-Li; Pearse, Rupert M
Inotropes and vasopressors are biologically and clinically important compounds that originate from different pharmacological groups and act at some of the most fundamental receptor and signal transduction systems in the body. More than 20 such agents are in common clinical use, yet few reviews of their pharmacology exist outside of physiology and pharmacology textbooks. Despite widespread use in critically ill patients, understanding of the clinical effects of these drugs in pathological states is poor. The purpose of this article is to describe the pharmacology and clinical applications of inotropic and vasopressor agents in critically ill patients. LINKED ARTICLES This article is commented on by Bracht et al., pp. 2009–2011 and De Backer and Scolletta, pp. 2012–2014 of this issue. To view Bracht et al. visit http://dx.doi.org/10.1111/j.1476-5381.2011.01776.x and to view De Backer and Scolletta visit http://dx.doi.org/10.1111/j.1476-5381.2011.01746.x PMID:21740415
Plank, L D
Critical illness is characterised by catabolism of the skeletal muscle that releases amino acids for protein synthesis to support tissue repair, immune defence and inflammatory and acute-phase responses. Protein requirements for these patients have generally been based on levels that result in the lowest catabolic rates or most favourable nitrogen balance. The definition of these levels, in particular, in relation to indexing to a measure of patient weight or lean body mass, is controversial. Furthermore, optimal nitrogen balance may not necessarily equate to best clinical outcome. There is some evidence that administration of specific amino acids may be advantageous at least during the early or most catabolic phases of illness, in order to support the specific amino acid requirements of the metabolic pathways activated by the injury or infection. Current widely used guidelines differ in the protein prescription they recommend and in the timing of administration in relation to intensive care admission. A pressing need exists for well-designed randomised trials that compare differing levels of protein or amino acid provision, and the timing of this provision, for their effects on clinical endpoints.
Grau, Teodoro; Bonet, Alfonso; Rubio, Mercedes; Mateo, Dolores; Farré, Mercé; Acosta, José Antonio; Blesa, Antonio; Montejo, Juan Carlos; de Lorenzo, Abelardo García; Mesejo, Alfonso
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
Limaye, Ajit P.; Kirby, Katharine A.; Rubenfeld, Gordon D.; Leisenring, Wendy M.; Bulger, Eileen M.; Neff, Margaret J.; Gibran, Nicole S.; Huang, Meei-Li; Santo, Tracy K.; Corey, Lawrence; Boeckh, Michael
Context Cytomegalovirus (CMV) infection is associated with adverse clinical outcomes in immunosuppressed persons, but the incidence and association of CMV reactivation with adverse outcomes in persons lacking evidence of immunosuppression (“immunocompetent”) with critical illness have not been well-defined. Objective To determine the association of CMV reactivation with intensive care unit (ICU) and hospital length of stay in critically-ill immunocompetent persons. Methods We prospectively assessed CMV plasma DNAemia by real-time PCR twice weekly and clinical outcomes in a cohort of CMV seropositive, immunocompetent adults admitted to an ICU. Clinical parameters were assessed by personnel blinded to CMV PCR results. Risk factors for CMV reactivation and association with hospital and ICU length of stay (LOS) were assessed by multivariable logistic regression and proportional odds models. Setting Six ICU’s at two separate hospitals at a large tertiary care academic medical center between 2004–2006. Participants A total of 120 critically-ill, CMV seropositive adults lacking evidence of immunosuppression. Main Outcome Measures Association of CMV reactivation with prolonged hospital length of stay or death. Results The primary composite endpoint of continued hospitalization (n=35) or death (n=10) at 30 days occurred in 45 (35%) of the 120 patients. CMV viremia at any level or > 1,000 copies/ml occurred in 33% (39 of 120, 95% confidence interval [CI] 24%–41%) and 20% (24 of 120, 95% CI 13%–28%), at a median of 12 days (range 3–57) and 26 days (range 9–56), respectively. By logistic regression, CMV infection at any level (adjusted OR: 4.3 [1.6–11.9], p = 0.005), >1,000 copies/ml (adjusted OR 13.9 [3.2–60], p < 0.001), or average CMV area under the curve [AUC] (adjusted OR 2.1 [1.3–3.2], p < 0.001), was independently associated with hospitalization or death by 30 days. In multivariable partial proportional odds models, both CMV seven-day moving
Gruartmoner, G; Mesquida, J; Baigorri, F
Hemodynamic resuscitation seeks to correct global macrocirculatory parameters of pressure and flow. However, current evidence has shown that despite the normalization of these global parameters, microcirculatory and regional perfusion alterations can persist, and these alterations have been independently associated with a poorer patient prognosis. This in turn has lead to growing interest in new technologies for exploring regional circulation and microcirculation. Near infra-red spectroscopy allows us to monitor tissue oxygen saturation, and has been proposed as a noninvasive, continuous and easy-to-obtain measure of regional circulation. The present review aims to summarize the existing evidence on near infra-red spectroscopy and its potential clinical role in the resuscitation of critically ill patients in shock.
Murata, A; Kikuchi, M; Mishima, S; Sakaki, S; Goto, H; Matsuoka, T; Tanaka, H; Yukioka, T; Shimazaki, S
It remains difficult to treat severely ill patients, especially those who have sepsis and subsequent multiple organ dysfunction syndrome. We propose the hypothesis that the pathophysiology in the sequential sepsis and multiple organ dysfunction syndrome may be strongly related to the imbalance between inflammatory cytokines and antiinflammatory cytokines induced for the host defense to active neutrophils and endothelial cells. Thus we attempted to develop cytokine modulation therapy to normalize the cytokine balance in the host defense system. In this review, we elucidate the relationship between cytokine imbalance and SIRS/CARS in patients with severe burn injury. Furthermore, we examine the possible usage of G-CSF to amplify neutrophil function, and clarify the reasons why various innovative therapies against sepsis have failed.
Shizgal, H.M.; Martin, M.F.
The caloric requirement of the critically ill septic patient was determined by measuring body composition, by multiple isotope dilution, before and at 2-wk intervals while receiving total parenteral nutrition (TPN) in 86 septic and 57 nonseptic malnourished patients. All patients received a TPN solution containing 25% dextrose and 2.75% crystalline amino acids. The body composition of the nonseptic patients, who received 51.9 +/- 1.5 kcal/kg.day, improved significantly, while that of the septic patients, receiving 46.8 +/- 1.1 kcal/kg.day was only maintained. The relationship between caloric intake and the restoration of a malnourished body cell mass (BCM) was determined for each group by correlating, using multiple linear regression, the mean daily change in the BCM with the caloric intake and the nutritional state, as determined by body composition. According to the resultant regressions, an intake of 35.1 and 50.7 kcal/kg.day was required to maintain the BCM of the septic and nonseptic patients, respectively. To restore a depleted BCM, caloric intakes in excess of this amount are required.
Oliveira, Stefanie Griebeler; Quintana, Alberto Manuel; Denardin-Budó, Maria de Lourdes; de Moraes, Natália de Andrade; Lüdtke, Manoela Fonseca; Cassel, Paula Argemi
This study was aimed at getting to know the relationships built among patients, family caregivers and the health care team, during home care,from the perspective of the family caregiver It is a qualitative study with 11 family caregivers of terminal patients, registered on a home care service of a university hospital in the South of Brazil. Data collection was carried out through narrative interviews that were recorded transcribed and analyzed through content analysis. Three categories were built from data analysis: relationships among the family caregiver, the patient and the health care team; awareness of the patient's terminal condition. the caregiver's perspective; and situation in which patients are unaware of their terminal condition. They approach how the home care relationships are established among the caregivers, such as health care professionals and family caregivers, and the people who are taken care of such as the patients, highlighting the importance of communication in such care related context.
Briassoulis, George; Venkataraman, Shekhar; Thompson, Ann
It is not known if cytokines, which are cell-derived mediators released during the host immune response to stress, affect metabolic response to stress during critical illness. The aim of this prospective study was to determine whether the metabolic response to stress is related to the inflammatory interleukin-6 (IL-6), 10 (IL-10), and other stress mediators' responses and to assess their relationships with different feeding patterns, nutritional markers, the severity of illness as assessed by the Multiple Organ System Failure (MOSF), the Pediatric Risk of Mortality Score (PRISM), systemic inflammatory response syndrome (SIRS), and mortality in critically ill children. Patients were classified as hypermetabolic, normometabolic, and hypometabolic when the measured resting energy expenditures (REE) were >110%, 90–110% and, <90% of the predicted basal metabolic rate, respectively. The initial predominance of the hypometabolic pattern (48.6%) declined within 1 week of acute stress (20%), and the hypermetabolic patterns dominated only after 2 weeks (60%). Only oxygen consumption (VO2) and carbon dioxide production (VCO2) (P < .0001) but none of the cytokines and nutritional markers, were independently associated with a hypometabolic pattern. REE correlated with the IL-10 but not PRISM. In the presence of SIRS or sepsis, CRP, IL-6, IL-10, Prognostic Inflammatory and Nutritional Index (NI), and triglycerides—but not glucose, VO2, or VCO2 increased significantly. High IL-10 levels (P = .0000) and low measured REE (P = .0000) were independently associated with mortality (11.7%), which was higher in the hypometabolic compared to other metabolic patterns (P < .005). Our results showed that only VO2 and VCO2, but not IL-6 or IL-10, were associated with a hypometabolic pattern which predominated the acute phase of stress, and was associated with increased mortality. Although in SIRS or sepsis, the cytokine response was reliably reflected by increases in NI and
Wu, Lisa M.; Mohamed, Nihal E.; Winkel, Gary; Diefenbach, Michael A.
Objective Among married prostate cancer (PC) patients, the spouse is often the primary provider of emotional support and personal care. However, few studies have investigated spouses’ illness beliefs (i.e., about disease duration and treatment control) and their impact on patients’ quality of life (QOL). Spouses’ beliefs about disease duration (timeline) were hypothesised to mediate relationships between spouses’ treatment control beliefs and patients’ QOL six months later. Methods Fifty-three patients, who underwent localised treatment for PC, and their spouses, completed an illness beliefs measure (the revised Illness Perception Questionnaire). Patients completed a QOL measure (the Functional Assessment of Cancer Therapy – General) six months later. Results Spouse timeline beliefs mediated the association between spouse treatment control beliefs and patient QOL six months later (total indirect effect = −0.71, 95% CI 0.02-2.03). That is, spouse beliefs that the treatment would control their loved one's illness led to beliefs that the disease would be of shorter duration, which in turn led to improved patient QOL six months later. This relationship did not occur with patients’ beliefs. Conclusions Results highlight the important influence of spouse illness beliefs over time on patient QOL with implications for clinical care and dyadic research. PMID:22971045
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
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. PMID:24068269
D'Avolio, Antonio; Pensi, Debora; Baietto, Lorena; Pacini, Giovanni; Di Perri, Giovanni; De Rosa, Francesco Giuseppe
Infections, including sepsis, are associated with high mortality rates in critically ill patients in the intensive care unit (ICU). Appropriate antibiotic selection and adequate dosing are important for improving patient outcomes. Daptomycin is bactericidal in bloodstream infections caused by Staphylococcus aureus and other Gram-positive pathogens cultured in ICU patients. The drug has concentration-dependent activity, and the area under the curve/minimum inhibitory concentration ratio is the pharmacokinetic/pharmacodynamic (PK/PD) index that best correlates with daptomycin activity, whereas toxicity correlates well with daptomycin plasma trough concentrations (or minimum concentration [C min]). Adequate daptomycin exposure can be difficult to achieve in ICU patients; multiple PK alterations can result in highly variable plasma concentrations, which are difficult to predict. For this reason, therapeutic drug monitoring could help clinicians optimize daptomycin dosing, thus improving efficacy while decreasing the likelihood of serious adverse events. This paper reviews the literature on daptomycin in ICU patients with sepsis, focusing on dosing and PK and PD parameters.
Smuszkiewicz, Piotr; Szałek, Edyta; Tomczak, Hanna; Grześkowiak, Edmund
Antibiotics are the most commonly used drugs in intensive care unit patients and their supply should be based on pharmacokinetic/pharmacodynamic rules. The changes that occur in septic patients who are critically ill may be responsible for subtherapeutic antibiotic concentrations leading to poorer clinical outcomes. Evolving in time the disturbed pathophysiology in severe sepsis (high cardiac output, glomerular hyperfiltration) and therapeutic interventions (e.g. haemodynamically active drugs, mechanical ventilation, renal replacement therapy) alters antibiotic pharmacokinetics mainly through an increase in the volume of distribution and altered drug clearance. The lack of new and efficacious drugs and increased bacterial resistance are current problems of contemporary antibiotic therapy. Although intermittent administration is a standard clinical practice, alternative methods of antibiotic administration are sought, which may potentialise effects and reduce toxicity as well as contribute to inhibition of bacterial resistance. A wide range of studies prove that the application of continuous infusion of time-dependent antibiotics (beta-lactams, glycopeptides) is more rational than standard intermittent administration. However, there are also studies which do not confirm the advantage of one method over the other. In spite of controversy the continuous administration of this group of antibiotics is common practice, because the results of both studies point to the higher efficacy of this method in critically ill patients. Authors reviewed the literature to determine whether any clinical benefits exist for administration of time-dependent antibiotics by continuous infusion. Definite specification of the clinical advantage of administration this way over standard dosage requires a large-scale multi-centre randomised controlled trial.
Frommelt, K H
This study sought to determine the effectiveness of an education program on nurses' attitudes toward caring for terminally ill persons and their family members. The program, based on the hospice concept of care, included a didactic section based on Kubler-Ross' stages of death and dying, and a role-play model designed by the researcher. Data were collected from 34 licensed nurses, aged 18 to 65, practicing in the midwestern United States. The Frommelt Attitude Toward Care of the Dying Scale (FATCOD) was designed by the researcher to assess nurses' attitudes. The FATCOD was found to be a valid and reliable tool. All nurses completed the tool before and after the education program (pre-test, post-test). Compared by a t-test, the scores for the nurses were significantly higher after participation in the educational program. The t-value was found to be 2.97, significant at the less than 0.01 level, 2-tailed probability = 0.006. These findings support the hypothesis that nurses have a more positive attitude toward caring for terminally ill persons and their family members after participation in the program, than the same nurses had before participating in the program. Demographic information including age, years of experience in nursing, highest degree held, basic type of nursing preparation and previous education on death and dying were analyzed to determine their relationship to the nurses' attitudes. The only information which demonstrated any significant relationship to the nurses' attitudes was that of previous education on death and dying. These were computed by an analysis of variance (ANOVA) F = 3.22, F prob = 0.04, significant at less than 0.05 level.(ABSTRACT TRUNCATED AT 250 WORDS)
Murphy, Claire V; Coffey, Rebecca; Cook, Charles H; Gerlach, Anthony T; Miller, Sidney F
Glucose management in patients with burn injury is often difficult because of their hypermetabolic state with associated hyperglycemia, hyperinsulinemia, and insulin resistance. Recent studies suggest that time to glycemic control is associated with improved outcomes. The authors sought to determine the influence of early glycemic control on the outcomes of critically ill patients with burn injury. A retrospective analysis was performed at the Ohio State University Medical Center. Patients hospitalized with burn injury were enrolled if they were admitted to the intensive care unit between March 1, 2006, and February 28, 2009. Early glycemic control was defined as the achievement of a mean daily blood glucose of ≤150 mg/dl for at least two consecutive days by postburn day 3. Forty-six patients made up the study cohort with 26 achieving early glycemic control and 20 who did not. The two groups were similar at baseline with regard to age, pre-existing diabetes, APACHE II score and burn size and depth. There were no differences in number of surgical interventions, infectious complications, or length of stay between patients who achieved or failed early glycemic control. Failure of early glycemic control was, however, associated with significantly higher mortality both by univariate (35.0 vs 7.7%, P = .03) and multivariate analyses (hazard ratio 6.754 [1.16-39.24], P = .03) adjusting for age, TBSA, and inhalation injury. Failure to achieve early glycemic control in patients with burn injury is associated with an increased risk of mortality. However, further prospective controlled trials are needed to establish causality of this association.
Thomas, Joseph; Iyer, Neeraj N; Collins, William B
Patient beliefs about their illness can motivate behaviors consistent with good disease management. Perceived high-quality chronic care would be expected to increase likelihood of having such beliefs. Associations between perceived quality of chronic care and illness representations, and associations between patient centeredness and illness representations were assessed among persons with diabetes. A mail survey of diabetic patients visiting a multispecialty physician network serving urban and suburban populations in a large midwestern city was conducted. The Patient Assessment of Chronic Illness Care-5A questionnaire was used to assess perceived chronic care quality and patient centeredness. The Brief Illness Perception Questionnaire was used to assess illness representations. Of 500 mailed surveys, 89 completed surveys were returned. The sample consisted mostly of retirees (61%), Whites (81%), and women (60%). Higher perceived chronic care quality was associated with better disease understanding of diabetes (0.24, p = .05). Patients reporting higher patient centeredness (or lower patient-centeredness scores) indicated better disease understanding (-0.26, p = .04) and those reporting higher patient centeredness (or lower patient-centeredness scores) perceived less impact of illness (0.29, p = .02). Chronic care quality as defined in the Chronic Care Model and consistency of chronic care with patient expectations (patient centeredness) was associated with illness representations favorable for good self-care management.
Bergdahl, Jan; Mårell, Lena; Bergdahl, Maud; Perris, Hjördis
The aim of the present study was to investigate the psychobiological personality dimensions in two subgroups of patients with environmental illness (EI). Fifty-nine patients, 34 women and 25 men (aged 32-69 years), were referred for symptoms allegedly caused by abnormal sensitivity to either dental fillings (DF; n=26) or electromagnetic fields (EMF; n=33). For the evaluation of personality, the Swedish 238-item version of the Temperament and Character Inventory (TCI) was used. Compared with a control group, the EMF group scored higher on the temperament dimension Persistence. The DF group scored higher on the TCI subscales Harm Avoidance (fatigability and asthenia) and Self-Directedness (self-acceptance). Women scored higher than men did on the Novelty Seeking and Reward Dependence (RD) dimensions in the DF group and on RD in the control group, indicating an inherited gender difference. No differences were found between men and women in the EMF group. Our results indicate that the high level of persistence found in the EMF group and the high level of fatigability and asthenia in combination with high self-acceptance found in the DF group represent vulnerable personalities. No significant differences were found between the two patient groups, indicating that these groups are quite similar regarding personality. This vulnerability can be expressed as various mental and somatic symptoms, which can be interpreted as EI symptoms by the affected individual.
Hanson, Mark D.; Johnson, Samantha; Niec, Anne; Pietrantonio, Anna Marie; High, Bradley; MacMillan, Harriet; Eva, Kevin W.
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…
Hoffman, Ralph E.; Grasemann, Uli; Gueorguieva, Ralitza; Quinlan, Donald; Lane, Douglas; Miikkulainen, Risto
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
Varner, Ashley; Ellis, Erin; Ebner, Stephen; Moxley, John; Siegrist, Erika; Weng, David
Background and Purpose. The cost of illness in cancer care and the subsequent distress has attracted scrutiny. Guidelines recommend enhanced discussion of costs, assuming this will reduce both stress and costs. Little is known about patient attitudes about cost considerations influencing treatment decisions. Methods. A convenience-sample survey of patients currently receiving radiation and/or intravenous chemotherapy at an outpatient cancer center was performed. Assessments included prevalence and extent of financial burden, level of financial distress, attitudes about using costs to influence treatment decisions, and frequency or desirability of cost discussions with oncologists. Results. A total of 132 participants (94%) responded. Overall, 47% reported high financial stress, 30.8% felt well informed about costs prior to treatment, and 71% rarely spoke to their oncologists about cost. More than 71% of patients did not want either society’s or personal costs to influence treatment, and this result did not change based on degree of financial stress. Even when asked to assume that lower cost regimens were equally effective, only 28% would definitely want the lower cost regimen. Patients did not believe it was the oncologist’s duty to perform cost discussions. Conclusion. Even insured patients have a high degree of financial distress. Most, including those with the highest levels of distress, did not speak often with oncologists about costs and were strongly adverse to having cost considerations influence choice of regimen. The findings suggest that patients are not cost sensitive with regard to treatment decisions. Oncologists will require improved tools to have meaningful cost discussion, as recommended by the American Society of Clinical Oncology. Implications for Practice: This study raises important questions regarding optimal communication with patients about costs. If patients are not cost sensitive regarding treatment decisions, they will not be full
Di Mattei, Valentina E.; Carnelli, Letizia; Mazzetti, Martina; Bernardi, Martina; Di Pierro, Rossella; Bergamini, Alice; Mangili, Giorgia; Candiani, Massimo; Sarno, Lucio
Background Gestational Trophoblastic Disease comprises a group of benign and malignant disorders that derive from the placenta. Using Leventhal’s Common-Sense Model as a theoretical framework, this paper examines illness perception in women who have been diagnosed with this disease. Methods Thirty-one women diagnosed with Gestational Trophoblastic Disease in a hospital in Italy were asked to complete the Illness Perception Questionnaire-Revised to measure the following: illness Identity, illness opinions and causes of Gestational Trophoblastic Disease. Results High mean scores were observed in the Emotional representations and Treatment control subscales. A significant difference emerged between hydatidiform mole patients and those with gestational trophoblastic neoplasia on the Identity subscale. A significant correlation emerged between “time since diagnosis” and the Treatment control subscale. Discussion This study is the first to investigate illness perception in Gestational Trophoblastic Disease. From a clinical perspective the results highlight the need for multidisciplinary support programs to promote a more realistic illness perception. PMID:27101144
Pseudomonas Infections; Pseudomonas Septicemia; Pseudomonas; Pneumonia; Pseudomonal Bacteraemia; Pseudomonas Urinary Tract Infection; Pseudomonas Gastrointestinal Tract Infection; Sepsis; Sepsis, Severe; Critically Ill
Twycross, R. G.
Lung cancer is the commonest form of malignant disease seen at St Christopher's Hospice. More than 35% of the male and about 8% of the female cancer patients are admitted with this diagnosis. This means that each year approximately 100 patients with lung cancer are amitted and cared for at the hospice. The more common symptoms experienced by 185 consecutive terminal lung cancer patients admitted to St Christopher's Hospice are listed in Table 1. PMID:4132166
Gonzalez, Faustino; Galante, Mirta
We present the case of a woman who enrolled in the hospice benefit in order to obtain narcotics. We believe this is a cautionary tale for hospices because of our propensity to enroll patients with minimal corroborating information, in order not to delay symptom management. Also we are philosophically predisposed to believe a patient's self-report of pain and other distressing symptoms.
Kincade, Jean E.
Compared attitudes of physicians, housestaff, and nurses (N=483) on care of the dying. Overall, health professionals responding to the survey felt comfortable talking to dying patients and supported the belief that patients should be informed of their prognosis. Substantial differences were found in beliefs about analgesic administration.…
Duława, Anna; Bułdak, Łukasz; Krysiak, Robert; Okopień, Bogusław
One of the greatest challenges for a physician is a critically ill patient. Regardless of the reason for an admission to the Intensive Care Units (ICU) (e.g. myocardial infarction, severe pneumonia, trauma or many others) each of the above-mentioned conditions impairs homeostasis including instability of the endocrine system. The observed alterations in serum glucose level or clinical signs of hormonal imbalance alarm practitioners and prompt them to an intervention. However, side-effects of administered drugs have to be always considered, because every intervention in the endocrine system may have various consequences or prove itself maleficent. Since critical condition causes numerous changes in the hormonal system, the definition of endocrine gland failure in the ICU patients should differ from the definition related to the general population. This review is aimed at describing alterations, diagnosis and treatment options for an impaired carbohydrate metabolism and inadequate response of the adrenal and thyroid endocrine axis. It has been written in order to aid the choice between "the watch and wait strategy" and aggressive pharmacological intervention. Furthermore, several standard and innovative therapeutic procedures were described and, if possible, compared. Recent articles have been included in order to show current views on the up-to-date clinical approach.
Mulcahy, David; Wright, Christine; Mockus, Lorna; Yacoub, Magdi; Fox, Kim
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 PMID:3285954
Donati, Abele; Damiani, Elisa; Domizi, Roberta; Romano, Rocco; Adrario, Erica; Pelaia, Paolo; Ince, Can; Singer, Mervyn
Glycocalyx degradation may contribute to microvascular dysfunction and tissue hypoperfusion during systemic inflammation and sepsis. In this observational study we evaluated the alteration of the sublingual microvascular glycocalyx in 16 healthy volunteers and 50 critically ill patients. Sidestream Dark Field images of the sublingual microcirculation were automatically analyzed by dedicated software. The Perfused Boundary Region (PBR) was calculated as the dimensions of the permeable part of the glycocalyx allowing the penetration of circulating red blood cells, providing an index of glycocalyx damage. The PBR was increased in ICU patients compared to healthy controls (2.7 [2.59-2.88] vs. 2.46 [2.37-2.59]μm, p<0.0001) and tended to be higher in the 32 septic patients compared to non-septics (2.77 [2.62-2.93] vs. 2.67 [2.55-2.75]μm, p=0.05), suggesting more severe glycocalyx alterations. A PBR of 2.76 showed the best discriminative ability towards the presence of sepsis (sensitivity: 50%, specificity: 83%; area under the receiver operating characteristic curve: 0.67, 95% CI 0.52-0.82, p=0.05). A weak positive correlation was found between PBR and heart rate (r=0.3, p=0.03). In 17 septic patients, a correlation was found between PBR and number of rolling leukocytes in post-capillary venules (RL/venule) (r=0.55, p=0.02), confirming that glycocalyx shedding enhances leukocyte-endothelium interaction.
Wallace, David J.; Angus, Derek C.; Barnato, Amber E.; Kramer, Andrew A.; Kahn, Jeremy M.
BACKGROUND Hospitals are increasingly adopting 24-hour intensivist physician staffing as a strategy to improve intensive care unit (ICU) outcomes. However, the degree to which nighttime intensivists are associated with improvements in the quality of ICU care is unknown. METHODS We conducted a retrospective cohort study involving ICUs that participated in the Acute Physiology and Chronic Health Evaluation (APACHE) clinical information system from 2009 through 2010, linking a survey of ICU staffing practices with patient-level outcomes data from adult ICU admissions. Multivariate models were used to assess the relationship between nighttime intensivist staffing and in-hospital mortality among ICU patients, with adjustment for daytime intensivist staffing, severity of illness, and case mix. We conducted a confirmatory analysis in a second, population-based cohort of hospitals in Pennsylvania from which less detailed data were available. RESULTS The analysis with the use of the APACHE database included 65,752 patients admitted to 49 ICUs in 25 hospitals. In ICUs with low-intensity daytime staffing, nighttime intensivist staffing was associated with a reduction in risk-adjusted in-hospital mortality (adjusted odds ratio for death, 0.62; P = 0.04). Among ICUs with high-intensity daytime staffing, nighttime intensivist staffing conferred no benefit with respect to risk-adjusted in-hospital mortality (odds ratio, 1.08; P = 0.78). In the verification cohort, there was a similar relationship among daytime staffing, nighttime staffing, and in-hospital mortality. The interaction between nighttime staffing and daytime staffing was not significant (P = 0.18), yet the direction of the findings were similar to those in the APACHE cohort. CONCLUSIONS The addition of nighttime intensivist staffing to a low-intensity daytime staffing model was associated with reduced mortality. However, a reduction in mortality was not seen in ICUs with high-intensity daytime staffing. (Funded by the
Katavic, Snježana Stanarevic; Tanackovic, Sanjica Faletar; Badurina, Boris
Introduction: This study examined possible correlations between health information behaviour and illness perception among patients with rare chronic diseases. Illness perception is related to coping strategies used by patients, and some health information behaviour practices may be associated with better coping and more positive perception of…
Oflaz, Serap; Guveli, Hulya; Kalelioglu, Tevfik; Akyazı, Senem; Yıldızhan, Eren; Kılıc, Kasım Candas; Basyigit, Sehnaz; Ozdemiroglu, Filiz; Akyuz, Fatma; Gokce, Esra; Bag, Sevda; Kurt, Erhan; Oral, Esat Timucin
Dropout is a common problem in the treatment of psychiatric illnesses including bipolar disorders (BD). The aim of the present study is to investigate illness perceptions of dropout patients with BD. A cross sectional study was done on the participants who attended the Mood Disorder Outpatient Clinic at least 3 times from January 2003 through June 2008, and then failed to attend clinic till to the last one year, 2009, determined as dropout. Thirty-nine dropout patients and 39 attendent patients with BD were recruited for this study. A sociodemographic form and brief illness perception questionnaire were used to capture data. The main reasons of patients with BD for dropout were difficulties of transport (31%), to visit another doctor (26%), giving up drugs (13%) and low education level (59%) is significant for dropout patients. The dropout patients reported that their illness did not critically influence their lives, their treatment had failed to control their illnesses, they had no symptoms, and that their illness did not emotionally affect them. In conclusion, the nonattendance of patients with serious mental illness can result in non-compliance of therapeutic drug regimens, and a recurrence of the appearance symptoms. The perception of illness in dropout patients with BD may be important for understanding and preventing nonattendance.
Christensen, Alan J.; And Others
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…
Edgar, Maggie; Uhl, Monica
These guidelines are intended to assist states and local communities in developing quality respite services that meet the diverse needs of families and children with disabilities, with chronic and terminal illnesses, or at risk of abuse or neglect. The guidelines support the philosophy that all families can benefit from temporary intervals of rest…
Lynn, J; Harrell, F; Cohn, F; Wagner, D; Connors, A F
Troubling aspects of the experiences of patients at the ends of their lives have fueled interest in special benefits or privileges for this group. There is a presumption that being "at the end of life" is discernible. This study examines this presumption using data from two previously collected databases: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) and the Acute Physiology and Chronic Health Evaluation III (APACHE III). Both studies generated multivariable estimates of survival prognosis for hospitalized patients. SUPPORT included 9,105 patients with one of nine serious illnesses in five hospitals over 4 yrs, of whom 2,360 died in the hospital and 4,537 died within 180 days of entry into the study. The APACHE III database describes 2,750 deaths in 16,622 ICU patients in 40 hospitals. The relationship of median estimates with time to death were examined for each source of data, for different diseases, and for ICU settings of care. In SUPPORT, the median predicted chance of survival for 2 months on the day before actual death was .17 (interquartile range, .02-.40) and was .51 (.31-.66) 1 wk before death. Median prognoses varied substantially among diseases: the median for congestive heart failure patients was a .62 chance of living 2 months on the day before death, while lung cancer had only a .17 chance and coma patients only an .11 chance. Median prognostication estimates were not much different when given by physicians and were only a little more pessimistic in APACHE (median estimate for hospital survival on the day before death was .14 and 7 days before was .45). To make plans about care and to optimally support most dying persons and families, conversations must occur while the patient still has a considerable chance of surviving the current episode of illness. Using statistical estimates of prognosis to designate a category of "terminally ill" patients for public policy purposes is unavoidably arbitrary
Nguyen, Nam Q; Fraser, Robert J; Bryant, Laura K; Chapman, Marianne; Holloway, Richard H
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. PMID:17226907
Cooke, Amanda; Resmini, Jonathan; Garinther, Alexander; Chow, Vinca; Quiñones, Rebecca; Noveroske, Sarah; Baccari, Andrew; Smith, Patrick T.; Peteet, John; Balboni, Tracy A.; Balboni, Michael J.
Abstract Background: Clergy are often important sources of guidance for patients and family members making medical decisions at the end-of-life (EOL). Previous research revealed spiritual support by religious communities led to more aggressive care at the EOL, particularly among minority patients. Understanding this phenomenon is important to help address disparities in EOL care. Objective: The study objective was to explore and describe clergy perspectives regarding “good” versus “poor” death within the participant's spiritual tradition. Methods: This was a qualitative, descriptive study. Community clergy from various spiritual backgrounds, geographical locations within the United States, and races/ethnicities were recruited. Participants included 35 clergy who participated in one-on-one interviews (N = 14) and two focus groups (N = 21). Semistructured interviews explored clergy viewpoints on factors related to a “good death.” Principles of grounded theory were used to identify a final set of themes and subthemes. Results: A good death was characterized by wholeness and certainty and emphasized being in relationship with God. Conversely, a “poor death” was characterized by separation, doubt, and isolation. Clergy identified four primary determinants of good versus poor death: dignity, preparedness, physical suffering, and community. Participants expressed appreciation for contextual factors that affect the death experience; some described a “middle death,” or one that integrates both positive and negative elements. Location of death was not viewed as a significant contributing factor. Conclusions: Understanding clergy perspectives regarding quality of death can provide important insights to help improve EOL care, particularly for patients highly engaged with faith communities. These findings can inform initiatives to foster productive relationships between clergy, clinicians, and congregants and reduce health disparities. PMID:26317801
Health psychology researchers have begun to focus greater attention on people's beliefs about health/illness since these beliefs can clearly affect behavior. This cross-sectional study aimed at (1) identifying the most common factors psychotic patients attribute their illness to and (2) assessing the association between causal attribution and illness perception (cognitive, emotional, and comprehensibility dimensions). Sixty-two patients (56.5% females) who had been treated for psychosis at a public psychiatric hospital in Mexico answered the Angermeyer and Klusmann Illness Attribution Scale and the Brief Illness Perception Questionnaire. Results showed that most patients attributed psychosis onset to social factors and that attribution to their personality might have an overwhelmingly negative effect on their lives. Acknowledging psychotic patient attributional beliefs and considering them in clinical practice could improve treatment efficacy and overall recovery success. This is particularly important in psychosis, since symptoms are often severe and/or persistent and require long-term treatment.
Health psychology researchers have begun to focus greater attention on people's beliefs about health/illness since these beliefs can clearly affect behavior. This cross-sectional study aimed at (1) identifying the most common factors psychotic patients attribute their illness to and (2) assessing the association between causal attribution and illness perception (cognitive, emotional, and comprehensibility dimensions). Sixty-two patients (56.5% females) who had been treated for psychosis at a public psychiatric hospital in Mexico answered the Angermeyer and Klusmann Illness Attribution Scale and the Brief Illness Perception Questionnaire. Results showed that most patients attributed psychosis onset to social factors and that attribution to their personality might have an overwhelmingly negative effect on their lives. Acknowledging psychotic patient attributional beliefs and considering them in clinical practice could improve treatment efficacy and overall recovery success. This is particularly important in psychosis, since symptoms are often severe and/or persistent and require long-term treatment. PMID:25525628
While racial disparity in the use of hospice care by older African Americans is widely acknowledged, little is known about the values that they consider as important in receiving health care services along with direct experiences with having these values respected by hospice care providers. Using individual, face-to-face interviews, data were collected directly from 28 African American hospice patients about their experiences in hospice care. Content analysis was used to identify and categorize themes from multiple readings of the qualitative data. Resulting themes included: dying at home, open communications, independent decision-making, autonomy in daily life, unwillingness to be a burden, and relationships. Through the initial assessment, value preferences can be explored and then shared with hospice team members to ensure that services are provided in such a way that their values and preferences are respected.
Razali, S M; Khan, U A; Hasanah, C I
The concept of aetiology of mental illness in 134 Malay patients was investigated by means of a 20-item checklist. About 53% of the patients attributed their illnesses to supernatural agents. Witchcraft and possession by evil spirits were regarded as common causes of illness. The number of patients who believed in supernatural causes of their mental illness was significantly higher among those who had consulted bomohs (Malay traditional healers) than among those who had not consulted them. The belief that mental illness is caused by supernatural agents is firmly held by bomohs, who reinforce this notion in those who seek their advice. Belief in supernatural causes of mental illness was not significantly associated with age, gender, level of education or occupation of the patients. Patients who believed in supernatural causes of mental illness were also found to show poor drug compliance, and the number of such patients at 6 months follow-up was significantly lower than the corresponding figure for those who did not believe in supernatural causes. The importance of understanding the patients' cultural background when treating psychiatric patients is highlighted.
Siever, B A
Optimal pain control in the dying child often requires aggressive opioid therapy that exceeds recommended parameters and may hasten death caused by respiratory depression. For pediatric nurses caring for the dying child, the administration of potentially life-shortening analgesia gives rise to a number of ethical issues. Pediatric nurses often express concern that aggressive pain control is a form of euthanasia or fear the child will develop a drug dependence. Lack of clarity about the ethical obligations and professional responsibilities of nurses who administer potentially life-shortening analgesia may also contribute to the dilemmas surrounding such situations. If left unresolved, these issues can interfere with the nurse's ability to implement an appropriate pain regimen. To provide adequate pain control, pediatric nurses who care for dying children must accomplish the following: critically examine ethical issues and underlying principles; understand the phenomena of addiction, tolerance, and physical dependence; and identify the boundaries of acceptable nursing practice when administering potentially life-shortening analgesia to terminally ill children.
Park, Yoonyoung; Franklin, Jessica M.; Schneeweiss, Sebastian; Levin, Raisa; Crystal, Stephen; Gerhard, Tobias; Huybrechts, Krista F.
OBJECTIVES Earlier studies have documented a greater mortality risk associated with conventional compared with atypical antipsychotics. Concern remains that the association is not causal, but due to residual confounding by differences in underlying health. To address this concern, we evaluated whether adjustment for prognostic indices specifically developed fornursing home (NH) populations affected the magnitude of the previously observed associations. DESIGN Cohort study SETTING A merged dataset of Medicaid, Medicare, the Minimum Data Set (MDS), the Online Survey Certification and Reporting system (OSCAR), and the National Death Index in the US for 2001-2005 PARTICIPANTS Dual eligible subjects ≥ 65 years who initiated antipsychotic treatment in a NH (n=75,445). MEASUREMENTS Three mortality risk scores (MRIS, MMRI-R, and ADEPT) were derived for each patient using baseline MDS data, and their performance was assessed using c-statistics and goodness-of-fit tests. The impact of adjusting for these indices in addition to propensity scores (PS) on the antipsychotic-mortality association was evaluated using Cox models with and without adjustment for risk scores. RESULTS Each risk score showed moderate discrimination for 6-month mortality with c-statistics ranging from 0.61 to 0.63. There was no evidence of lack of fit. Imbalances in risk scores between conventional and atypical antipsychotic users in the full cohort, suggesting potential confounding, were greatly reduced within PS deciles. Accounting for each score in the Cox model did not change the relative risk estimates: 2.24 with PS only adjustment vs. 2.20, 2.20, 2.22 after further adjustment for the three risk scores. CONCLUSION Although causality cannot be proven based on non-randomized studies, this study adds to the body of evidence rejecting alternative explanations for the increased mortality risk associated with conventional antipsychotics. PMID:25752911
Obayashi, Patricia A C
Issues regarding food safety are seen increasingly in the news; outbreaks of foodborne illness have been associated with public health concerns ranging from mild illness to death. For the solid organ transplant patient, immunosuppressive and antibacterial drugs, which maintain transplant organ function, can expose the transplant patient to increased risk of foodborne illness from bacteria, viruses, fungi, and parasites. This review article describes the clinical consequences, sources of foodborne illness, and food safety practices needed to minimize risks to the solid organ transplant patient who must take lifelong immunosuppressive drugs. All members of the transplant team share responsibility for education of the solid organ transplant patient in preventing infections. The registered dietitian, as part of the transplant team, is the recognized expert in providing food safety education in the context of medical nutrition therapy to solid organ transplant patients, the patients' caregivers, and other healthcare providers.
Izumi, Shigeko; Baggs, Judith G; Knafl, Kathleen A
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.
Lerman, C E; Brody, D S; Caputo, G C; Smith, D G; Lazaro, C G; Wolfson, H G
This report describes the development of the Perceived Involvement in Care Scale (PICS), a self-report questionnaire for patients, and its relation to primary care patients' attitudes regarding their illnesses and the management of them. The questionnaire was administered to three independent samples of adult primary care patients. Patients' satisfaction and their attitudes regarding their illnesses are evaluated after their medical visits. This instrument is designed to examine three relatively distinct factors: 1) doctor facilitation of patient involvement, 2) level of information exchange, and 3) patient participation in decision making. Of these factors, doctor facilitation and patient decision making were related significantly to patients' satisfaction with care. Doctor facilitation and information exchange related consistently to patients' perceptions of post-visit changes in their understanding, reassurance, perceived control over illness, and expectations for improvement in functioning. The role of physicians in enhancing patient involvement in care and the potential therapeutic benefits of physician facilitative behavior are addressed.
Zmak, Ljiljana; Obrovac, Mihaela; Lovric, Zvjezdana; Jankovic Makek, Mateja; Katalinic Jankovic, Vera
As tuberculosis incidence decreases, the possibility of overlooking the disease increases, especially in vulnerable populations. We describe here a major tuberculosis outbreak among mentally ill patients in Croatia, focusing on 1 regional hospital where most patients were hospitalized. The outbreak emphasizes the vulnerability of mentally ill patients to tuberculosis infection and the complexity of infection control measures in psychiatric institutions. The awareness of tuberculosis in these settings should be maintained to interrupt prolonged exposure and avoid unnecessary infection.
mechanisms of adverse effects related to RBC storage age in critically ill patients. To date we have enrolled 130 patients at the three clinical sites in...Prospective clinical studies investigating the mechanisms and clinical outcomes associated with increased or decreased RBC storage age in critically ill...patients including traumatic injury have not been performed. The ABLE study presents a unique and probably one-time opportunity to investigate mechanisms
Monajemi, Alireza; Schmidt, Henk G.; Rikers, Remy M. J. P.
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…
Analyzed how nurses deal with terminal and dying patients in two inpatient wards in Belgian general hospital. Observed that nurses often felt dissatisfied with their terminal caregiving. Suggests terminal care include specific physical, social, religious, and psychological services, given to terminal patient and family, to obtain as high a level…
Beard, Walter L; Long, R Craig; Geraci, Stephen A
Heart failure is a chronic disease afflicting millions of patients worldwide. Advances in treatment have allowed sufferers to enjoy overall prolonged survival and enhanced quality of life. Yet, a consequence of these therapeutic successes is that more patients survive to end-stage disease, with severe symptoms, poor quality of life, and no options available to prolong their survival reasonably. End-stage heart failure patients require a comprehensive palliative approach to care during their final months, with treatment goals focusing on symptom relief. Often, specific heart failure therapies can further this cause and should be administered when appropriate to alleviate specific symptoms, while other general palliative measures should also be considered as with other terminal patients. End-of-life palliative strategies must conform to accepted principles of ethical care. Constant communication with patients and families is essential to achieve best treatment goals for this growing segment of the population.
Holden, Richard J; Valdez, Rupa S; Schubert, Christiane C; Thompson, Morgan J; Hundt, Ann S
Human factors/ergonomics recognises work as embedded in and shaped by levels of social, physical and organisational context. This study investigates the contextual or macroergonomic factors present in the health-related work performed by patients. We performed a secondary content analysis of findings from three studies of the work of chronically ill patients and their informal caregivers. Our resulting consolidated macroergonomic patient work system model identified 17 factors across physical, social and organisational domains and household and community levels. These factors are illustrated with examples from the three studies and discussed as having positive, negative or varying effects on health and health behaviour. We present three brief case studies to illustrate how macroergonomic factors combine across domains and levels to shape performance in expected and unexpected ways. Findings demonstrate not only the importance of context for patients' health-related activities but also specific factors to consider in future research, design and policy efforts. Practitioner Summary: Health-related activities of patients are embedded in and shaped by levels of social, physical and organisational context. This paper combined findings from three studies to specify 17 contextual or macroergonomic factors in home- and community-based work systems of chronically ill patients. These factors have research, design and policy implications.
Gardner, William; And Others
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…
Undergraduate students need to gain more exposure to communicating, assessing, and planning appropriate care and evaluating outcomes of care with diverse critically ill geriatric patients. This project developed teaching strategies that facilitated additional opportunities for gaining these valuable learning experiences for students. Nurse educators can use the Guidelines for Caring for Diverse Critically Ill Older Adults, the case study and simulation examples, and topical outline to assist them in teaching critical care students and nurses about diverse critically ill older adults.
Lindh, A.; Roessner, S.
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.
Lu, Yanxia; Tang, Catherine; Liow, Chiew Shan; Ng, Winnie Wei Ni; Ho, Cyrus Su Hui; Ho, Roger Chun Mun
Although illness perception has been shown to be associated with illness outcomes in various chronic physical diseases, the association of illness perception and rumination are not well elucidated in mental disorders. This study aims to investigate the mediational effects of adaptive and maladaptive rumination in the relationship between illness perception and negative emotions (depression, anxiety and stress) in male and female patients (N=110) suffering from depressive disorders. The results showed that maladaptive rumination mediated the relationship between illness perception and negative emotions in both male and female depressive patients. However, no mediating effects of adaptive rumination were found in the relationship between illness perception and negative emotion. Maladaptive rumination mediated the relationship between perceived identity, chronicity of illness, consequences of illness and emotional representation of illness and negative emotions in males. It also mediated the relationship between perceived identity and emotional representation of illness and negative emotions in females. The results, possible clinical implications and limitations of this study are also discussed.
Horta, A L; Araújo, A P; Aprile, C M; Echalar, C M; Paredes, F N; Caminada, S
This study reported family's reaction of the child terminally ill, identified by the pediatric nurses. It focuses on the suggested assistance to the family and on the pediatric nurses difficulties in this situation. This study was carried out with 35 nurses working at two University Hospitals. We based the analysis on the phases of dying of KUBLER-ROSS and Guide of Communication with parents of WHALEY & WONG, besides our own categorization.
Latalova, Klara; Kamaradova, Dana; Prasko, Jan
The aims of this paper are to review data on the prevalence and correlates of violent victimization of persons with severe mental illness, to critically evaluate the literature, and to explore possible approaches for future research. PubMed/MEDLINE and PsycINFO databases were searched using several terms related to severe mental illness in successive combinations with terms describing victimization. The searches identified 34 studies. Nine epidemiological studies indicate that patients with severe mental illness are more likely to be violently victimized than other community members. Young age, comorbid substance use, and homelessness are risk factors for victimization. Victimized patients are more likely to engage in violent behavior than other members of the community. Violent victimization of persons with severe mental illness has long-term adverse consequences for the course of their illness, and further impairs the quality of lives of patients and their families. Victimization of persons with severe mental illness is a serious medical and social problem. Prevention and management of victimization should become a part of routine clinical care for patients with severe mental illness. PMID:25336958
Karataş, Tuğba; Özen, Şükrü; Kutlutürkan, Sevinç
Objective: The main aim of this study was to investigate the factor structure and psychometric properties of the Brief Illness Perception Questionnaire (BIPQ) in Turkish cancer patients. Methods: This methodological study involved 135 cancer patients. Statistical methods included confirmatory or exploratory factor analysis and Cronbach alpha coefficients for internal consistency. Results: The values of fit indices are within the acceptable range. The alpha coefficients for emotional illness representations, cognitive illness representations, and total scale are 0.83, 0.80, and 0.85, respectively. Conclusions: The results confirm the two-factor structure of the Turkish BIPQ and demonstrate its reliability and validity. PMID:28217734
Darmann-Finck, Ingrid; Sahm, Martina
The article examines two concepts of counselling of patients by nurses that are popular in the German-speaking area with regard to their underlying scientific standpoint and ideals and their implications on counselling-process and -result. The authors determine that both concepts disregard the biographic construction processes which are so important for coping with and tackling chronic illness. The article concludes with a discussion of prospective use of biographic diagnostics in counselling of patients with chronic illness.
Popovic, Nada; Djordjevic, Dragan
Immunoinflammatory response in critically ill patients is very complex. This review explores some of the new elements of immunoinflammatory response in severe sepsis, tumor necrosis factor-alpha in severe acute pancreatitis as a clinical example of immune response in sepsis, immune response in severe trauma with or without secondary sepsis, and genetic aspects of host immuno-inflammatory response to various insults in critically ill patients. PMID:24371374
Poznansky, M. C.; Coker, R.; Skinner, C.; Hill, A.; Bailey, S.; Whitaker, L.; Renton, A.; Weber, J.
OBJECTIVES--To study the presentation and survival of patients who present with their first diagnosis of being HIV positive at the same time as their AIDS defining illness. DESIGN--Retrospective study of patients presenting with AIDS between 1991 and 1993. SETTING--Department of genitourinary medicine, St Mary's Hospital, London. MAIN OUTCOME MEASURES--AIDS defining illness at presentation and survival after diagnosis of AIDS. RESULTS--Between January 1991 and December 1993, 97 out of 436 patients (22%) presented with their first AIDS defining illness coincident with their first positive result of an HIV test (group B). The remaining 339 patients (78%) had tested positive for HIV-1 infection within the previous eight years and had consequently been followed up in clinics before developing their first AIDS defining illness (group A). The two groups of patients did not differ in age and sex distribution, risk factors for HIV-1 infection, nationality, country of origin, or haematological variables determined at the time of the AIDS defining illness. However, the defining illnesses differed between the two groups. Illnesses associated with severe immunodeficiency (the wasting syndrome, cryptosporidiosis, and cytomegalovirus infection) were seen almost exclusively in group A whereas extrapulmonary tuberculosis and Pneumocystis carinii pneumonia were more common in group B. The survival of patients in group B after the onset of AIDS was significantly longer than that of patients in group A as determined by Kaplan-Meier log rank analysis (P = 0.0026). CONCLUSIONS--Subjects who are HIV positive and present late are a challenge to the control of the spread of HIV infection because they progress from asymptomatic HIV infection to AIDS without receiving health care. The finding that presentation with an AIDS defining illness coincident with a positive result in an HIV test did not have a detrimental effect on survival gives insights into the effects of medical intervention on
Etkind, Simon Noah; Bristowe, Katherine; Bailey, Katharine; Selman, Lucy Ellen; Murtagh, Fliss EM
Background: Uncertainty is common in advanced illness but is infrequently studied in this context. If poorly addressed, uncertainty can lead to adverse patient outcomes. Aim: We aimed to understand patient experiences of uncertainty in advanced illness and develop a typology of patients’ responses and preferences to inform practice. Design: Secondary analysis of qualitative interview transcripts. Studies were assessed for inclusion and interviews were sampled using maximum-variation sampling. Analysis used a thematic approach with 10% of coding cross-checked to enhance reliability. Setting/participants: Qualitative interviews from six studies including patients with heart failure, chronic obstructive pulmonary disease, renal disease, cancer and liver failure. Results: A total of 30 transcripts were analysed. Median age was 75 (range, 43–95), 12 patients were women. The impact of uncertainty was frequently discussed: the main related themes were engagement with illness, information needs, patient priorities and the period of time that patients mainly focused their attention on (temporal focus). A typology of patient responses to uncertainty was developed from these themes. Conclusion: Uncertainty influences patient experience in advanced illness through affecting patients’ information needs, preferences and future priorities for care. Our typology aids understanding of how patients with advanced illness respond to uncertainty. Assessment of these three factors may be a useful starting point to guide clinical assessment and shared decision making. PMID:27129679
Maremmani, Angelo Giovanni Icro; Rovai, Luca; Rugani, Fabio; Pacini, Matteo; Lamanna, Francesco; Bacciardi, Silvia; Perugi, Giulio; Deltito, Joseph; Dell’Osso, Liliana; Maremmani, Icro
In a group of 1066 heroin addicts, who were seeking treatment for opioid agonist treatment, we looked for differences in historical, demographic, and clinical characteristics, between patients with different levels of awareness of illness (insight). The results showed that, in the cohort studied, a majority of subjects lacked insight into their heroin-use behavior. Compared with the impaired-insight group, those who possessed insight into their illness showed significantly greater awareness of past social, somatic, and psychopathological impairments, and had a greater number of past treatment-seeking events for heroin addiction. In contrast with other psychiatric illnesses, the presence of awareness appears to be related to the passing of time and to the worsening of the illness. Methodologies to improve the insight of patients should, therefore, be targeted more directly on patients early in their history of heroin dependence, because the risk of lack of insight is greatest during this period. PMID:22787450
Hueso Montoro, César; Siles González, José; Amezcua, Manuel; Bonill de Las Nieves, Candela; Pastor Montero, Sonia; Celdrán Mañas, Miriam
The aim of this study is to understand the suffering of a patient with an illness, by using a secondary research method, that is, a qualitative meta-study. The primary data source of the meta-study includes "biographical reports". This project is based on a case study, in which the first-hand experiences of a patient with an illness were collected. The findings of the reports were compiled using the Archivos de la Memoria collection of the Index Foundation (Granada, Spain) and journals specialized in editing these materials. A selection of 20 biographical reports was targeted. The results of the meta-study show that suffering is a multidimensional process within a framework of ambiguous feelings. The suffering involves family and social network participation. Patients develop a range of strategies to overcome the illness. One of the effects is the fear of illness relapse or worsening.
Wald, Heidi L.; Leykum, Luci K.; Mattison, Melissa L. P.; Vasilevskis, Eduard E.; Meltzer, David O.
Hospitalists and others acute care providers are limited by gaps in evidence addressing the needs of the acutely ill older adult population. The Society of Hospital Medicine (SHM) sponsored the Acute Care of Older Patients (ACOP) Priority Setting Partnership to develop a research agenda focused on bridging this gap. Informed by the Patient-Centered Outcomes Research Institute (PCORI) framework for identification and prioritization of research areas, we adapted a methodology developed by the James Lind Alliance to engage diverse stakeholders in the research agenda setting process. The work of the Partnership proceeded through four steps: convening, consulting, collating, and prioritizing. First, the steering committee convened a Partnership of 18 stakeholder organizations in May 2013. Next, stakeholder organizations surveyed members to identify important unanswered questions in the acute care of older persons, receiving 1299 responses from 580 individuals. Finally, an extensive and structured process of collation and prioritization resulted in a final list of ten research questions in the following areas: advanced care planning, care transitions, delirium, dementia, depression, medications, models of care, physical function, surgery, and training. With the changing demographics of the hospitalized population, a workforce with limited geriatrics training, and gaps in evidence to inform clinical decision-making for acutely ill older patients, the identified research questions deserve the highest priority in directing future research efforts to improve care for the older hospitalized patient and enrich training. PMID:25877486
Wald, Heidi L; Leykum, Luci K; Mattison, Melissa L P; Vasilevskis, Eduard E; Meltzer, David O
Hospitalists and others acute-care providers are limited by gaps in evidence addressing the needs of the acutely ill older adult population. The Society of Hospital Medicine sponsored the Acute Care of Older Patients Priority Setting Partnership to develop a research agenda focused on bridging this gap. Informed by the Patient-Centered Outcomes Research Institute framework for identification and prioritization of research areas, we adapted a methodology developed by the James Lind Alliance to engage diverse stakeholders in the research agenda setting process. The work of the Partnership proceeded through 4 steps: convening, consulting, collating, and prioritizing. First, the steering committee convened a partnership of 18 stakeholder organizations in May 2013. Next, stakeholder organizations surveyed members to identify important unanswered questions in the acute care of older persons, receiving 1299 responses from 580 individuals. Finally, an extensive and structured process of collation and prioritization resulted in a final list of 10 research questions in the following areas: advanced-care planning, care transitions, delirium, dementia, depression, medications, models of care, physical function, surgery, and training. With the changing demographics of the hospitalized population, a workforce with limited geriatrics training, and gaps in evidence to inform clinical decision making for acutely ill older patients, the identified research questions deserve the highest priority in directing future research efforts to improve care for the older hospitalized patient and enrich training.
Ruchlewska, Asia; Kamperman, Astrid M; van der Gaag, Mark; Wierdsma, André I; Mulder, Niels C L
Working alliance has been characterized as an important predictor of positive treatment outcomes. We examined whether illness insight, psychosocial functioning, social support and locus of control were associated with working alliance as perceived by both patient and clinician. We assessed 195 outpatients with psychotic or bipolar disorders. Our findings indicated that patients rated the alliance more positively when they experienced a greater need for treatment, fewer behavioral and social problems, and more psychiatric symptoms. Clinicians rated the alliance more positively in patients who reported fewer social problems and better illness insight. Patients' demographic characteristics, including being female and married, were also positively related to the clinician-rated alliance. Our results suggest that patients and clinicians have divergent perceptions of the alliance. Clinicians may need help developing awareness of the goals and tasks of patients with certain characteristics, i.e., singles, men, those with poor illness insight and those who report poor social functioning.
Allen, Dawn; Wainwright, Megan; Hutchinson, Thomas
With only 50% of patients in developed countries following the therapies prescribed for them by health professionals, "non-compliance" is commonly described as causing increases in morbidity, hospital visits, and overall healthcare costs. A plethora of non-compliance studies have failed to identify consistent predictors for, or solutions to, patients' non-compliance. Our longitudinal (September 2006-September 2008) participatory action research (PAR) focused on (a) understanding hemodialysis patients' perspectives on the challenges and solutions to living well with their chronic illness and (b) taking action to improve this population's quality of life. The study's participants included seven purposefully sampled patients in two hospital hemodialysis units in Canada. A small sample size was essential to accommodate our commitment to conducting a PAR study with this patient population whose unpredictable health status presented significant challenges to recruitment, follow-up interviews, and participation in data analysis. Data collection and analysis over 2 years included over 100 h of ethnographic field observation, bi-weekly unrecorded and 12 audio-recorded in-dialysis interviews, five video-recorded life-history interviews, two video-recorded focus groups, and five video-recorded dialysis treatment sessions. Thematic content analysis drew attention to patients' descriptions of adversarial interactions with health professionals. In these interactions, three points of tension were identified: (a) between whole person care and "assembly line" treatment, (b) between patient knowledge and medical expertise, and (c) between shared decision-making and "digging to find out". The article concludes that these adversarial relationships are indicative of a lack of trust stemming from health professionals' failure to interact with patients as whole persons with unique expertise on their bodies, their experience of illness, and their lives.
Sancho, Jesus; Servera, Emilio; Jara-Palomares, Luis; Barrot, Emilia; Sanchez-Oro-Gómez, Raquel; Gómez de Terreros, F Javier; Martín-Vicente, M Jesús; Utrabo, Isabel; Núñez, M Belen; Binimelis, Alicia; Sala, Ernest; Zamora, Enrique; Segrelles, Gonzalo; Ortega-Gonzalez, Angel; Masa, Fernando
Chronically critically ill patients often undergo prolonged mechanical ventilation. The role of noninvasive ventilation (NIV) during weaning of these patients remains unclear. The aim of this study was to determine the value of NIV and whether a parameter can predict the need for NIV in chronically critically ill patients during the weaning process. We conducted a prospective study that included chronically critically ill patients admitted to Spanish respiratory care units. The weaning method used consisted of progressive periods of spontaneous breathing trials. Patients were transferred to NIV when it proved impossible to increase the duration of spontaneous breathing trials beyond 18 h. 231 chronically critically ill patients were included in the study. 198 (85.71%) patients achieved weaning success (mean weaning time 25.45±16.71 days), of whom 40 (21.4%) needed NIV during the weaning process. The variable which predicted the need for NIV was arterial carbon dioxide tension at respiratory care unit admission (OR 1.08 (95% CI 1.01-1.15), p=0.013), with a cut-off point of 45.5 mmHg (sensitivity 0.76, specificity 0.67, positive predictive value 0.76, negative predictive value 0.97). NIV is a useful tool during weaning in chronically critically ill patients. Hypercapnia despite mechanical ventilation at respiratory care unit admission is the main predictor of the need for NIV during weaning.
Servera, Emilio; Barrot, Emilia; Sanchez-Oro-Gómez, Raquel; Gómez de Terreros, F. Javier; Martín-Vicente, M. Jesús; Utrabo, Isabel; Núñez, M. Belen; Binimelis, Alicia; Sala, Ernest; Zamora, Enrique; Segrelles, Gonzalo; Ortega-Gonzalez, Angel; Masa, Fernando
Chronically critically ill patients often undergo prolonged mechanical ventilation. The role of noninvasive ventilation (NIV) during weaning of these patients remains unclear. The aim of this study was to determine the value of NIV and whether a parameter can predict the need for NIV in chronically critically ill patients during the weaning process. We conducted a prospective study that included chronically critically ill patients admitted to Spanish respiratory care units. The weaning method used consisted of progressive periods of spontaneous breathing trials. Patients were transferred to NIV when it proved impossible to increase the duration of spontaneous breathing trials beyond 18 h. 231 chronically critically ill patients were included in the study. 198 (85.71%) patients achieved weaning success (mean weaning time 25.45±16.71 days), of whom 40 (21.4%) needed NIV during the weaning process. The variable which predicted the need for NIV was arterial carbon dioxide tension at respiratory care unit admission (OR 1.08 (95% CI 1.01–1.15), p=0.013), with a cut-off point of 45.5 mmHg (sensitivity 0.76, specificity 0.67, positive predictive value 0.76, negative predictive value 0.97). NIV is a useful tool during weaning in chronically critically ill patients. Hypercapnia despite mechanical ventilation at respiratory care unit admission is the main predictor of the need for NIV during weaning. PMID:28053973
Heaton, Lisa J.; Hyatt, Halee A.; Huggins, Kimberly Hanson; Milgrom, Peter
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. PMID:24876662
Novak, Primoz; Vidmar, Gaj; Kuret, Zala; Bizovicar, Natasa
Critical illness polyneuropathy and myopathy (CIPNM) frequently develops in patients hospitalized in intensive care units. The number of patients with CIPNM admitted to inpatient rehabilitation is increasing. The aim of this study was to comprehensively evaluate the outcome of their rehabilitation. Twenty-seven patients with CIPNM were included in…
Mahmoud, Sahar; Zaki, Rania A.
This study was a comparative study aiming to assess the extent of internalized stigma of mental illness among patients with schizophrenia & identify stigma as perceived by family members caring schizophrenic patients. The study was conducted in two settings 1st clinic was outpatient clinic for psychiatric patient affiliated to Abbasia…
Aoun, Samar M; O'Connor, Moira; Breen, Lauren J; Deas, Kathleen; Skett, Kim
This project implemented and evaluated two models of care for terminally ill people living alone at home: installing personal alarms (PA) and providing extra care aide (CA) support. The primary aim was to assess the feasibility of using a randomised controlled trial (RCT) approach with this group. A secondary aim was to assess the potential impact of the models of care on the participants' quality of life, symptom distress, anxiety and depression, and perceived benefits and barriers to their use. The two models of care were piloted in collaboration with Silver Chain Hospice Care Service (SCHCS) in Western Australia during 2009-2010. Using a pilot RCT design, equal numbers of participants were randomised to receive extra CA time, PAs or standard care. Attrition reduced the sample size from 20 in each group to 12, 14 and 17 respectively. The intervention period was between 6 and 12 weeks depending on prognosis. The participants were functionally and psychologically well and the majority lived alone by choice. There were physical and psychological benefits associated with provision of the two models of care, particularly for the group supported by CAs in terms of improved sleeping and appetite. However, the impact was mostly not statistically significant due to small sample sizes. The study has highlighted two methodological challenges: the wide variation in the degree of living alone at home leading to complex inclusion criteria, and an RCT approach with attrition differing across groups and patients not wanting to be included in the assigned group. The RCT approach is not considered appropriate for the 'home alone' palliative care population that would have been better supported by providing each participant with a personalised model of care according to needs. However, the outcomes of the project have prompted changes in SCHCS practice when providing care to these patients.
Hooijman, Pleuni E.; Beishuizen, Albertus; Witt, Christian C.; de Waard, Monique C.; Girbes, Armand R. J.; Spoelstra-de Man, Angelique M. E.; Niessen, Hans W. M.; Manders, Emmy; van Hees, Hieronymus W. H.; van den Brom, Charissa E.; Silderhuis, Vera; Lawlor, Michael W.; Labeit, Siegfried; Stienen, Ger J. M.; Hartemink, Koen J.; Paul, Marinus A.; Heunks, Leo M. A.
Rationale: The clinical significance of diaphragm weakness in critically ill patients is evident: it prolongs ventilator dependency, and increases morbidity and duration of hospital stay. To date, the nature of diaphragm weakness and its underlying pathophysiologic mechanisms are poorly understood. Objectives: We hypothesized that diaphragm muscle fibers of mechanically ventilated critically ill patients display atrophy and contractile weakness, and that the ubiquitin–proteasome pathway is activated in the diaphragm. Methods: We obtained diaphragm muscle biopsies from 22 critically ill patients who received mechanical ventilation before surgery and compared these with biopsies obtained from patients during thoracic surgery for resection of a suspected early lung malignancy (control subjects). In a proof-of-concept study in a muscle-specific ring finger protein-1 (MuRF-1) knockout mouse model, we evaluated the role of the ubiquitin–proteasome pathway in the development of contractile weakness during mechanical ventilation. Measurements and Main Results: Both slow- and fast-twitch diaphragm muscle fibers of critically ill patients had approximately 25% smaller cross-sectional area, and had contractile force reduced by half or more. Markers of the ubiquitin–proteasome pathway were significantly up-regulated in the diaphragm of critically ill patients. Finally, MuRF-1 knockout mice were protected against the development of diaphragm contractile weakness during mechanical ventilation. Conclusions: These findings show that diaphragm muscle fibers of critically ill patients display atrophy and severe contractile weakness, and in the diaphragm of critically ill patients the ubiquitin–proteasome pathway is activated. This study provides rationale for the development of treatment strategies that target the contractility of diaphragm fibers to facilitate weaning. PMID:25760684
Heli, Vaartio-Rajalin; Helena, Leino-Kilpi; Liisa, Iire; Kimmo, Lehtonen; Heikki, Minn
Cancer and its management affect patients' cognitive resources and education needs in several ways. The objective of this study is to identify significant factors affecting cognitive resources and knowledge expectations of adult patients with cancer during the course of their illness trajectory. Current or former patients with cancer (n = 53) were recruited to focus group interviews and individual in-depth interviews. The informants' knowledge expectations vary during their illness trajectory and are affected by personal, situational, and clinical factors. These should be acknowledged to provide person-centered, holistic nursing care and patient education.
Steca, P; Greco, A; Monzani, D; Politi, A; Gestra, R; Ferrari, G; Malfatto, G; Parati, G
Numerous empirical studies have investigated the relationships between cardiovascular diseases (CVD) and patients' psychological well-being, with a focus almost exclusively on its dark side. Very little is known on the impact of illness severity on both negative and positive indicators of patients' well-being, as well as on the psychosocial variables that may mediate this association. Aim of the study was to investigate the impact of illness severity on depression as well as on health satisfaction and life satisfaction of patients undergoing a cardiovascular rehabilitation. It also aimed at testing the mediation of illness perception and self-efficacy beliefs in managing cardiac risk factors. The study involved 172 patients (mean age = 66.43 years; SD = 9.99 years; 76.2% men). Illness severity was measured in terms of left ventricular ejection fraction at discharge from the cardiology department, whereas all psychological dimensions were assessed one week later. Results showed significant relationships among illness severity, depression and health satisfaction that were fully mediated by illness perception and self-efficacy beliefs, but not significant relation between disease severity and life satisfaction (χ2 (1) = 2.30, p = n.s.). Overall, findings underline the importance of working on illness perception and self-efficacy beliefs to contrast depression and to improve health and life satisfaction in patients with CVD.
Kaufman, David R; Ruland, Cornelia M
influenced by different context-related factors, such as type of access terminal (eg, desktop computer, tablet, mobile phone) and phases of illness. Based on the observed results, we proposed design and functionality recommendations that can be used for the development of mobile apps for cancer patients to support their health management process. Conclusions Understanding and addressing users’ requirements is one of the main prerequisites for developing useful and effective technology-based health interventions. The results of this study outline different user requirements related to the design of the mobile patient support app for cancer patients. The results will be used in the iterative development of the Connect Mobile app and can also inform other developers and researchers in development, integration, and evaluation of mobile health apps and services that support cancer patients in managing their health-related issues. PMID:25119490
Israel, Jared I; White, Kamila S; Gervino, Ernest V
Illness-specific cognitions are associated with outcomes in numerous health conditions, however, little is known about their role in noncardiac chest pain (NCCP). NCCP is prevalent, impairing, and associated with elevated health care utilization. Our objective was to investigate the relations between illness perceptions, emotion, and pain in a sample of 196 adult patients diagnosed with NCCP. We found that negative illness perceptions were associated with greater anxiety, depression, chest pain, and pain-related life interference while controlling for the effects of demographic and pain-related variables. These results expand current NCCP theory and may inform future treatment development.
Voltzenlogel, Virginie; Ernst, Alexandra; de Sèze, Jérôme; Brassat, David; Manning, Liliann; Berna, Fabrice
Multiple sclerosis (MS) patients are often unable to adequately fulfill their established roles due to physical disabilities and cognitive changes, making this chronic illness particularly threatening to personal identity. Twenty-five MS patients and 25 healthy controls were asked to recall five self-defining memories (SDM). Overall characteristics of SDM did not differ between patients and controls; MS patients displayed preserved capacity to draw meaning upon past events. Moreover, almost two-thirds of MS patients mentioned at least one illness related SDM and about 25% of patients' SDM referred to MS. These memories were experienced as more negative and associated with more tension than other SDM but led toward more positive emotion and less negative emotion over time; they were also more central and more integrated to the personal identity. We concluded that self-challenging events due to MS may trigger both cognitive and emotional processes enabling the integration of illness in patients' self-representations.
Moos, Manfred; Wolfersdorf, Manfred
According to a study in two clinics in the region of "Oberfranken" (1997) employment or unemployment has a different effect on the development of the mental illness: According to therapist inside opinion women suffered more from paid employment, men, however, from unemployment. In comparisons between the different diagnosis groups comparatively unfavourable effects of unemployment on the development of the illness of, addicted people became evident, negative effects of paid employment, however, were particularly found with patients suffering from F4 disorders (ICD-10).
Kovačević, Tijana; Avram, Sanja; Milaković, Dragana; Špirić, Nikolina; Kovačević, Pedja
Objective: Therapeutic drug monitoring (TDM) enables individualization in the treatment to optimize clinical benefit and minimize drugs' side effects. Critically ill septic patients represent a challenge for antimicrobial treatment because of pathophysiological impact of sepsis on pharmacokinetics of drugs. The aim of this study was to assess the appropriateness of gentamicin and amikacin dosing in critically and noncritically ill patients, as well as to estimate the need for its regular therapeutic monitoring. Subjects and Methods: It was a prospective study which included 31 patients on gentamicin and 16 patients on amikacin from four different units who met the inclusion criteria. Trough concentrations of drugs were measured in serum just before third or fourth dose of antibiotic, whereas peak concentrations were measured in serum 1 h after the completion of drug administration (steady state). Relevant data on patients' clinical course of disease, comorbidities, and concomitant medication were collected from medical charts in order to identify their possible influence on drugs' concentrations. Results: Peak concentrations of amikacin were in reference range in 81.8% critically ill and in 80% of noncritically ill patients (P = 0.931). Peak concentrations of gentamicin were in reference range in 88.9% critically ill and in 77.3% of noncritically ill patients (P = 0.457). Conclusion: Serum concentrations of aminoglycosides (amikacin and gentamicin) were in reference range in most of the patients in our study, suggesting that dosing of these drugs in the University Hospital Clinical Center, Banja Luka, was adequate. In patients without kidney or liver disease, regular TDM of aminoglycosides is not necessary. PMID:27330257
Singh, Gurmeet; Pitoyo, Ceva Wicaksono; Aditianingsih, Dita; Rumende, Cleopas Martin
Background: The incidence of invasive fungal disease (IFD) is increasing worldwide in the past two to three decades. Critically ill patients in Intensive Care Units are more vulnerable to fungal infection. Early detection and treatment are important to decrease morbidity and mortality in critically ill patients. Objective: Our study aimed to assess factors associated with early IFD in critically ill patients. Materials and Methods: This prospective cohort study was conducted in critically ill patients, from March to September 2015. Total number of patients (74) in this study was drawn based on one of the risk factors (human immunodeficiency virus). Specimens were collected on day 5–7 of hospitalization. Multivariate analysis with logistic regression was performed for factors, with P < 0.25 in bivariate analysis. Results: Two hundred and six patients were enrolled in this study. Seventy-four patients were with IFD, majority were males (52.7%), mean age was 58 years (range 18–79), mean Leon's score was 3 (score range 2–5), majority group was nonsurgical/nontrauma (72.9%), and mean fungal isolation was positive on day 5. Candida sp. (92.2%) is the most frquently isolated fungal infection. Urine culture yielded the highest number of fungal isolates (70.1%). Mortality rate in this study was 50%. In multivariate analysis, diabetes mellitus (DM) (P = 0.018, odds ratio 2.078, 95% confidence interval 1.135–3.803) was found as an independent factor associated with early IFD critically ill patients. Conclusion: DM is a significant factor for the incidence of early IFD in critically ill patients. PMID:27994377
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. PMID:24885562
Eder, Johanna; Kammerstätter, Martina; Erhart, Friedrich; Mairhofer-Muri, Daniela; Trautinger, Franz
There is currently no information available on illness perception in primary cutaneous T-cell lymphomas (CTCL). The aim of this study was therefore to gather initial information on disease understanding and interpretation in patients with CTCL. Consecutive patients from a hospital-based primary cutaneous lymphoma ward completed the Revised Illness Perception Questionnaire (IPQ-R) on 2 consecutive visits. A total of 24 patients with different variants of CTCL were included in the study. Patients experienced their condition as being long-lasting, but not fundamentally affecting their lives. Patients had poor belief in personal control, but strong belief in treatment control. They did not show a good understanding of their disease, and had a moderately negative emotional response to their illness. In conclusion, the IPQ-R provides a feasible and reproducible tool for measurement and better understanding of illness perception in patients with CTCL. Knowledge of patients' attitudes towards their disease should enable optimization of the patient-physician relationship and patient care.
López, M J; Cortés, J A
Urinary tract infections (UTIs) account for 20-50% of all hospital-acquired infections occurring in the intensive care unit (ICU). In some reports UTI was found to be more frequent than hospital-acquired pneumonia and intravascular device bacteremia, with a greater incidence in developing countries. The risk factors associated with the appearance of UTI include the severity of illness at the time of admission to the ICU, female status, prolonged urinary catheterization or a longer ICU stay and poor urinary catheter management - mainly disconnection of the closed system. about the present study offers data on the epidemiology of UTI in the ICU, the identified risk factors, etiology, diagnosis, impact upon morbidity and mortality, and the measures to prevent its appearance.
Iwaszczyszyn, J; Kwiecińska, A
Patient suffering from terminal disease is depended on his environment more than any other one. He often suffers from nervous break down, anxiety and fear and he is usually unprotected from the environment. Fast development of medical science and its technicisation can lead towards dehumanization and lack of psychological and spiritual care, which should be based on clear ethical principles. Main lines of ethical principles of Health Service which are included in Deontological Code of Physicians and Collection of ethical principles for a qualified nurse are the main rules how to proceed as to fulfill the rule: "benefit of a patient is the superior law." According to its speciality Palliative Medicine introduces also four general ethical principles: 1. Patient will is a rule of treatment. 2. The principle of proportion--benefits from the treatment should be higher than losses and suffering from iatrogenic acting. 3. The principle of equality--stop taking a cure does not differ from not undertaking treatment. 4. The principle of relativity--life is not an absolute good, death is not an absolute evil. Holistic acts of Palliative Medicine determines also specific ethical attitudes, especially in the following: 1. Communication between a therapist and a patient and his family (interpersonal attitudes). 2. Procedures how to lessen suffering and its interpretation according to culture, tradition and religion ("nonsense and significance of suffering"). 3. Negation of euthanasia. 4. Spiritual, psychological and social care of patients.
Lim, Seung Hui; Lee, Jong Seok; Chae, Sang Hee; Ahn, Bo Sook; Chang, Dong Jin
It was reported that 30-50% of inpatients are in a malnutrition status. Measuring the prealbumin level is a sensitive and cost-effective method for assessing the severity of illness in critically or chronically ill patients. However it is uncertain whether or not the prealbumin level correlates with the level of nutrition support and outcomes in critically ill patients. The aim of this study was to evaluate serum prealbumin level as an indicator of the effectiveness of nutrition support and the prognosis in critically ill patients. Forty-four patients who received total parenteral nutrition for more than 7 days at an intensive care unit (ICU) were studied. The serum prealbumin was measured at the initial time of nutrition support and at the almost seventh day since the first measurement. The patients were allocated into two groups. In Group 1 (n=31) and 2 (n=13), the prealbumin level increased and decreased, respectively. Age, APACHE II score, nutrition status, nutritional requirement and amount of supply, mortality, hospital day and ICU day in the two groups were compared. The serum prealbumin level increased in 31 out of the 44 patients. The average calorie intake was 1334 Kcal/day (83% of energy requirement) in Group 1 and 1170 kcal/day (76% of energy requirement) in Group 2 (p=0.131). The mortality was 42% in Group 1 and 54% in Group 2 (p=0.673). The average hospital day/ ICU day in Groups 1 and 2 were 80 days/38 days and 60 days/31 days respectively. In conclusion, in critically ill patients, the serum prealbumin level did not respond sensitively to nutritional support. In addition an increase in the prealbumin level dose not indicate a better prognosis for critically ill patients. PMID:15744801
Turpie, A G G
Summary. Patients who are hospitalized for an acute medical illness are at risk of venous thromboembolism (VTE). Current evidence-based guidelines recommend prophylaxis with unfractionated heparin or low-molecular-weight heparin in acutely ill medical patients who are admitted to hospital with congestive heart failure, severe respiratory disease, or who are bedridden with an additional VTE risk factor. The need for thromboprophylaxis is therefore clear in this patient population; however, the optimal duration of prophylaxis in these patients is less clear. In patients undergoing orthopedic or cancer surgery, extended-duration prophylaxis has been shown to be superior to placebo. To date, however, no large-scale clinical trials have assessed the benefits of extended-duration prophylaxis in acutely ill medical patients. This review therefore focuses on the VTE risk profile of acutely ill medical patients, examines the currently available literature for evidence of a potential benefit of extended-duration prophylaxis in these patients, and provides a rationale for the testing of such a hypothesis in a randomized clinical trial.
Zaragoza, Rafael; Pemán, Javier; Quindós, Guillermo; Iruretagoyena, Jose R.; Cuétara, María S.; Ramírez, Paula; Gómez, Maria D.; Camarena, Juan J.; Viudes, Angel; Pontón, José
The influence of kinetic patterns of Candida albicans germ tube antibodies (CAGTA) on mortality was analyzed in six intensive care units. Statistically significant lower mortality rates were found in patients with patterns of increasing CAGTA titers who had been treated with antifungal agents. Thus, antifungal treatment should be considered when CAGTA titers are increasing in critically ill patients. PMID:19675223
Lemon, Sherry; Reveal, Marge
A survey of 138 dental hygiene programs gathered information on didactic and clinical experiences for preparing students to treat patients with mental illnesses. Although most curricula addressed the issue, inadequate time was allotted. Over half did not provide oral care to these patients; few felt the community's need was met. (MSE)
Thapinta, Darawan; Anders, Robert L; Wiwatkunupakan, Srinuan; Kitsumban, Voranut; Vadtanapong, Siriluck
Psychiatric patients' satisfaction with their hospital care has not been reported in the Western literature. The concept of asking psychiatric patients about their perceptions of care is relatively new. The purpose of the present investigation was to assess the satisfaction of the care received by a group of acutely mentally ill hospitalized Thai patients. This post-test design examined a random sample of 182 persons hospitalized between 1 March 2000 and 31 July 2000. Using a validated Perception of Care instrument, research assistants assessed patient satisfaction. Patients rated the care as average with none of the items achieving a very good or excellent score. The lowest scoring items were receiving information about their rights, consistency of information provided, and the ease of obtaining information. Women tended to be more satisfied with care as were patients over the age of 55 years (P = 0.02). Patients with a diagnosis of schizophrenia were more satisfied with the care than other patients (P = 0.05). It is unknown if satisfaction levels are similar in other institutions in Thailand. None of the areas received excellent or very good ratings. The findings of this study were shared with the staff at the study site. There appears to be a need to develop performance improvement activities designed to address the areas identified as needing improvement. Replication of this study in other Thailand sites would provide an opportunity for agencies to benchmark their findings. By consenting to be a part of this study the staff and patients have taken a positive step forward to improve patient satisfaction with care.
Does RBC Storage Age Effect Inflammation, Immune Function and Susceptibility to Transfusion Associated Microchimerism in Critically Ill Patients? Adverse Effects of RBC Storage in Critically Ill Patients
STATEMENT Approved for public release; distribution unlimited 13. SUPPLEMENTARY NOTES 14. ABSTRACT The study aim is to investigate specific mechanisms of...the mechanisms and clinical outcomes associated with increased or decreased RBC storage age in critically ill patients including traumatic injury have...not been performed. The ABLE study presents a unique and probably one-time opportunity to investigate mechanisms in the context of clinical
Al-Smadi, Ahmed Mohammad; Ashour, Ala; Hweidi, Issa; Gharaibeh, Besher; Fitzsimons, Donna
The aim of this study was to conduct a systematic review that investigates the differences in illness perception with age and gender in patients diagnosed with coronary artery disease. Previous studies show some discrepancies regarding the influence of age and gender on the specific dimensions of coronary artery disease patients' illness perception. A systematic review using a narrative synthesis process included preliminary synthesis, exploration of relationships and assessment of the robustness of the synthesis and findings was conducted. Search terms were used to identify research studies published between 1996 and December 2014 across four key databases: CINAHL, Medline, PsycINFO and Web of Science. A total of 14 studies met the inclusion criteria of the review. The review found that men had a stronger perception that their own behaviour had caused their illness than women. In addition, older patients had lower perceptions of the consequences and chronicity of their illness. This analysis concludes that some dimensions of illness perception vary according to age and gender of patients with coronary artery disease. These differences should be taken into consideration, particularly when providing health education and cardiac rehabilitation.
James, Caryl C A B; Peltzer, Karl
The aim of this study was to investigate traditional and alternative therapy for mental illness in Jamaica: patients' conceptions and practitioners' attitudes. The sample included 60 psychiatric patients selected from Ward 21 at the University of the West Indies, Kingston as well as Princess Margaret outpatient clinic, and 30 Afro-centric psychiatric nurses, psychiatrist and clinical psychologists from Kingston and St. Thomas, Jamaica. Patients were interviewed with the Short Explanatory Model Interview (SEMI) and practitioners completed a self administered questionnaire on attitudes towards traditional and alternative medicine. Results indicate that among psychiatric patients more than a third expressed the belief that the overall cause of their mental illness was as a result of supernatural factors. In general, the majority of patients felt that their perception of their problems did not concur with the western practitioner, which in turn caused distress for these patients. In case for those who also sought traditional medicine, they were more inclined to feel pleased about their interaction and the treatment they received. Results from western trained practitioners found that although they acknowledged that traditional medicine plays a major role in the treatment of mental illness among psychiatric patients the treatment was not advantageous. For the most part when all three traditional approaches were examined alternative medicine seemed more favourable than traditional healing and traditional herbal treatment. There is a need to develop models of collaboration that promote a workable relationship between the two healing systems in treating mental illness.
OFLAZ, Serap; YÜKSEL, Şahika; ŞEN, Fatma; ÖZDEMİROĞLU, Filiz; KURT, Ramazan; OFLAZ, Hüseyin; KAŞIKCIOĞLU, Erdem
Introduction Myocardial infarction (MI) as a life-threatening event, carrying high risk of recurrence and chronic disabling complications, increases the risk of developing acute stress disorder (ASD), posttraumatic stress disorder (PTSD), or both. The aim of this study was to investigate the relationship between illness perceptions and having ASD, PTSD, or both in patients after MI. Method Seventy-six patients diagnosed with acute MI were enrolled into our prospective study. We evaluated patients during the first week and six months after MI. Patients were assessed by using the Clinician Administered PTSD Scale (CAPS), the Hamilton Depression Rating Scale (HDRS), the Hamilton Anxiety Rating Scale (HARS), the Brief Illness Perception Questionnaire (BIPQ), and a semi-structured interview for socio-demographic characteristics during both the first and second evaluations. Results Acute stress disorder (ASD) developed in 9.2% of patients and PTSD developed in 11.9% of patients with MI. Illness perception factors of ‘consequences, identity and concern’ predicted the occurrence of both ASD and PTSD, whereas ‘emotion’ predicted only PTSD. Conclusion The factors of illness perceptions predicted the induction of ASD and PTSD in patients who had acute MI.
Usami, Osamu; Saitoh, Hiroki; Ashino, Yugo; Hattori, Toshio
Acyclovir is known for its antiviral activity against some pathogenic viruses such as the Epstein-Barr virus (EBV) that causes infectious mononucleosis (IM) and IM-like illness. Therefore, we empirically administered acyclovir to patients with suspected EBV-IM and IM like-illness, upon their admission to our hospital. We admitted 25 patients, who were hospitalized for fever and lymphadenopathy, to the Tohoku University Hospital Infectious Disease Ward. As part of treatment, 8 of these patients were given acyclovir (750 mg/day) with their consent and were assigned to the acyclovir group; the remaining 17 patients were assigned to the control group. The mean age of acyclovir patients (all men) was 42±5.2 years, and that of control patients (13 men and 4 women) was 31±3.0 years. The cause of illness was confirmed as EBV-IM in 6 patients (1, acyclovir; 5, control), and remained unknown for the other 19 IM-like illness patients (7, acyclovir; 12, control). A shorter duration of hospitalization and fever was observed in the acyclovir compared to that in the control patients (hospitalization duration: 16±3.7 vs. 27±7.7 days, P=0.36; fever duration: 4.5±1.8 vs. 18±6.5 days, P=0.04). Additionally, serum amyloid A (SAA) levels were lower in acyclovir than that in control patients (98±37 vs. 505±204 µg/mL, P=0.02). Therefore, we propose that acyclovir is a potential therapeutic agent for both EBV-IM and IM like-illnesses. Future studies should further examine its mechanism of action.
Motoki, Emi; Mori, Kikuko; Kaji, Hidesuke; Nonami, Yoko; Fukano, Chika; Kayano, Tomonori; Kawada, Terue; Kimura, Yukari; Yasui, Kumiko; Ueki, Hiroko; Ugai, Kazuhiro
The aim of this research was to develop a pamphlet that would enable patients with diabetes, rheumatic diseases, chronic respiratory disease, and dialysis treatment to be aware of changes in their physical conditions at an early stage of a disaster, cope with these changes, maintain self-care measures, and recover their health. Illness-specific pamphlets were produced based on disaster-related literature, news articles, surveys of victims of the Great Hanshin-Awaji Earthquake Disaster and Typhoon Tokage, and other sources. Each pamphlet consisted of seven sections-each section includes items common to all illnesses as well as items specific to each illness. The first section, "Physical Self-Care", contains a checklist of 18 common physical symptoms as well as symptoms specific to each illness, and goes on to explain what the symptoms may indicate and what should be done about them. The main aim of the "Changes in Mental Health Conditions" section is to detect posttraumatic stress disorder (PTSD) at an early stage. The section "Preventing the Deterioration of Chronic Illnesses" is designed to prevent the worsening of each illness through the provision of information on cold prevention, adjustment to the living environment, and ways of coping with stress. In the sections, "Medication Control" and "Importance of Having Medical Examinations", spaces are provided to list medications currently being used and details of the hospital address, in order to ensure the continued use of medications. The section, "Preparing for Evacuations" gives a list of everyday items and medical items needed to be prepared for a disaster. Finally, the "Methods of Contact in an Emergency" section provides details of how to use the voicemail service. The following content-specific to each illness also was explained in detail: (1) for diabetes, complications arising from the deterioration of the illness, attention to nutrition, and insulin management; (2) for rheumatic diseases, a checklist of
Uekuzu, Yoshihiro; Higashiguchi, Takashi; Futamura, Akihiko; Ito, Akihiro; Mori, Naoharu; Murai, Miyo; Ohara, Hiroshi; Awa, Hiroko; Chihara, Takeshi
There have been few detailed reports on respiratory depression due to overdoses of opioids in terminal cancer patients. We investigated the situation of treatment with opioid antagonists for respiratory depression that occurred after administration of opioid at optimal doses in terminal cancer patients, to clarify pathological changes as well as causative factors. In 2443 terminal cancer patients receiving opioids, 7 patients (0.3%) received opioid antagonists: 6, morphine (hydrochloride, 5; sulfate, 1); 1, oxycodone. The median dosage of opioids was 13.3 mg/d, as converted to morphine injection. Respiratory depression occurred on this daily dose in 4 patients and after changed dose and route in 3 patients. Opioids were given through the vein in 6 patients and by the enteral route in 1 patient. Concomitant drugs included nonsteroidal anti-inflammatory drugs in 3 patients and zoledronic acid in 2 patients. In morphine-receiving patients, renal functions were significantly worsened at the time of administration of an opioid antagonist than the day before the start of opioid administration. These findings indicate that the proper use of opioids was safe and acceptable in almost all terminal cancer patients. In rare cases, however, a risk toward respiratory depression onset is indicated because morphine and morphine-6-glucuronide become relatively excessive owing to systemic debility due to disease progression, especially respiratory and renal dysfunctions. At the onset of respiratory depression, appropriate administration of an opioid antagonist mitigated the symptoms. Thereafter, opioid switching or continuous administration at reduced dosages of the same opioids prevented the occurrence of serious adverse events.
Greco, Andrea; Steca, Patrizia; Pozzi, Roberta; Monzani, Dario; Malfatto, Gabriella; Parati, Gianfranco
The importance of psychological factors in improving conditions of cardiovascular disease (CVD) patients is stressed by the guidelines for their prevention and rehabilitation, but little is known about the impact of illness severity on patients' well-being, and on the psychosocial variables that may mediate this association. The aim of this study was to investigate the role of illness perception and self-efficacy beliefs on the relationship between illness severity and health satisfaction in 75 CVD patients undergoing rehabilitation (80% men; mean age = 65.44) at the St. Luca Hospital, Istituto Auxologico Italiano, Milan, Italy. Illness severity was measured in terms of left ventricular ejection fraction; psychological factors were assessed at the beginning and end of rehabilitation. Results from path analyses showed that the relationships among CVD severity and health satisfaction were mediated by illness perception and self-efficacy beliefs. Findings underscored the importance of considering illness representations and self-efficacy beliefs to improve well-being in CVD patients.
Thromboprophylaxis for venous thromboembolism is widely used in critically ill patients. However, only limited evidence exists regarding the efficacy and safety of the various thromboprophylaxis techniques, especially mechanical thromboprophylaxis. Therefore, we performed meta-analysis of randomized controlled trials (RCTs) that compared the overall incidence of deep vein thrombosis (DVT) for between unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), and intermittent pneumatic compression (IPC) in critically ill patients. A Bayesian random effects model for multiple treatment comparisons was constructed. The primary outcome measure was the overall incidence of DVT at the longest follow-up. The secondary outcome measure was the incidence of major bleeding, as defined by the original trials. Our analysis included 8,622 patients from 12 RCTs. The incidence of DVT was significantly lower in patients treated with UFH (OR, 0.45; 95% CrI, 0.22–0.83) or LMWH (OR, 0.38; 95% CrI, 0.18–0.72) than in patients in the control group. IPC was associated with a reduced incidence of DVT compared to the control group, but the effect was not statistically significant (OR, 0.50; 95% CrI, 0.20–1.23). The risk of DVT was similar for patients treated with UFH and LMWH (OR, 1.16; 95% CrI, 0.68–2.11). The risk of major bleeding was similar between the treatment groups in medical critically ill patients and also in critically ill patients with a high risk of bleeding. In critically ill patients, the efficacy of mechanical thromboprophylaxis in reducing the risk of DVT is not as robust as those of pharmacological thromboprophylaxis. PMID:27709864
Brusko, C.S.; Marten, J.T. )
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.
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.
Jørgensen, C K; Fink, P; Olesen, F
BACKGROUND: Musculoskeletal illness is a common cause of absenteeism from work, workers' compensation, and disability retirement, and accounts for 9.3% to 17% of patient contacts in general practice. To understand the increase in self-reported musculoskeletal illness and to improve treatment and prevention, it is important to know which factors to target when dealing with these patients. AIM: To investigate whether the prognosis for patients with musculoskeletal illness referred to physiotherapy from general practice can be predicted by the presence of psychological distress and somatisation identified by a general practitioner (GP) and standard questionnaires. METHOD: A multi-practice survey based on questionnaires (index and three-month follow-up). Nine hundred and five consecutive patients referred to physiotherapy from 124 different general practices in Denmark were included. Outcome measures were physical health change, sick leave, patient self-rated improvement, and change in use of medication. RESULTS: Psychological distress and somatisation rated by both GPs and standard questionnaires acted with almost no exception as significant predictors of all four outcome measures. CONCLUSION: Psychological distress and somatisation are important factors when considering preventive initiatives and treatment of patients with musculoskeletal illness in general practice. PMID:10954933
Punj, Pragya; Nattanmai, Premkumar; George, Pravin
In neurologically injured patients, predictors for extubation success are not well defined. Abnormal breathing patterns may result from the underlying neurological injury. We present three patients with abnormal breathing patterns highlighting failure of successful extubation as a result of these neurologically driven breathing patterns. Recognizing abnormal breathing patterns may be predictive of extubation failure and thus need to be considered as part of extubation readiness. PMID:28348899
Introduction Hematology patients admitted to the ICU frequently experience respiratory failure and require mechanical ventilation. Noninvasive mechanical ventilation (NIMV) may decrease the risk of intubation, but NIMV failure poses its own risks. Methods To establish the impact of ventilatory management and NIMV failure on outcome, data from a prospective, multicenter, observational study were analyzed. All hematology patients admitted to one of the 34 participating ICUs in a 17-month period were followed up. Data on demographics, diagnosis, severity, organ failure, and supportive therapies were recorded. A logistic regression analysis was done to evaluate the risk factors associated with death and NIVM failure. Results Of 450 patients, 300 required ventilatory support. A diagnosis of congestive heart failure and the initial use of NIMV significantly improved survival, whereas APACHE II score, allogeneic transplantation, and NIMV failure increased the risk of death. The risk factors associated with NIMV success were age, congestive heart failure, and bacteremia. Patients with NIMV failure experienced a more severe respiratory impairment than did those electively intubated. Conclusions NIMV improves the outcome of hematology patients with respiratory insufficiency, but NIMV failure may have the opposite effect. A careful selection of patients with rapidly reversible causes of respiratory failure may increase NIMV success. PMID:22827955
Aji, Budi; Yamamoto, Shelby Suzanne; Sauerborn, Rainer
Background Little research has focused on the economic hardship among the insured with severe illnesses and high treatment costs, in particular, the consequence of poorer insurance coverage for high-cost illnesses. Therefore, we presented the case for identifying the experiences of insured patients with severe chronic and acute illnesses. This study identified a qualitative understanding of the economic impact of severe chronic and acute illnesses and household strategies to deal with high treatment costs. Design Interviews were conducted with 19 insured households of three different health insurance programs with a family member that had been hospitalized for severe chronic or acute illnesses in either Banyumas or Margono Sukarjo hospitals in Banyumas, Central Java, Indonesia. A thematic analysis was applied to guide the interpretation of the data. Results Insured households with a family member that had been hospitalized for severe chronic and acute illnesses were greatly affected by the high treatment costs. Four major issues emerged from this qualitative study: insured patients are still burdened with high out-of-pocket payments, households adopt various strategies to cope with the high cost of treatments, households experience financial hardships, and positive and negative perceptions of the insured regarding their health insurance coverage for acute and chronic illnesses. Conclusions Askes and Jamsostek patients faced financial burdens from high cost sharing for hospital amenities, non-covered drugs, and treatments and other indirect costs. Meanwhile, Jamkesmas beneficiaries faced no financial burden for related medical services but were rather burdened with indirect costs for the carers. Households relied on internal resources to cover hospital bills as the first strategy, which included the mobilization of savings, sale of assets, and borrowing of money. External support was tapped secondarily and included financial support from extended family members
Becker, G; Kaufman, S R
Uncertainty is a central feature of a chronic illness trajectory, resulting from questions about the effects of the illness on daily life, what symptoms mean, and what the future holds. When chronic illness occurs late in life, uncertainty is magnified, and serious questions arise about whether the individual will be able to weather the disruption and go on with daily life. This article examines illness trajectories from two vantage points, that of older persons who have had a stroke and that of physicians who care for stroke patients, by means of interviews with 36 persons who had strokes and with 20 physicians. Physicians' views of stroke were informed not only by knowledge of physiological processes but also by biomedical ideologies and cultural meanings associated with their patients' ages and impairments. People who had strokes focused on recovery; they assumed the trajectory was open to manipulation if they worked hard enough. The vague medical response to uncertainty affected patients' interpretations; what they were not told shaped their expectations about recovery as much as what they were told. The uncertain trajectory of stroke in old age is one example of how illness experience is affected by cultural attitudes about age, biomedical ideologies, the provision of health care services, and economically driven health policies. The anticipation of recovery by persons who have had strokes and the letdown when recovery does not occur reflect critical dilemmas in biomedicine and in society itself that have implications for health policy.
Stöllberger, Claudia; Wegner, Christian; Finsterer, Josef
Background and Objective: Little is known about the general indications for echocardiography and the prevalence of abnormalities detected by echocardiography in patients who are referred from a neurological department. Left ventricular hypertrabeculation/noncompaction (LVHT) is associated with neuromuscular disorders and embolism. The aim of the study was to assess the indications for echocardiography in patients from a neurological department and to review the cine-loops of the examinations in order to assess the frequency of abnormal echocardiographic findings with special regard to LVHT. Methods and Results: Included were 126 patients, 58 females (mean age 65 years). Indications were stroke (84%), heart failure (6%), endocarditis (6%) and arrhythmia (3%). The most frequent abnormalities were impaired relaxation (71%) and left ventricular wall thickening (63%). Females were older (68 vs. 62 years, p = 0.0214) and more frequently had normally sized left ventricles than males (98 vs. 88%, p = 0.0376). Patients ≥66 years more frequently had stroke as an indication (91 vs. 77%, p = 0.05), showed a thickened myocardium (72 vs. 53%, p = 0.0272), valvular abnormalities (52 vs. 13%, p = 0.0000) and impaired relaxation (86 vs. 54%, p = 0.0001) than patients <66 years. LVHT was diagnosed in 3 patients; in one of them the diagnosis was already known. In 45% LVHT and in 38% left ventricular thrombus could neither be excluded nor established since the image quality was poor. Conclusion: Care should be taken to visualize the left ventricular apical regions when investigating patients referred from a neurologic department in order not to overlook LVHT and thrombi within the left ventricular apex.
Muschalla, Beate; Glatz, Johannes; Linden, Michael
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.
Rushton, Cynda Hylton; Reina, Michelle L; Reina, Dennis S
A difficult case study involving repeated health crises and irreversible organ dysfunction illustrates the challenges critical care professionals face in caring for patients and their families. In such cases, trust is especially fragile, and coexists with its counterpart, betrayal. The Reina Trust & Betrayal Model defines 3 types of Transactional Trust. The first, Competence Trust, or the Trust of Capability, requires that clinicians practice humility, engage in inquiry, honor the patient's choices, and express compassion. The second, Contractual Trust, or the Trust of Character, demands that clinicians keep agreements, manage expectations, establish boundaries, and encourage mutually serving expectations. The third, Communication Trust, or the Trust of Disclosure, must be rooted in respect and based on truth-telling. Particularly in life-and-death situations, communication requires honesty and clarity. Each type of trust involves specific behaviors that build trust and can guide critical care professionals as they interact with patients and their families.
Givens, Melissa L.
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. PMID:22545217
Torres, Viviane B. L.; Vassalo, Juliana; Silva, Ulysses V. A.; Caruso, Pedro; Torelly, André P.; Silva, Eliezer; Teles, José M. M.; Knibel, Marcos; Rezende, Ederlon; Netto, José J. S.; Piras, Claudio; Azevedo, Luciano C. P.; Bozza, Fernando A.; Spector, Nelson; Salluh, Jorge I. F.; Soares, Marcio
Introduction Cancer patients are at risk for severe complications related to the underlying malignancy or its treatment and, therefore, usually require admission to intensive care units (ICU). Here, we evaluated the clinical characteristics and outcomes in this subgroup of patients. Materials and Methods Secondary analysis of two prospective cohorts of cancer patients admitted to ICUs. We used multivariable logistic regression to identify variables associated with hospital mortality. Results Out of 2,028 patients, 456 (23%) had cancer-related complications. Compared to those without cancer-related complications, they more frequently had worse performance status (PS) (57% vs 36% with PS≥2), active malignancy (95% vs 58%), need for vasopressors (45% vs 34%), mechanical ventilation (70% vs 51%) and dialysis (12% vs 8%) (P<0.001 for all analyses). ICU (47% vs. 27%) and hospital (63% vs. 38%) mortality rates were also higher in patients with cancer-related complications (P<0.001). Chemo/radiation therapy-induced toxicity (6%), venous thromboembolism (5%), respiratory failure (4%), gastrointestinal involvement (3%) and vena cava syndrome (VCS) (2%) were the most frequent cancer-related complications. In multivariable analysis, the presence of cancer-related complications per se was not associated with mortality [odds ratio (OR) = 1.25 (95% confidence interval, 0.94–1.66), P = 0.131]. However, among the individual cancer-related complications, VCS [OR = 3.79 (1.11–12.92), P = 0.033], gastrointestinal involvement [OR = 3.05 (1.57–5.91), P = <0.001] and respiratory failure [OR = 1.96(1.04–3.71), P = 0.038] were independently associated with in-hospital mortality. Conclusions The prognostic impact of cancer-related complications was variable. Although some complications were associated with worse outcomes, the presence of an acute cancer-related complication per se should not guide decisions to admit a patient to ICU. PMID:27764143
Heinemann, V; Bosse, D; Jehn, U; Kähny, B; Wachholz, K; Debus, A; Scholz, P; Kolb, H J; Wilmanns, W
The liposomal formulation of amphotericin B (AmBisome) greatly reduces the acute and chronic side effects of the parent drug. The present study describes the pharmacokinetic characteristics of AmBisome applied to 10 patients at a dose of 2.8 to 3.0 mg/kg of body weight and compares them to the pharmacokinetics observed in 6 patients treated with amphotericin B deoxycholate at the standard dose of 1.0 mg/kg. Interpatient variabilities of amphotericin B peak concentrations (Cmax) and areas under concentration-time curves (AUC) were 8- to 10-fold greater for patients treated with AmBisome than for patients treated with amphotericin B deoxycholate. At the threefold greater dose of AmBisome, median Cmaxs were 8.4-fold higher (14.4 versus 1.7 microg/ml) and median AUCs exceeded those observed with amphotericin B deoxycholate by 9-fold. This was in part explained by a 5.7-fold lower volume of distribution (0.42 liters/kg) in AmBisome-treated patients. The elimination of amphotericin B from serum was biphasic for both formulations. However, the apparent half-life of elimination was twofold shorter for AmBisome (P = 0.03). Neither hemodialysis nor hemofiltration had a significant impact on AmBisome pharmacokinetics as analyzed in one patient. In conclusion, the liposomal formulation of amphotericin B significantly (P = 0.001) reduces the volume of drug distribution, thereby allowing for greater drug concentrations in serum. The low toxicity of AmBisome therefore cannot readily be explained by its serum pharmacokinetics.
Irfan, Muna; Selim, Bernardo; Rabinstein, Alejandro A; St Louis, Erik K
Sleep-disordered breathing (SDB) is a frequent presenting manifestation of neuromuscular disorders and can lead to significant morbidity and mortality. If not recognized and addressed early in the clinical course, SDB can lead to clinical deterioration with respiratory failure. The pathophysiologic basis of SDB in neuromuscular disorders, clinical features encountered in specific neuromuscular diseases, and diagnostic and management strategies for SDB in neuromuscular patients in the critical care setting are reviewed. Noninvasive positive pressure ventilation has been a crucial advance in critical care management, improving sleep quality and often preventing or delaying mechanical ventilation and improving survival in neuromuscular patients.
Irfan, Muna; Selim, Bernardo; Rabinstein, Alejandro A.
Synopsis Sleep-disordered breathing (SDB) is a frequent presenting manifestation of neuromuscular disorders and can lead to significant morbidity and mortality. If not promptly recognized and addressed early in the clinical course, SDB can lead to clinical deterioration with respiratory failure. In this article, we review the pathophysiologic basis of SDB in neuromuscular disorders, clinical features encountered in specific neuromuscular diseases, and diagnostic and management strategies for SDB in neuromuscular patients in the critical care setting. Non-invasive positive pressure ventilation (NIPV) has been a crucial advance in critical care management, improving sleep quality and often preventing or delaying mechanical ventilation and improving survival in neuromuscular patients. PMID:26118919
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
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.
Vermeulen, Mechteld A. R.; Brinkmann, Saskia J. H.; Buijs, Nikki; Beishuizen, Albertus; Bet, Pierre M.; Houdijk, Alexander P. J.; van Goudoever, Johannes B.; van Leeuwen, Paul A. M.
Glutamine supplementation in specific groups of critically ill patients results in favourable clinical outcome. Enhancement of citrulline and arginine synthesis by glutamine could serve as a potential mechanism. However, while receiving optimal enteral nutrition, uptake and enteral metabolism of glutamine in critically ill patients remain unknown. Therefore we investigated the effect of a therapeutically relevant dose of L-glutamine on synthesis of L-citrulline and subsequent L-arginine in this group. Ten versus ten critically ill patients receiving full enteral nutrition, or isocaloric isonitrogenous enteral nutrition including 0.5 g/kg L-alanyl-L-glutamine, were studied using stable isotopes. A cross-over design using intravenous and enteral tracers enabled splanchnic extraction (SE) calculations. Endogenous rate of appearance and SE of glutamine citrulline and arginine was not different (SE controls versus alanyl-glutamine: glutamine 48 and 48%, citrulline 33 versus 45%, and arginine 45 versus 42%). Turnover from glutamine to citrulline and arginine was not higher in glutamine-administered patients. In critically ill nonseptic patients receiving adequate nutrition and a relevant dose of glutamine there was no extra citrulline or arginine synthesis and glutamine SE was not increased. This suggests that for arginine synthesis enhancement there is no need for an additional dose of glutamine when this population is adequately fed. This trial is registered with NTR2285. PMID:27200186
Luedde, Mark; Benz, Fabian; Niedeggen, Jennifer; Vucur, Mihael; Hippe, Hans-Joerg; Spehlmann, Martina E.; Schueller, Florian; Loosen, Sven; Frey, Norbert; Trautwein, Christian; Koch, Alexander; Luedde, Tom; Tacke, Frank
Introduction. Omentin, a recently described adipokine, was shown to be involved in the pathophysiology of inflammatory and infectious diseases. However, its role in critical illness and sepsis is currently unknown. Materials and Methods. Omentin serum concentrations were measured in 117 ICU-patients (84 with septic and 33 with nonseptic disease etiology) admitted to the medical ICU. Results were compared with 50 healthy controls. Results. Omentin serum levels of critically ill patients at admission to the ICU or after 72 hours of ICU treatment were similar compared to healthy controls. Moreover, circulating omentin levels were independent of sepsis and etiology of critical illness. Notably, serum concentrations of omentin could not be linked to concentrations of inflammatory cytokines or routinely used sepsis markers. While serum levels of omentin were not predictive for short term survival during ICU treatment, low omentin concentrations were an independent predictor of patients' overall survival. Omentin levels strongly correlated with that of other adipokines (e.g., leptin receptor or adiponectin), which have also been identified as prognostic markers in critical illness. Conclusions. Although circulating omentin levels did not differ between ICU-patients and controls, elevated omentin levels were predictive for an impaired patients' long term survival. PMID:27867249
Bauer, Michael; Glenn, Tasha; Monteith, Scott; Bauer, Rita; Whybrow, Peter C; Geddes, John
The digital revolution in medicine not only offers exciting new directions for the treatment of mental illness, but also presents challenges to patient privacy and security. Changes in medicine are part of the complex digital economy based on creating value from analysis of behavioral data acquired by the tracking of daily digital activities. Without an understanding of the digital economy, recommending the use of technology to patients with mental illness can inadvertently lead to harm. Behavioral data are sold in the secondary data market, combined with other data from many sources, and used in algorithms that automatically classify people. These classifications are used in commerce and government, may be discriminatory, and result in non-medical harm to patients with mental illness. There is also potential for medical harm related to poor quality online information, self-diagnosis and self-treatment, passive monitoring, and the use of unvalidated smartphone apps. The goal of this paper is to increase awareness and foster discussion of the new ethical issues. To maximize the potential of technology to help patients with mental illness, physicians need education about the digital economy, and patients need help understanding the appropriate use and limitations of online websites and smartphone apps.
van Vught, Lonneke A; Wiewel, Maryse A; Hoogendijk, Arie J; Scicluna, Brendon P; Belkasim-Bohoudi, Hakima; Horn, Janneke; Schultz, Marcus J; van der Poll, Tom
Critically ill patients show signs of immune suppression, which is considered to increase vulnerability to nosocomial infections. Whole-blood stimulation is frequently used to test the function of the innate immune system. We here assessed the association between whole-blood leukocyte responsiveness to lipopolysaccharide (LPS) and subsequent occurrence of nosocomial infections in critically ill patients admitted to the intensive care unit (ICU). All consecutive critically ill patients admitted to the ICU between April 2012 and June 2013 with two or more systemic inflammatory response syndrome criteria and an expected length of ICU stay of more than 24 h were enrolled. Age- and sex-matched healthy individuals were included as controls. Blood was drawn the first morning after ICU admission and stimulated ex vivo with 100 ng/mL ultrapure LPS for 3 h. Tumor necrosis factor-α, interleukin-1β (IL-1β), and IL-6 were measured in supernatants. Seventy-three critically ill patients were included, of whom 10 developed an ICU-acquired infection. Compared with healthy subjects, whole-blood leukocytes of patients were less responsive to ex vivo stimulation with LPS, as reflected by strongly reduced tumor necrosis factor-α, IL-1β, and IL-6 levels in culture supernatants. Results were not different between patients who did and those who did not develop an ICU-acquired infection. The extent of reduced LPS responsiveness of blood leukocytes in critically ill patients on the first day after ICU admission does not relate to the subsequent development of ICU-acquired infections. These results argue against the use of whole-blood stimulation as a functional test applied early after ICU admission to predict nosocomial infection.
Tsai, Danny; Stewart, Penelope; Goud, Rajendra; Gourley, Stephen; Hewagama, Saliya; Krishnaswamy, Sushena; Wallis, Steven C; Lipman, Jeffrey; Roberts, Jason A
Currently there are no pharmacokinetic (PK) data to guide antibiotic dosing in critically ill Australian Indigenous patients with severe sepsis. This study aimed to determine whether the population pharmacokinetics of meropenem were different between critically ill Australian Indigenous and critically ill Caucasian patients. Serial plasma and urine samples as well as clinical and demographic data were collected over two dosing intervals from critically ill Australian Indigenous patients. Plasma meropenem concentrations were assayed by validated chromatography. Concentration-time data were analysed with data from a previous PK study in critically ill Caucasian patients using Pmetrics. The population PK model was subsequently used for Monte Carlo dosing simulations to describe optimal doses for these patients. Six Indigenous and five Caucasian subjects were included. A two-compartment model described the data adequately, with meropenem clearance and volume of distribution of the central compartment described by creatinine clearance (CLCr) and patient weight, respectively. Patient ethnicity was not supported as a covariate in the final model. Significant differences were observed for meropenem clearance between the Indigenous and Caucasian groups [median 11.0 (range 3.0-14.1) L/h vs. 17.4 (4.3-30.3) L/h, respectively; P <0.01]. Standard dosing regimens (1 g intravenous every 8 h as a 30-min infusion) consistently achieved target exposures at the minimum inhibitory concentration breakpoint in the absence of augmented renal clearance. No significant interethnic differences in meropenem pharmacokinetics between the Indigenous and Caucasian groups were detected and CLCr was found to be the strongest determinant of appropriate dosing regimens.
de Almeida, Thiago Miranda Lopes; de Azevedo, Luciano Cesar Pontes; Nosé, Paulo Maurício Garcia; de Freitas, Flavio Geraldo Resende; Machado, Flávia Ribeiro
Objective To evaluate the incidence of agitation in the first 7 days after intensive care unit admission, its risk factors and its associations with clinical outcomes. Methods This single-center prospective cohort study included all patients older than 18 years with a predicted stay > 48 hours within the first 24 hours of intensive care unit admission. Agitation was defined as a Richmond Agitation Sedation Scale score ≥ +2, an episode of agitation or the use of a specific medication recorded in patient charts. Results Agitation occurred in 31.8% of the 113 patients. Multivariate analysis showed that delirium [OR = 24.14; CI95% 5.15 - 113.14; p < 0.001], moderate or severe pain [OR = 5.74; CI95% 1.73 - 19.10; p = 0.004], mechanical ventilation [OR = 10.14; CI95% 2.93 - 35.10; p < 0.001], and smoking habits [OR = 4.49; CI95% 1.33 - 15.17; p = 0.015] were independent factors for agitation, while hyperlactatemia was associated with a lower risk [OR = 0.169; CI95% 0.04 - 0.77; p = 0.021]. Agitated patients had fewer mechanical ventilation-free days at day 7 (p = 0.003). Conclusion The incidence of agitation in the first 7 days after admission to the intensive care unit was high. Delirium, moderate/severe pain, mechanical ventilation, and smoking habits were independent risk factors. Agitated patients had fewer ventilator-free days in the first 7 days. PMID:28099638
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
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. PMID:11775669
Skelton, J R; Murray, J; Hobbs, F D
Uncertainty is believed to be a central feature in illness experiences. Conversations between a consultant hematologist and 61 seriously ill patients were transcribed, entered on a database and scrutinized for patterns of language uncertainty by linguistic concordancing analysis. Transcripts were then discussed in detail with the hematologist, and techniques of protocol analysis were used to gain insight into his thought processes during consultations. The main findings were that the doctor used many more expressions of uncertainty than did patients: that evaluative terms were widely used to reassure rather than to worry patients; and that patients and doctor together used certain key terms ambiguously, in a manner which allowed the doctor to feel that facts were not misrepresented while perhaps permitting the patient to feel reassured. PMID:10692882
Papurica, Marius; Rogobete, Alexandru Florin; Sandesc, Dorel; Dumache, Raluca; Nartita, Radu; Sarandan, Mirela; Cradigati, Alina Carmen; Luca, Loredana; Vernic, Corina; Bedreag, Ovidiu Horea
The critically ill polytrauma patient is a constant challenge for the trauma team due to the complexity of the complications presented. Intense inflammatory response and infections, as well as multiple organ dysfunctions, significantly increase the rate of morbidity and mortality in these patients. Moreover, due to the physiological and biochemical imbalances present in this type of patients, the bioproduction of free radicals is significantly accelerated, thus installing the oxidative stress. In the therapeutic management of such patients, multiple surgical interventions are required and therefore they are being subjected to repeated general anesthesia. In this paper, we want to present the pathophysiological implications of oxidative stress in critically ill patients with multiple traumas and the implications of general anesthesia on the redox mechanisms of the cell. We also want to summarize the antioxidant treatments able to reduce the intensity of oxidative stress by modulating the biochemical activity of some cellular mechanisms. PMID:26693352
Jacq, Gwenaëlle; Gritti, Karine; Carré, Cécile; Fleury, Nadège; Lang, Annie; Courau-Courtois, Josette; Bedos, Jean-Pierre; Legriel, Stephane
Few studies assessed modalities of invasive arterial pressure monitoring (IAPM). We evaluated effects on measured values of various combinations of transducer level, catheter access site, and patient position. Prospective observational study in consecutive adults admitted to a French intensive care unit in 2009 to 2011 and fulfilling our inclusion criteria. Four combinations (B–E) of transducer level, catheter access site, and patient position were compared with a reference combination (A) (A: patient supine with all catheters in the same plane and a single transducer level (M) for zero point reference (Z) aligned on the phlebostatic axis; B: 45° head-of-bed elevation with M and Z aligned on the phlebostatic axis; C: 45° head-of-bed elevation with M aligned on the catheter access site and Z on the phlebostatic axis; D: 45° head-of-bed elevation with M and Z aligned on the catheter access site; and E: 45° head-of-bed elevation with M aligned on the phlebostatic axis and Z on the catheter access site). We included 103 patients, 68 men and 35 women, with a median age of 69 years (interquartile range [IQR], 56–78); at inclusion, 91 (88.3%) received mechanical ventilation, 45 (43.7%) catecholamines, and 66 (64.1%) sedation. The IAPM access site was femoral in 49 (47.6%) and radial in 54 (52.4%) patients, with 62 of 103 (60.2%) catheters on the right side. Measured absolute mean arterial pressure values were significantly higher with 3 study combinations (C–E) than with the reference combination (A). After adjustment, the differences versus A (median, 83 [IQR, 74–92] mm Hg) remained significant for D (median, 91 [IQR, 85–100] mm Hg, P < 0.001) and E (median, 88 [IQR, 77–99] mm Hg, P < 0.001). The difference versus A was not significant for B (median, 85 [IQR, 76–94] mm Hg, P = 0.21) or C (median, 90 [IQR, 84–100] mm Hg, P = 0.006). Several modalities used for zeroing and/or transducer leveling during IAPM may result in
Turner, S L; Higby, D; Rososky, J
1. LOS was not significantly influenced by the type of insurance carrier. 2. Age was not a factor in LOS of the terminal patient. However, Medicare patients averaged the greatest number of days lost/patient. 3. Terminal Medicare cancer patients whose physician was an oncologist had a shorter LOS. 4. The growing commitment to home hospice will result in a decreasing number of patients coming into the hospital to die. 5. The decreasing number of terminal cancer patients who expire within 72 hours of admission will result in an increase in the average LOS of those remaining hospitalized cancer patients.
Demirkiran, O; Dikmen, Y; Utku, T; Urkmez, S
We aimed to determine the morbidity and mortality among obstetric patients admitted to the intensive care unit. In this study, we analyzed retrospectively all obstetric admissions to a multi-disciplinary intensive care unit over a five-year period. Obstetric patients were identified from 4733 consecutive intensive care unit admissions. Maternal age, gestation of newborns, mode of delivery, presence of coexisting medical problems, duration of stay, admission diagnosis, specific intensive care interventions (mechanical ventilation, continuous veno-venous hemofiltration, central venous catheterization, and arterial cannulation), outcome, maternal mortality, and acute physiology and chronic health evaluation (APACHE) II score were recorded. Obstetric patients (n=125) represented 2.64% of all intensive care unit admissions and 0.89% of all deliveries during the five-year period. The overall mortality of those admitted to the intensive care unit was 10.4%. Maternal age and gestation of newborns were similar in survivors and non-survivors. There were significant differences in length of stay and APACHE II score between survivors and non-survivors P < 0.05. The commonest cause of intensive care unit admission was preeclampsia/eclampsia (73.6%) followed by post-partum hemorrhage (11.2%). Intensive care specialists should be familiar with these complications of pregnancy and should work closely with obstetricians.
Scherer, Jennifer S; Holley, Jean L
Technologic advances, such as continuous RRT, provide lifesaving therapy for many patients. AKI in the critically ill patient, a fatal diagnosis in the past, is now often a survivable condition. Dialysis decision making for the critically ill patient with AKI is complex. What was once a question solely of survival now is nuanced by an individual's definition of quality of life, personal values, and short- and long-term prognoses. Clinical evaluation of AKI in the critically ill is multifaceted. Treatment decision making requires consideration of the natural evolution of the patient's AKI within the context of the global prognosis. Situations are often marked by prognostic uncertainty and clinical unknowns. In the face of these uncertainties, establishment of patient-directed therapies is imperative. A time-limited trial of continuous RRT in this setting is often appropriate but difficult to execute. Using patient preferences as a clinical guide, a proper time-limited trial requires assessment of prognosis, elicitation of patient values, strong communication skills, clear documentation, and often, appropriate integration of palliative care services. A well conducted time-limited trial can avoid interprofessional conflict and provide support for the patient, family, and staff.
The literature consists of numerous references to coping styles of patients facing life-threatening illness, but the general consensus denotes the following as the predominant ones: denial, depression, anger, suicide, anxiety and fear reactions, psychosomatic compaining, schizoid-type and neurotic-type reactions, regression, dependency, and…
King, Judy; Taylor, Maurice C.
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,…
Besen, Bruno Adler Maccagnan Pinheiro; Gobatto, André Luiz Nunes; Melro, Lívia Maria Garcia; Maciel, Alexandre Toledo; Park, Marcelo
Fluids are considered the cornerstone of therapy for many shock states, particularly states that are associated with relative or absolute hypovolemia. Fluids are also commonly used for many other purposes, such as renal protection from endogenous and exogenous substances, for the safe dilution of medications and as “maintenance” fluids. However, a large amount of evidence from the last decade has shown that fluids can have deleterious effects on several organ functions, both from excessive amounts of fluids and from their non-physiological electrolyte composition. Additionally, fluid prescription is more common in patients with systemic inflammatory response syndrome whose kidneys may have impaired mechanisms of electrolyte and free water excretion. These processes have been studied as separate entities (hypernatremia, hyperchloremic acidosis and progressive fluid accumulation) leading to worse outcomes in many clinical scenarios, including but not limited to acute kidney injury, worsening respiratory function, higher mortality and higher hospital and intensive care unit length-of-stays. In this review, we synthesize this evidence and describe this phenomenon as fluid and electrolyte overload with potentially deleterious effects. Finally, we propose a strategy to safely use fluids and thereafter wean patients from fluids, along with other caveats to be considered when dealing with fluids in the intensive care unit. PMID:25938027
Mangiante, Gerardo; Padoan, Roberto; Mengardo, Valentina; Bencivenga, Maria; de Manzoni, Giovanni
The acute abdomen (AA) still remains a challenging situation for surgeons. New pathological conditions have been imposed to our attention in this field in recent years. The definition of abdominal compartmental syndrome (ACS) in surgical practice and the introduction of new biological matrices, with the concepts of tension-free (TS) repair of incisional hernias, prompted us to set up new therapeutic strategies for the treatment of patients with AA. Thus we reviewed the cases of AA that we observed in recent years in which we performed a laparostomy in order to prevent or to treat an ACS. They are all cases of acute abdomen (AA), but from different origin, including chronic diseases, as in the course of inflammatory bowel disease (IBD), and acute pancreatitis. In all the cases, the open abdominal cavity was covered with a polyethylene sheet. The edges of the wound were sutured to the plastic sheet, and a traction exerted by a device that causes a negative pressure was added. This method was adopted in several cases without randomization, and resulted in excellent patient's outcomes.
Jerome, Rebecca N.; Edwards, Terri L.; Boswell, Haley C.; Bernard, Gordon R.; Harris, Paul A.; Pulley, Jill M.
When clinical trial enrollment is not an option for seriously ill patients whose illnesses have not responded to approved treatment options, those patients and their physicians may consider gaining access to investigational therapies through a pathway established by the Food and Drug Administration (FDA) called expanded access. However, recent events have highlighted the challenging dynamics involved in accessing investigational therapies through expanded access that include a complex interplay of factors involving the patient, physician, drug company, FDA, and, increasingly, social media. The authors offer several potential strategies to streamline what is otherwise an arduous process for all involved. (1) The drug company should prospectively determine whether it will establish an expanded access program for specific drugs. (2) A central clearinghouse for companies should support registration of expanded access drugs for suitable patients. (3) The determination of whether a patient fits criteria would be made by an independent review board of clinicians. (4) An independent coordinating center is needed; academic health centers are ideally suited for that role. (5) Adequate financing of the costs of therapy need to be in place to make expanded access a reality, given frequent lack of payor coverage for therapies. (6) Further enhancement of regulatory pathways, approaches, or rules would promote expanded access. (7) Patients should explicitly acknowledge the limited data available. (8) There should be a shared, secure, technical platform to facilitate expanded access. All the authors’ strategies present important prospects for improving treatment options for the most seriously ill patients. PMID:26445080
Dengue fever and scrub typhus are common causes of acute febrile illness of unclear origin in Asia. Though coinfections of many vector-borne diseases have been described, articles on dengue and scrub typhus coinfection are distinctly limited. In case of coinfection with dengue and scrub typhus, vigilant monitoring of vitals, platelets transfusion, and timely treatment with doxycycline are necessary. High degree of suspicion has to be made for coinfection in a patient presenting with febrile illness with thrombocytopenia and deranged laboratory parameters in postmonsoon season in endemic regions in Asia. PMID:28386493
Freire, Geruza Diogo; de Campos, Débora Rebollo; Boemer, Magali Roseira
The purpose of this study is to understand the reality of living with a seriously ill patient, from the point of view of the carer family member. We have contacted families who cared for seriously ill family members at home. Our intent was to understand the essence of the meaning of this situation for the carer family member. This was a qualitative study that relied on the theoretical and methodological framework of phenomenology. Thematic categories emerged from the careful analysis of testimonies of the carer family member, pointing to the essence of the day-to-day experience of providing this care.
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. PMID:21929761
Carrese, Joseph A; Mullaney, Jamie L; Faden, Ruth R; Finucane, Thomas E
Objective To understand how elderly patients think about and approach future illness and the end of life. Design Qualitative study conducted 1997-9. Setting Physician housecall programme affiliated to US university. Participants 20 chronically ill housebound patients aged over 75 years who could participate in an interview. Participants identified through purposive and random sampling. Main outcome measures In-depth semistructured interviews lasting one to two hours. Results Sixteen people said that they did not think about the future or did not in general plan for the future. Nineteen were particularly reluctant to think about, discuss, or plan for serious future illness. Instead they described a “one day at a time,” “what is to be will be” approach to life, preferring to “cross that bridge” when they got to it. Participants considered end of life matters to be in the hands of God, though 13 participants had made wills and 19 had funeral plans. Although some had completed advance directives, these were not well understood and were intended for use only when death was near and certain. Conclusions The elderly people interviewed for this study were resistant to planning in advance for the hypothetical future, particularly for serious illness when death is possible but not certain. What is already known on this topicAdvance care planning is widely endorsed as a means to improve quality of care for patients near the end of lifeWhat this study addsElderly housebound patients described a world view that does not easily accommodate advance care planning: they live life a day at a time, preferring not to consider problems until they occurThese patients resisted planning for the hypothetical futureThey most resisted planning for those situations when the most difficult decisions often arise, such as for serious illness when death is possible but not certain PMID:12130597
Koutra, Katerina; Triliva, Sofia; Roumeliotaki, Theano; Stefanakis, Zacharias; Basta, Maria; Lionis, Christos; Vgontzas, Alexandros N
The present study aimed to investigate possible differences in family environment among patients experiencing their First Episode of Psychosis (FEP), chronic patients and controls. Family cohesion and flexibility (FACES-IV) and psychological distress (GHQ-28) were evaluated in families of 50 FEP and 50 chronic patients, as well as 50 controls, whereas expressed emotion (FQ) and family burden (FBS) were assessed in families of FEP and chronic patients. Multivariable linear regression analysis, adjusted for confounders, indicated impaired cohesion and flexibility for families of FEP patients compared to controls, and lower scores for families of chronic patients compared to those of FEP patients. Caregivers of chronic patients scored significantly higher in criticism, and reported higher burden and psychological distress than those of FEP patients. Our findings suggest that unbalanced levels of cohesion and flexibility, high criticism and burden appeared to be the outcome of psychosis and not risk factors triggering the onset of the illness. Furthermore, emotional over-involvement both in terms of positive (i.e. concern) and negative behaviors (i.e. overprotection) is prevalent in Greek families. Psychoeducational interventions from the early stages of the illness should be considered to promote caregivers' awareness regarding the patients' illness, which in turn, may ameliorate dysfunctional family interactions.
Donoso F, Alejandro; Arriagada S, Daniela; Cruces R, Pablo
Despite advances in the development of renal replacement therapy, mortality of acute renal failure remains high, especially when occurring simultaneously with distant organic failure as it is in the case of the acute respiratory distress syndrome. In this update, birideccional deleterious relationship between lung and kidney on the setting of organ dysfunction is reviewed, which presents important clinical aspects of knowing. Specifically, the renal effects of acute respiratory distress syndrome and the use of positive-pressure mechanical ventilation are discussed, being ventilator induced lung injury one of the most common models for studying the lung-kidney crosstalk. The role of renal failure induced by mechanical ventilation (ventilator-induced kidney injury) in the pathogenesis of acute renal failure is emphasized. We also analyze the impact of the acute renal failure in the lung, recognizing an increase in pulmonary vascular permeability, inflammation, and alteration of sodium and water channels in the alveolar epithelial. This conceptual model can be the basis for the development of new therapeutic strategies to use in patients with multiple organ dysfunction syndrome.
McCorkle, Ruth; Ercolano, Elizabeth; Lazenby, Mark; Schulman-Green, Dena; Schilling, Lynne S.; Lorig, Kate; Wagner, Edward H.
With recent improvements in early detection, diagnosis and treatment of cancer, people with cancer are living longer, and their cancer may be managed as a chronic illness. Cancer as a chronic illness places new demands on patients and families to manage their own care, and it challenges old paradigms that oncology's work is done after treatment. As a chronic illness, however, cancer care occurs on a continuum that stretches from prevention to the end of life, with early detection, diagnosis, treatment, and survivorship in between. In this paper, we review self-management interventions that enable patients and families to participate in managing their care along this continuum. We review randomized controlled trials of self-management interventions with cancer patients and families in the treatment, survivorship, and end-of-life phases of the cancer-care continuum. We also present the Chronic Care Model as a model of care that oncology practices can use to enable and empower patients and families to engage in self-management. We conclude that, the need for a common language by which to speak about self-management and a common set of self-management actions for cancer care notwithstanding, oncology practices can now build strong relationships with their patients and formulate mutually-agreed upon care plans that enable and empower patients to care for themselves in the way they prefer. PMID:21205833
Objective As the rates of TB world over have increased during the past 10 years, there has been a growing awareness of depression and its role in the outcome of chronic disorders. Though depression is common in patients with TB no study as yet has examined the prevalence of depression in this group in Pakistan. We aimed to determine the presence of depression, anxiety and illness perceptions in patients suffering from Tuberculosis (TB) in Pakistan. Methods 108 consecutive outpatients with tuberculosis completed the Hospital Anxiety and Depression scale (HADS) and the Illness Perception Questionnaire (IPQ). Results Out of 108 patients, 50 (46.3%) were depressed and 51 (47.2%) had anxiety. Raised depression and anxiety scores were associated with an increase in the number of symptoms reported (HADS Depression: r = 0.346, p = < 0.001), more serious perceived consequences (HADS Depression: r = 0.279, p = 0.004, HADS Anxiety: r = 0.234, p = 0.017) and less control over their illness (HADS Depression: r = 0.239, p = 0.014, HADS Anxiety: r = 0.271, p = 0.005). Conclusion We found that about a half of patients in our sample met the criteria for probable depression and anxiety based on HADS score. Negative illness perceptions were clearly related to reports of mood symptoms. As depression and lack of perceived control over illness in those suffering from tuberculosis are reported to be independent predictors of poor adherence further studies to investigate their relationship with medication adherence are required. PMID:18302758
Cohen, Alexander Thomas; Spiro, Theodore Erich; Büller, Harry Roger; Haskell, Lloyd; Hu, Dayi; Hull, Russell; Mebazaa, Alexandre; Merli, Geno; Schellong, Sebastian; Spyropoulos, Alex; Tapson, Victor
Patients with acute medical illnesses are at increased risk of venous thromboembolism (VTE), a significant cause of morbidity and mortality. Thromboprophylaxis is recommended in these patients but questions remain regarding the optimal duration of therapy. The aim of this study is to determine whether oral rivaroxaban is non-inferior to standard-duration (approximately 10 days) subcutaneous (s.c.) enoxaparin for the prevention of VTE in acutely ill medical patients, and whether extended-duration (approximately 5 weeks) rivaroxaban is superior to standard-duration enoxaparin. Patients aged 40 years or older and hospitalized for various acute medical illnesses with risk factors for VTE randomly receive either s.c. enoxaparin 40 mg once daily (od) for 10 ± 4 days or oral rivaroxaban 10 mg od for 35 ± 4 days. The primary efficacy outcomes are the composite of asymptomatic proximal deep vein thrombosis (DVT), symptomatic DVT, symptomatic non-fatal pulmonary embolism (PE), and VTE-related death up to day 10 + 4 and up to day 35 + 4. The primary safety outcome is the composite of treatment-emergent major bleeding and clinically relevant non-major bleeding. As of July 2010, 8,101 patients from 52 countries have been randomized. These patients have a broad range of medical conditions: approximately one-third were diagnosed with acute heart failure, just under one-third were diagnosed with acute infectious disease, and just under one-quarter were diagnosed with acute respiratory insufficiency. MAGELLAN will determine the efficacy, safety, and pharmacological profile of oral rivaroxaban for the prevention of VTE in a diverse population of medically ill patients and the potential of extended-duration therapy to reduce incidence of VTE.
Awan, Naila Riaz; Jehangir, Syeda Farhana; Irfan, Muhammad; Naeem, Farooq; Farooq, Saeed
This randomized controlled trial was conducted at Department of Psychiatry, Lady Reading Hospital, Peshawar from February to August 2015 to explore beliefs and concepts of patients with schizophrenia about their illness and to find out the effectiveness of structured educational intervention in changing the explanatory models of illness of the patients and in their symptoms reduction. One hundred and three patients were recruited in the trial who were randomly assigned to two groups i.e., Experimental (n=53) and Control i.e., Treatment As Usual, TAU (n=50). Intervention was applied to experimental group only, once a month for three months. Short Explanatory Model Interview (SEMI), Brief Psychiatric Rating Scale (BPRS), Positive And Negative Syndrome Scale (PANSS), Global Assessment of Functioning (GAF) and Compliance Rating Scale were applied on all patients at baseline and at 3months follow up. Scores on PANSS (Total), BPRS and GAF showed improvement in the experimental group as compared to TAU group, at follow up, with the p values of 0.000, 0.002 and 0.000, respectively. On follow up, 44 (95.6%) patients of experimental group achieved complete compliance as compared to 17 (47.2%) patients of TAU group [p=0.000]. On baseline analysis of SEMI, in the experimental group, only 3.8% (n=2) knew about name of the illness, which increased to 54.3% (n=25) on follow up, while in TAU group it improved to 5.6% (n=2) as compared to 0% at baseline (p=0.000). The result suggest that Structured educational intervention can be effective in modifying the beliefs of the patients regarding their illness.
Lee, Yoojin; Kwon, Oran; Shin, Cheung Soo
Malnutrition is common in the critically ill patients and known to cause a variety of negative clinical outcomes. However, various conventional methods for nutrition assessment have several limitations. We hypothesized that body composition data, as measured using bioelectrical impedance analysis (BIA), may have a significant role in evaluating nutritional status and predicting clinical outcomes in critically ill patients. We gathered clinical, biochemical, and BIA data from 66 critically ill patients admitted to an intensive care unit. Patients were divided into three nutritional status groups according to their serum albumin level and total lymphocyte counts. The BIA results, conventional indicators of nutrition status, and clinical outcomes were compared and analyzed retrospectively. Results showed that the BIA indices including phase angle (PhA), extracellular water (ECW), and ECW/total body water (TBW) were significantly associated with the severity of nutritional status. Particularly, PhA, an indicator of the health of the cell membrane, was higher in the well-nourished patient group, whereas the edema index (ECW/TBW) was higher in the severely malnourished patient group. PhA was positively associated with albumin and ECW/TBW was negatively associated with serum albumin, hemoglobin, and duration of mechanical ventilation. In non-survivors, PhA was significantly lower and both ECW/TBW and %TBW/fat free mass were higher than in survivors. In conclusion, several BIA indexes including PhA and ECW/TBW may be useful for nutritional assessment and represent significant prognostic factors in the care of critically ill patients. PMID:25713790
Hu, Shu-Chin; Lee, Ru-Ping
Ventilator-associated pneumonia (VAP) is a hospital-acquired pneumonia that occurs in patients usually 48 hours or more after mechanical ventilator intubation. VAP is the most common nosocomial infection in critically ill patients. Mechanical ventilators are critical oxygenation and ventilation systems for patients. However, there is a close relationship among self-use efficacy, system settings, and VAP infection rate. VAP not only results in higher mortality, longer hospital stays, and higher medical costs, but also negatively affects patient outcomes and medical care quality. The purpose of this article was to provide reference information on VAP risk factors and prevention measures.
Wandrag, L; Brett, S J; Frost, G; Hickson, M
Muscle wasting during critical illness impairs recovery. Dietary strategies to minimise wasting include nutritional supplements, particularly essential amino acids. We reviewed the evidence on enteral supplementation with amino acids or their metabolites in the critically ill and in muscle wasting illness with similarities to critical illness, aiming to assess whether this intervention could limit muscle wasting in vulnerable patient groups. Citation databases, including MEDLINE, Web of Knowledge, EMBASE, the meta-register of controlled trials and the Cochrane Collaboration library, were searched for articles from 1950 to 2013. Search terms included 'critical illness', 'muscle wasting', 'amino acid supplementation', 'chronic obstructive pulmonary disease', 'chronic heart failure', 'sarcopenia' and 'disuse atrophy'. Reviews, observational studies, sport nutrition, intravenous supplementation and studies in children were excluded. One hundred and eighty studies were assessed for eligibility and 158 were excluded. Twenty-two studies were graded according to standardised criteria using the GRADE methodology: four in critical care populations, and 18 from other clinically relevant areas. Methodologies, interventions and outcome measures used were highly heterogeneous and meta-analysis was not appropriate. Methodology and quality of studies were too varied to draw any firm conclusion. Dietary manipulation with leucine enriched essential amino acids (EAA), β-hydroxy-β-methylbutyrate and creatine warrant further investigation in critical care; EAA has demonstrated improvements in body composition and nutritional status in other groups with muscle wasting illness. High-quality research is required in critical care before treatment recommendations can be made.
Leone, Daniela; Borghi, Lidia; Lamiani, Giulia; Barlascini, Luca; Bini, Teresa; d’Arminio Monforte, Antonella; Vegni, Elena
Introduction: It is important for HIV positive patients to be engaged in their care and be adherent to treatment in order to reduce disease progression and mortality. Studies found that illness representations influence adherence through the mediating role of coping behaviors. However, no study has ever tested if patient engagement to the visits mediate the relationship between illness perceptions and adherence. This study aimed to explore illness representations of HIV positive patients and test the hypothesis that illness representations predict adherence through the mediating role of a component of behavioral engagement. Methods: HIV-positive patients treated with highly active antiretroviral therapy (HAART) for at least one year and presenting to a check-up visit were eligible to participate in the study. Patients completed the Illness Perception Questionnaire-Revised. Behavioral engagement was measured based on the patients’ clinical attendance to the check-up visits; adherence to HAART was measured by viral load. Undetectable viral load or HIV-RNA < 40 copies/ml were considered indexes of virologic success. Results: A total of 161 patients participated in the study. Most of them coherently attributed the experienced symptoms to HIV/HAART; perceived their condition as chronic, stable, coherent, judged the therapy as effective, and attributed their disease to the HIV virus and to their behavior or bad luck. The majority of patients (80.1%) regularly attended check-up visits and 88.5% of them reached virologic success. The mediation model did not show good fit indexes. However, a significant direct effect of two independent variables on virologic success was found. Specifically, the perception that the disease does not have serious consequences on patient’s life and the prevalence of negative emotions toward HIV were associated with virologic success. On the contrary, the patient’s perception that the disease has serious consequences on his/her life and
Ferreira, Lucas Lima; Vanderlei, Luiz Carlos Marques; Valenti, Vitor Engrácia
Objective To analyze the outcomes enabled by the neuromuscular electric stimulation in critically ill patients in intensive care unit assisted. Methods A systematic review of the literature by means of clinical trials published between 2002 and 2012 in the databases LILACS, SciELO, MEDLINE and PEDro using the descriptors “intensive care unit”, “physical therapy”, “physiotherapy”, “electric stimulation” and “randomized controlled trials”. Results We included four trials. The sample size varied between 8 to 33 individuals of both genders, with ages ranging between 52 and 79 years, undergoing invasive mechanical ventilation. Of the articles analyzed, three showed significant benefits of neuromuscular electrical stimulation in critically ill patients, such as improvement in peripheral muscle strength, exercise capacity, functionality, or loss of thickness of the muscle layer. Conclusion The application of neuromuscular electrical stimulation promotes a beneficial response in critically patients in intensive care. PMID:25295458
Kohler, Matthew; Chiu, Felicia; Gelber, Katherine M; Webb, Christopher Aj; Weyker, Paul D
Pain management for critically ill patients provides physicians with the challenge of maximizing patient comfort while avoiding the risks that arise with oversedation. Preventing oversedation has become increasingly important as we better understand the negative impact it has on patients' experiences and outcomes. Current research suggests that oversedation can result in complications such as thromboembolism, pulmonary compromise, immunosuppression and delirium. Fortunately, the analgesic options available for physicians to limit these complications are growing as more treatment modalities are being researched and implemented in the intensive care unit. Our goal is to outline some of the effective and widely utilized tools available to physicians to appropriately and safely manage pain while avoiding oversedation in the critically ill population.
Venters, Homer; Keller, Allen S
Over 350,000 immigrants are detained by U.S. Immigration and Customs Enforcement (ICE) each year. An unknown fraction of these detainees have serious mental illnesses and are taken into ICE custody even though a criminal court has ordered them to enter inpatient mental health care. The authors report findings from 16 such cases in which they have provided advocacy over the past four years. In some cases, they were able to secure release of detainees into inpatient care in community (nonforensic) settings, which involved substantial logistical challenges. Given the well-documented concerns about securing adequate care for ICE detainees with mental illness, a logical policy change would be for ICE to allow these patients to enter court-ordered inpatient care. This move would improve care for patients and would also unburden ICE from the untenable proposition of caring for patients that the criminal justice system has deemed unfit for incarceration.
Vera, P; Palomar, M; Álvarez-Lerma, F
Quality indicators have been applied to many areas of health care in recent years, including intensive care. However, they have not been specifically developed and validated for antimicrobial use in critically ill patients. Antimicrobials play a key role in intensive care units not only in the prognosis of each individual patient, but also in the development of resistance and changes in the flora in this setting. Evaluating the use of these agents is complex in the intensive care unit, however, because the indications vary greatly and antimicrobial treatment is often changed during admission. We designed and developed specific quality indicators regarding the use of antimicrobials in critically ill patients admitted to the intensive care unit. These indicators are proposed as a tool for application in intensive care units to detect problems in the use of antimicrobials. Future trials are needed, however, to validate these indicators in a large population over time.
Guzman-Parra, Jose; Moreno-Küstner, Berta; Rivas, Fabio; Alba-Vallejo, Mercedes; Hernandez-Pedrosa, Javier; Mayoral-Cleries, Fermin
People with severe mental illness have multiple and complex needs that often are not addressed. The purpose of this study was to analyse needs and support perceived and the relationship with hospital readmission. We assessed 100 patients with severe mental illness at discharge from an acute inpatient unit in terms of needs (Camberwell Assessment of Needs), clinical status (The Brief Psychiatric Rating Scale), and social functioning (Personal and Social Performance); we also followed up these patients for 1 year. The group of patients who were readmitted had more total needs than did the non-readmitted, in addition to more unmet needs, although the differences were not significant. The highest risk factor for rehospitalisation was the number of previous admissions. In addition, the help of informal carers in alleviating psychological distress was associated with the risk of readmission. The main conclusion concerns the role of the psychological support provided by informal networks in preventing readmission.
Beltran, Nohra E; Ceron, Ulises; Sanchez-Miranda, Gustavo; Remolina, Miguel; Godinez, Maria M; Peralta, Itzel Y; Sacristan, Emilio
Gastric reactance has been proposed as a measure of mucosal ischemic injury in the critically ill. The purpose of this study was to evaluate the incidence of gastric mucosal injury as measured by gastric reactance in different subgroups of critical patients. We studied 100 adult patients admitted to 7 different hospital intensive care units, requiring a nasogastric tube. Gastric impedance measurements were continuously obtained from each patient for 24 hours. Patients were managed based on conventional protocols by hospital staff, blinded to the changes in gastric impedance parameters. The low-frequency central reactance (X L) reflects tissue edema caused by prolonged ischemia. The previously reported threshold of X L ≥ 13 - jΩ was used to classify injured mucosa; 80% of all patients had mean X L above this threshold. No significant differences were found in the incidence of mucosal ischemia between medical versus surgical, hemodynamic versus respiratory or neurological patients. Significant lower urine output was found in patients with X L above threshold (P < .01); also, there was a significant effect of fluid balance in those patients (P < .05). More complicated patients had higher average reactance. This study shows that gastric ischemia as estimated by gastric reactance has a very high incidence in the critically ill, independently of the reason for admission. High reactance is related with higher morbidity in agreement with other reports using different methods of assessing splanchnic hypoperfusion in this patient population.
Junod Perron, Noelle; Hudelson, Patricia
Background Somatisation is particularly challenging in multicultural contexts where patients and physicians often differ in terms of their illness-related beliefs and practices and health care expectations. This paper reports on a exploratory study aimed at better understanding how asylum seeker and refugee patients from the former country of Yugoslavia who were identified by their physicians as somatising make sense of their suffering. Methods We conducted semi-structured interviews with 26 asylum seeker and refugee patients from the former country of Yugoslavia who attended the general medicine outpatient clinic of a Swiss teaching Hospital and were identified as presenting with somatisation. Interviews explored patients' illness perspectives and health care expectations. Interviews were audio taped, transcribed verbatim and analyzed to identify key themes in patients' narratives. Results Patients attributed the onset of symptoms to past traumatic experiences and tended to attribute their persistence to current living conditions and uncertain legal status. Patients formulated their suffering in both medical and social/legal terms, and sought help from physicians for both types of problems. Conclusion Awareness of how asylum seeker and refugee patients make sense of their suffering can help physicians to better understand patients' expectations of the clinical encounter, and the particular nature and constraints of the patient-provider relationship in the context of asylum. PMID:16480514
Grudzen, Corita R; Emlet, Lillian L; Kuntz, Joanne; Shreves, Ashley; Zimny, Erin; Gang, Maureen; Schaulis, Monique; Schmidt, Scott; Isaacs, Eric; Arnold, Robert
The emergency department visit for a patient with serious illness represents a sentinel event, signalling a change in the illness trajectory. By better understanding patient and family wishes, emergency physicians can reinforce advance care plans and ensure the hospital care provided matches the patient's values. Despite their importance in care at the end of life, emergency physicians have received little training on how to talk to seriously ill patients and their families about goals of care. To expand communication skills training to emergency medicine, we developed a programme to give emergency medicine physicians the ability to empathically deliver serious news and to talk about goals of care. We have built on lessons from prior studies to design an intervention employing the most effective pedagogical techniques, including the use of simulated patients/families, role-playing and small group learning with constructive feedback from master clinicians. Here, we describe our evidence-based communication skills training course EM Talk using simulation, reflective feedback and deliberate practice.
Bogovic, Petra; Logar, Mateja; Avsic-Zupanc, Tatjana; Strle, Franc; Lotric-Furlan, Stanka
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. PMID:24895617
Saarti, S; Hajj, A; Karam, L; Jabbour, H; Sarkis, A; El Osta, N; Rabbaa Khabbaz, L
The relationship between adherence to antihypertension medications, treatment satisfaction and illness perception has not been studied so far. The primary objective of this study was to examine the association between adherence to medication, treatment satisfaction and illness perception in Lebanese hypertensive patients. The relation between medication adherence and blood pressure (BP) control was also assessed. In this cross-sectional study, patients were recruited from the physician's practice offices and community pharmacies in Beirut. Patients who had been treated for hypertension for at least 3 months were invited to participate in the study; they completed three questionnaires: the 8-item Morisky Medication Adherence Scale (MMAS-8), the Treatment Satisfaction Questionnaire for Medication (TSQM-4) and the Brief Illness Perception Questionnaire (BIPQ). BP was also measured and recorded. A total of 117 subjects were included, of whom 29.1% had poor adherence to their antihypertension treatment (MMAS-8 scores<6). The odds of having well-controlled hypertension was 3.5 times higher in patients with high adherence compared with patients with poor adherence (P=0.010). Treatment satisfaction was significantly greater in patients with good adherence (P<0.001). Neither socio-demographic, disease- nor drug-related characteristics of the participants were significantly associated with medication adherence. As for illness perception, even though the mean BIPQ score of adherent participants was lower than the mean score of non-adherent participants, this difference did not reach statistical significance. In conclusion, treatment satisfaction was found to be a predictor of adherence. Studies are needed to determine whether interventions to increase satisfaction can improve adherence and BP control.
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. PMID:24172136
Spratt, D I; Frohnauer, M; Cyr-Alves, H; Kramer, R S; Lucas, F L; Morton, J R; Cox, D F; Becker, K; Devlin, J T
In a prospective randomized placebo-controlled study, we assessed potential physiological effects of nonthyroidal illness syndrome (NTIS) in acute illness. Coronary artery bypass graft surgery was employed as a prospective model of acute illness and NTIS. Triiodothyronine (T(3)) or placebo was infused for 24 h after surgery, with a T(3) dose selected to maintain postoperative serum T(3) concentrations at preoperative levels. Patients were evaluated before coronary artery bypass graft and during the postoperative period. Cardiovascular function was monitored with Swan-Ganz catheter measurements and ECG. Urinary nitrogen excretion and L-[1-(13)C]leucine flux were used to evaluate protein metabolism. Serum measurements of relevant hormones, iron, and total iron-binding capacity were used to assess effects on sex steroid, growth hormone axis, and iron responses to illness. Cardiovascular function was not affected by T(3) infusion, except for a transient higher cardiac index in the T(3) group 6 h after surgery (3.04 +/- 0.12 for T(3) and 2.53 +/- 0.08 for placebo, P = 0.0016). Protein metabolism was not affected; changes in urinary nitrogen excretion and L-[1-(13)C]leucine flux were equivalent in the two groups (P = 0.35 and P = 0.95, respectively). No differences were observed in changes in testosterone, estrogens, growth hormone, insulin-like growth hormone I, iron, or total iron-binding capacity between T(3) and placebo groups. We conclude that, in the early stages of major illness, the decrease in circulating T(3) concentrations in NTIS has only a minimal transient physiological impact on cardiac function and plays no significant role in protecting against protein catabolism or modulating other endocrine responses or iron responses to illness.
Schellongowski, Peter; Sperr, Wolfgang R; Wohlfarth, Philipp; Knoebl, Paul; Rabitsch, Werner; Watzke, Herbert H; Staudinger, Thomas
This narrative review deals with the challenge of defining adequate therapy goals and intensive care unit (ICU) admission criteria for critically ill patients with cancer. Several specific complications of critically ill patients with cancer require close collaborations of intensive care and cancer specialists. Intensivists require a basic understanding of the pathophysiology, diagnosis and therapy of common cancer-specific problems. Cancer specialists must be knowledgeable in preventing, detecting and treating imminent or manifest organ failures. In case of one or more organ dysfunctions, ICU admissions must be evaluated early. In order to properly define the therapy goals for critically ill patients with cancer, decision-makers must be aware of the short-term intensive care prognosis as well as the long-term oncological options and perspectives. Multidisciplinary teamwork is key when it comes down to decisions on ICU admission, planning of therapeutic aims, patient management in the ICU and tailored therapy limiting with smooth transition into a palliative care (PC) setting, whenever appropriate. PMID:27843637
Plikat, Katharina; Langgartner, Julia; Buettner, Roland; Bollheimer, L Cornelius; Woenckhaus, Ulrike; Schölmerich, Jürgen; Wrede, Christian E
Acute and chronic critical conditions are associated with reduced serum levels of free triiodothyronine (FT(3)), free thyroxine FT(4), and thyrotropin, known as nonthyroidal illness syndrome (NTIS). It is still controversial whether these changes reflect a protective mechanism or a maladaptive process during prolonged illness. However, larger studies to determine the prevalence of the NTIS and its association with outcome in medical intensive care units (ICUs) are missing. Complete thyroid hormone levels from 247 of 743 patients admitted to our ICU between October 2002 and February 2004 were retrospectively evaluated. From these patients, Acute Physiology and Chronic Health II scores, ICU mortality, length of stay, mechanical ventilation, and concomitant medication were recorded. Ninety-seven patients (44.1%) had low FT(3) levels indicating an NTIS, either with normal (23.6%) or reduced (20.5%) serum thyrotropin levels. Of 97 patients with NTIS, 24 (23.3%) also showed reduced serum FT(4) levels. The NTIS was significantly associated with Acute Physiology and Chronic Health II scores, mortality, length of stay, and mechanical ventilation. In a multivariate Cox regression analysis, the combination of low FT(3) and low FT(4) was an independent risk factor for survival. Nonthyroidal illness syndrome is frequent at a medical ICU. A reduction of FT(4) together with FT(3) is associated with an increase in mortality and might reflect a maladaptive process, thereby worsening the disease.
Yamamoto, Takahiro; Todani, Masaki; Oda, Yasutaka; Kaneko, Tadashi; Kaneda, Kotaro; Fujita, Motoki; Miyauchi, Takashi; Tsuruta, Ryosuke
The objective of the study was to investigate the predictive factors for the hospitalization of patients who presented with mild to moderate heat illness at an emergency department. We conducted a retrospective survey of hospitals with an emergency department in Yamaguchi Prefecture, Japan. The survey questionnaire entries included patient age, sex, use of an ambulance, vital signs, blood examination conducted at the emergency department, the length of hospitalization, and outcome. We analyzed the predictive factors for hospitalization in patients with heat illness. A total of 127 patients were analyzed. Of these, 49 (37%) were admitted, with 59% discharged on the day following admission. In univariate analysis, the following inpatient characteristics were predictive for hospitalization: old age, low Glasgow Coma Scale score, elevated body temperature, increased serum C-reactive protein, and increased blood urea nitrogen. In logistic regression multivariate analysis, the following were predictive factors for hospitalization: age of ≥ 65 years (odds ratio (OR) 4.91; 95% confidence interval (CI) 1.42-17.00), body temperature (OR 1.97; 95% CI 1.14-3.41), Glasgow Coma Scale (OR 0.40; 95% CI 0.16-0.98), and creatinine (OR 2.92; 95% CI 1.23-6.94). The results suggest that the elderly with hyperthermia, disturbance of consciousness, and elevated serum creatinine have an increased risk for hospitalization with heat illness.
Weiler, Stefan; Überlacher, Elisabeth; Schöfmann, Julia; Stienecke, Eva; Dunzendorfer, Stefan; Joannidis, Michael
The pharmacokinetics of lipid-bound and liberated amphotericin B (AMB) was assessed in 11 critically ill patients with cholestatic liver disease (CSLD) and in 9 subjects with normal liver function treated with AMB colloidal dispersion (ABCD). Exposure to lipid-bound AMB was higher in patients with CSLD. Levels of liberated AMB were elevated by CSLD only after the first dose, whereas its pharmacokinetics was unaffected at steady state. The standard dosage of ABCD is probably adequate for patients with CSLD. PMID:22850517
Gunnerson, Kyle J; Saul, Melissa; He, Shui; Kellum, John A
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
Frati, Paola; Gulino, Matteo; Mancarella, Paola; Cecchi, Rossana; Ferracuti, Stefano
A year after Mario Monicelli's suicide, the death of another famous person in Italy, Lucio Magri, reawakened the Italian debate on social, ethical and juridical issues in end-of-life decisions. Unlike Monicelli, Lucio Magri decided to end his own life in Switzerland with the help of a physician because his mental illness rendered his life unbearable. Both Monicelli and Magri suffered from a severe depression. The authors analyze the ethical issues regarding the right to die for mentally ill patients and neurological disabled patients, discussing the decision-making autonomy in persons suffering from severe depression. The role of the psychiatry in the management of end-of-life decision requests is considered along with pros and cons of suicide prevention and rationale suicide.
Manzanares, W; Langlois, P L
Third-generation lipid emulsions (LE) are soybean oil sparing strategies with immunomodulatory and antiinflammatory effects. Current evidence supporting the use of intravenous (i.v) fish oil (FO) LE in critically ill patients requiring parenteral nutrition or receiving enteral nutrition (pharmaconutrient strategy) mainly derives from small phase ii clinical trials in heterogenous intensive care unit patient's population. Over the last three years, there have been published different systematic reviews and meta-analyses evaluating the effects of FO containing LE in the critically ill. Recently, it has been demonstrated that i.v FO based LE may be able to significantly reduce the incidence of infections as well as mechanical ventilation days and hospital length of stay. Nonetheless, more robust evidence is required before giving a definitive recommendation. Finally, we strongly believe that a dosing study is required before new phase iii clinical trials comparing i.v FO containing emulsions versus other soybean oil strategies can be conducted.
Villa, Gianluca; Neri, Mauro; Bellomo, Rinaldo; Cerda, Jorge; De Gaudio, A Raffaele; De Rosa, Silvia; Garzotto, Francesco; Honore, Patrick M; Kellum, John; Lorenzin, Anna; Payen, Didier; Ricci, Zaccaria; Samoni, Sara; Vincent, Jean-Louis; Wendon, Julia; Zaccaria, Marta; Ronco, Claudio
This article reports the conclusions of the second part of a consensus expert conference on the nomenclature of renal replacement therapy (RRT) techniques currently utilized to manage acute kidney injury and other organ dysfunction syndromes in critically ill patients. A multidisciplinary approach was taken to achieve harmonization of definitions, components, techniques, and operations of the extracorporeal therapies. The article describes the RRT techniques in detail with the relevant technology, procedures, and phases of treatment and key aspects of volume management/fluid balance in critically ill patients. In addition, the article describes recent developments in other extracorporeal therapies, including therapeutic plasma exchange, multiple organ support therapy, liver support, lung support, and blood purification in sepsis. This is a consensus report on nomenclature harmonization in extracorporeal blood purification therapies, such as hemofiltration, plasma exchange, multiple organ support therapies, and blood purification in sepsis.
Jørgensen, Kjetil Nordbø; Psychol, Cand; Skjærvø, Ingeborg; Mørch-Johnsen, Lynn; Haukvik, Unn Kristin; Lange, Elisabeth Heffermehl; Melle, Ingrid; Andreassen, Ole Andreas; Agartz, Ingrid
Background Magnetic resonance imaging (MRI) studies show reduced cortical thickness in patients with schizophrenia and bipolar disorder. These subtle brain abnormalities may provide insight into illness mechanisms. However, environmental and lifestyle-related factors, such as cigarette smoking, may contribute to brain structure changes. Cigarette smoking is highly prevalent in patients with severe mental illness. In nonpsychiatric samples, smoking has been associated with reduced thickness in the anterior (ACC) and posterior cingulate cortices, the insular cortex (INS), the dorsolateral prefrontal cortex and the orbitofrontal cortex. Methods We examined MRI scans from patients with schizophrenia, other psychotic disorders or bipolar disorder and healthy controls using FreeSurfer. Results We included 506 patients (49% smokers) and 237 controls (20% smokers) in our study. We found reduced cortical thickness in the left rostral ACC and the left INS in smoking patients compared with nonsmoking patients, but this difference was not found among healthy controls. No dose–response relationship was found between amount of smoking and cortical thickness in these regions. Among patients, maps of thickness along the whole cortical surface revealed reduced insular thickness but no effects in other regions. Among healthy controls, similar analyses revealed increased age-related cortical thinning in the left occipital lobe among smokers compared with nonsmokers. Limitations The causal direction could not be determined owing to the cross-sectional design and lack of detailed data on smoking addiction and smoking history. Conclusion The effect of cigarette smoking should be considered in MRI studies of patients with severe mental illness. PMID:25672482
Rathakrishnan, Anusyah; Wang, Seok Mui; Hu, Yongli; Khan, Asif M.; Ponnampalavanar, Sasheela; Lum, Lucy Chai See; Manikam, Rishya; Sekaran, Shamala Devi
Background Dengue is an important medical problem, with symptoms ranging from mild dengue fever to severe forms of the disease, where vascular leakage leads to hypovolemic shock. Cytokines have been implicated to play a role in the progression of severe dengue disease; however, their profile in dengue patients and the synergy that leads to continued plasma leakage is not clearly understood. Herein, we investigated the cytokine kinetics and profiles of dengue patients at different phases of illness to further understand the role of cytokines in dengue disease. Methods and Findings Circulating levels of 29 different types of cytokines were assessed by bead-based ELISA method in dengue patients at the 3 different phases of illness. The association between significant changes in the levels of cytokines and clinical parameters were analyzed. At the febrile phase, IP-10 was significant in dengue patients with and without warning signs. However, MIP-1β was found to be significant in only patients with warning signs at this phase. IP-10 was also significant in both with and without warning signs patients during defervescence. At this phase, MIP-1β and G-CSF were significant in patients without warning signs, whereas MCP-1 was noted to be elevated significantly in patients with warning signs. Significant correlations between the levels of VEGF, RANTES, IL-7, IL-12, PDGF and IL-5 with platelets; VEGF with lymphocytes and neutrophils; G-CSF and IP-10 with atypical lymphocytes and various other cytokines with the liver enzymes were observed in this study. Conclusions The cytokine profile patterns discovered between the different phases of illness indicate an essential role in dengue pathogenesis and with further studies may serve as predictive markers for progression to dengue with warning signs. PMID:23284941
Frings-Dresen, Monique H. W.
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
Maack, Kim Hovgaard; Tarp, Britta
The incidence of nosocomial fungal infections has increased over the past 20 years. Candida albicans is the most commonly involved pathogen. Concurrently, the number of non-albicans species with decreased susceptibility to commonly used antifungal agents has increased significantly. Invasive candidiasis is associated with significant morbidity and mortality. We present a case of unusually massive infection with a number of different Candida species, which caused severe prolonged infection in a critically ill patient.
Golombek, Sergio G
This article reviews the pathophysiology of non-thyroidal illness syndrome (NTIS) and euthyroid sick syndrome (ESS), a multifactorial phenomenon characterized by suppression of thyroid hormone levels that has been described in several disease states, probably due to different causes in different patients. It also describes the laboratory values of thyroid function tests (TFTs), relevant animal studies, the association of NTIS and ESS with cardiovascular problems and sepsis, and the rationale for treatment.
Davis, Mary C; Affleck, Glenn; Zautra, Alex J; Tennen, Howard
Action theory proposes that individuals actively shape and then respond to their environments, highlighting the role of stable person characteristics in the development and maintenance of life's interpersonal difficulties. In this study, the authors adopt the action perspective in their examination of predictors of daily interpersonal events among chronic pain patients with rheumatoid arthritis. They probe the extent to which stable symptoms of illness explained between-person variation, and fluctuating symptoms explain day-to-day variation in both positive and negative events. Their evaluation of patients' daily diary reports indicate that between-person differences accounted for more variance in the occurrence of positive events relative to negative events (48% vs. 31%, respectively). Likewise, between-person factors accounted for more variance in appraisals of positive compared to negative events across relationship domains. Both intractable illness symptoms and disability, and daily fluctuations in pain and fatigue, were only weakly related to patients' reports of their interpersonal experiences. Consistent with action theory, these results suggest that stable person characteristics are strongly related to daily stressors and particularly daily positive events in pain patients, but still account for less than 50% of the variance in events and their appraisals. In contrast, elevations in illness-related features, both between individuals and within individuals from day-to-day, are not robust predictors of positive or negative social exchanges. These findings point to the value of capturing the experiences of individuals intensively over time, an approach that can help to elaborate the contributions of both stable factors and circumstance in shaping social contexts in chronic illness.
Mahmoodpoor, Ata; Hamishehkar, Hadi; Shadvar, Kamran; Sanaie, Sarvin; Iranpour, Afshin; Fattahi, Vahid
Background and Aims: There have been variable results on the practice of tight glycemic control, and studies have demonstrated that point-of-care (POC) glucometers have variable accuracy. Glucometers must be accurate, and many variables can affect blood glucose levels. The purpose of this study was to determine the difference between blood glucose concentrations obtained from POC glucometers and laboratory results in critically ill patients with intensive insulin therapy. Materials and Methods: This was a descriptive study which enrolled 300 critically ill patients. Four samples of arterial blood were collected and analyzed at the bedside with the POC glucometer and also in the central laboratory to obtain the blood glucose level. To define the effect of various factors on this relation, we noted the levels of hemoglobin (Hb), PaO2, body temperature, bilirubin, history of drug usage, and sepsis. Results: There were not any significant differences between blood sugar levels using laboratory and glucometer methods of measurements. There was a good and significant correlation between glucose levels between two methods (r = 0.81, P < 0.001). Among evaluated factors (body temperature, bilirubin level, blood pressure, Hb level, PaO2, sepsis, and drugs) which added one by one in model, just drugs decreased the correlation more than others (r = 0.78). Conclusions: The results of POC glucometer differ from laboratory glucose concentrations, especially in critically ill patients with unstable hemodynamic status while receiving several drugs. This may raise the concern about using POC devices for tight glycemic control in critically ill patients. These results should be interpreted with caution because of the large variation of accuracy among different glucometer devices. PMID:27994380
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. PMID:23799988
Hvidberg, Line; Jensen, Line F; Pedersen, Anette F; Aro, Arja R; Vedsted, Peter
The aim of this study was to validate the measurement properties of the Danish version of the Illness Perception Questionnaire-Revised adapted to measure symptom representations among patients with colorectal cancer symptoms. A total of 488 colorectal cancer patients completed a questionnaire derived from the Illness Perception Questionnaire-Revised to retrospectively assess cognitive and emotional representations of experienced symptoms. A confirmatory factor analysis indicated no good comparative fit with the Illness Perception Questionnaire-Revised. Using exploratory factor analysis, a 7-factor structure was conducted, which fairly supported the Illness Perception Questionnaire-Revised. The modified Illness Perception Questionnaire-Revised is a promising tool for measuring symptom representations among Danish colorectal cancer patients.
Ye, Sheng; Xu, Dan; Zhang, Chenmei; Li, Mengyao
Purpose. The study aimed to investigate the effectiveness of antipyretic therapy on mortality in critically ill patients with sepsis requiring mechanical ventilation. Methods. In this study, we employed the multiparameter intelligent monitoring in intensive care II (MIMIC-II) database (version 2.6). All patients meeting the criteria for sepsis and also receiving mechanical ventilation treatment were included for analysis, all of whom suffer from fever or hyperthermia. Logistic regression model and R language (R version 3.2.3 2015-12-10) were used to explore the association of antipyretic therapy and mortality risk in critically ill patients with sepsis receiving mechanical ventilation treatment. Results. A total of 8,711 patients with mechanical ventilator were included in our analysis, and 1523 patients died. We did not find any significant difference in the proportion of patients receiving antipyretic medication between survivors and nonsurvivors (7.9% versus 7.4%, p = 0.49). External cooling was associated with increased risk of death (13.5% versus 9.5%, p < 0.001). In our regression model, antipyretic therapy was positively associated with mortality risk (odds ratio [OR]: 1.41, 95% CI: 1.20–1.66, p < 0.001). Conclusions. The use of antipyretic therapy is associated with increased risk of mortality in septic ICU patients requiring mechanical ventilation. External cooling may even be deleterious. PMID:28386165
Almalki, Mohammad; Al-Tawayjri, Ibrahim; Al-Anazi, Ahmed; Mahmoud, Sami
Introduction. Illness anxiety disorder (IAD) entails a preoccupation with having a serious, undiagnosed illness in which somatic symptoms are, if present, mild in intensity (American Psychiatric Association, 2013). Case Report. This is a case of seventy-three-year-old Saudi man who started visiting the primary health care center around twenty-five years ago. With concerns of having cancer, the patient continuously visited the hospital, costing over $170,000. Throughout this period, the patient has been exposed to extensive unnecessary imaging studies and laboratory tests that have effects on his life in all aspects with such concerns. Five years ago, a family doctor has put an end to that by directing the patient to the right path. The doctor made several actions; most importantly, he directed the patient to a cognitive behavioral therapy which significantly improved a range of hypochondriacal beliefs and attitudes. This patient's case demonstrates the fundamental importance of a proper health system that limits such patients from abusing the health system and depleting the medical resources. Moreover, this case emphasizes the important role of the family physician who can be the first physician to encounter such patients. Thus, proper understanding of the nature of such disorder is a key element for better diagnosis and management. PMID:27313939
Introduction This study was conducted to provide Intensive Care Units and Emergency Departments with a set of practical procedures (check-lists) for managing critically-ill adult patients in order to avoid complications during intra-hospital transport (IHT). Methods Digital research was carried out via the MEDLINE, EMBASE, CINAHL and HEALTHSTAR databases using the following key words: transferring, transport, intrahospital or intra-hospital, and critically ill patient. The reference bibliographies of each of the selected articles between 1998 and 2009 were also studied. Results This review focuses on the analysis and overcoming of IHT-related risks, the associated adverse events, and their nature and incidence. The suggested preventive measures are also reviewed. A check-list for quick execution of IHT is then put forward and justified. Conclusions Despite improvements in IHT practices, significant risks are still involved. Basic training, good clinical sense and a risk-benefit analysis are currently the only deciding factors. A critically ill patient, prepared and accompanied by an inexperienced team, is a risky combination. The development of adapted equipment and the widespread use of check-lists and proper training programmes would increase the safety of IHT and reduce the risks in the long-term. Further investigation is required in order to evaluate the protective role of such preventive measures. PMID:20470381
Nguyen, Thu AN; Abdelhamid, Yasmine Ali; Phillips, Liza K; Chapple, Leeanne S; Horowitz, Michael; Jones, Karen L; Deane, Adam M
Nutrient ingestion induces a substantial increase in mesenteric blood flow. In older persons (aged ≥ 65 years), particularly those with chronic medical conditions, the cardiovascular compensatory response may be inadequate to maintain systemic blood pressure during mesenteric blood pooling, leading to postprandial hypotension. In older ambulatory persons, postprandial hypotension is an important pathophysiological condition associated with an increased propensity for syncope, falls, coronary vascular events, stroke and death. In older critically ill patients, the administration of enteral nutrition acutely increases mesenteric blood flow, but whether this pathophysiological response is protective, or precipitates mesenteric ischaemia, is unknown. There are an increasing number of older patients surviving admission to intensive care units, who are likely to be at increased risk of postprandial hypotension, both during, and after, their stay in hospital. In this review, we describe the prevalence, impact and mechanisms of postprandial hypotension in older people and provide an overview of the impact of postprandial hypotension on feeding prescriptions in older critically ill patients. Finally, we provide evidence that postprandial hypotension is likely to be an unrecognised problem in older survivors of critical illness and discuss potential options for management. PMID:28224105
Kim, Do Yeun; Lee, Sang Min; Lee, Kyoung Eun; Lee, Hye Ran; Kim, Jee Hyun; Lee, Keun-Wook; Lee, Jong Seok
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. PMID:19771245
Daumit, Gail L.; McGinty, Emma E.; Pronovost, Peter; Dixon, Lisa B.; Guallar, Eliseo; Ford, Daniel E.; Cahoon, Elizabeth K.; Boonyasai, Romsai T.; Thompson, David
Objective This study explored the risk of patient safety events and associated nonfatal physical harms and mortality in a cohort of persons with serious mental illness. This group experiences high rates of medical comorbidity and premature mortality and may be at high risk of adverse patient safety events. Methods Medical record review was conducted for medical-surgical hospitalizations occurring during 1994–2004 in a community-based cohort of Maryland adults with serious mental illness. Individuals were eligible if they died within 30 days of a medical-surgical hospitalization and if they also had at least one prior medical-surgical hospitalization within five years of death. All admissions took place at Maryland general hospitals. A case-crossover analysis examined the relationships among patient safety events, physical harms, and elevated likelihood of death within 30 days of hospitalization. Results A total of 790 hospitalizations among 253 adults were reviewed. The mean number of patient safety events per hospitalization was 5.8, and the rate of physical harms was 142 per 100 hospitalizations. The odds of physical harm were elevated in hospitalizations in which 22 of the 34 patient safety events occurred (p<.05), including medical events (odds ratio [OR]=1.5, 95% confidence interval [CI]=1.3–1.7) and procedure-related events (OR=1.6, CI=1.2–2.0). Adjusted odds of death within 30 days of hospitalization were elevated for individuals with any patient safety event, compared with those with no event (OR=3.7, CI=1.4–10.3). Conclusions Patient safety events were positively associated with physical harm and 30-day mortality in nonpsychiatric hospitalizations for persons with serious mental illness. PMID:27181736
Hassan, Mohamed Basil; Hodge, David O.
Background Children diagnosed with some forms of strabismus were recently found to have an increased risk of developing mental illness by early adulthood. The purpose of this case-controlled study was to determine if adults with non-paralytic forms of strabismus are similarly at an elevated risk for developing mental illness. Methods The medical records of all patients diagnosed as adults (≥ 19 years of age) with convergence insufficiency (CI, n=118), divergence insufficiency (DI, n=80), and small angle hypertropia (HT, n=99) from January 1, 1985, through December 31, 2004, were retrospectively reviewed. Each case was compared with a sex- and birthdate-matched non-strabismic control. The medical records were reviewed for mental health diagnoses, including inpatient and outpatient encounters, psychiatric ER visits, and medication use. Results Mental health disorders were diagnosed in 65 (55.1%) patients with CI compared to 54 (45.8%) controls (p=0.15), in 51 (63.8%) patients with DI compared to 42 (52.5%) controls (p=0.15), and in 63 (63.6%) patients with HT compared to 57 (57.6%) controls (p=0.38). CI patients were not more likely to have mental health disorders than their controls (p=0.15). Mental health hospitalizations (p=0.02), psychiatric medication use (p=0.04), and unspecified anxiety disorders (p=0.03) were higher in DI patients compared to controls. HT patients were found to have more generalized anxiety disorders (p=0.003) than controls. Conclusions Adults with some forms of strabismus (DI and HT) appear to have an increased risk of mental illness and its comorbidities, compared to age- and gender-matched non-strabismic controls. PMID:26559866
Patient-centred care (PCC) is rapidly adopting a central position in discussions on the quality of healthcare, with patient-centredness deemed essential to transforming the healthcare system. PCC speaks to the quality of patient-provider relationships and has been defined as an approach to providing care that is respectful of and responsive to individual patient preferences, needs, and values, while ensuring that patient values guide all clinical decisions. However its place within pharmacy practice is unclear and is as yet undefined, particularly in relation to pharmaceutical care. Through my personal illness narrative, I briefly explore the visibility and evidence of PCC in the pharmacy literature as well as from personal experience of pharmacy care, and find it lacking. I conclude that an integrated, seamless understanding of PCC and the use of shared language within the health professions is essential in successful teamwork with both the patient and with other health professions.
Papathanassoglou, Elizabeth DE; Mpouzika, Meropi DA; Giannakopoulou, Margarita; Bozas, Evangelos; Middleton, Nicos; Tsiaousis, George; Karabinis, Andreas
Objective Lymphocyte apoptosis in critical illness is associated with immunosuppression. We explored for the first time the associations between pain ratings and expression of the apoptotic receptor Fas on B and T cells in critically ill patients and the potential mediating effects of adrenocorticotropic hormone (ACTH), cortisol, and substance P (SP). Design This is an exploratory correlational study with repeated measurements (14 days followup) and cross-sectional comparisons. Setting This study was conducted in a state hospital in the metropolitan area of Athens, Greece. Participants The participants were 36 consecutive critically ill patients and 36 matched controls. Outcome measures Pain measured by the self-reported numeric rating scale [NRS], the behavioral pain scale, and the pain assessment scale was the primary outcome measure. Flow cytometry (Fas), electrochemiluminescence (ACTH and cortisol) and enzyme-linked immunosorbent assay (SP) were used. Mixed linear models for repeated measurements and bivariable associations at discrete time points were employed. Results Significant pain at rest was noted. Pain ratings associated with Fas expression on cytotoxic T cells (P=0.041) and B cells (P=0.005), even after adjustment for a number of clinical treatment factors (P=0.006 and P=0.052, respectively). On the day that more patients were able to communicate, Fas on B cells (r=0.897, P=0.029) and cytotoxic T cells (r=0.832; P=0.037) associated with NRS ratings. Associations between pain ratings and ACTH serum levels were noted (P<0.05). When stress neuropeptide levels were added to the model, the statistical significance of the associations between pain ratings and Fas expression was attenuated (P=0.052–0.063), suggesting that stress neuropeptides may partially mediate the association. Conclusion Preliminary evidence for the association between pain and lymphocyte apoptotic susceptibility is provided. The role of pain management in maintaining immunocompetence
Gavala, Alexandra; Makris, Konstantinos; Korompeli, Anna
Background. Prolonged immobilization, nutritional and vitamin D deficiency, and specific drug administration may lead to significant bone resorption. Methods and Patients. We prospectively evaluated critically ill patients admitted to the ICU for at least 10 days. Demographics, APACHE II, SOFA scores, length of stay (LOS), and drug administration were recorded. Blood collections were performed at baseline and on a weekly basis for five consecutive weeks. Serum levels of PINP, β-CTx, iPTH, and 25(OH)vitamin D were measured at each time-point. Results. We enrolled 28 patients of mean age 67.4 ± 2.3 years, mean APACHE II 22.2 ± 0.9, SOFA 10.1 ± 0.6, and LOS 31.6 ± 5.7 days. Nineteen patients were receiving low molecular weight heparin, 17 nor-epinephrine and low dose hydrocortisone, 18 transfusions, and 3 phenytoin. 25(OH)vitamin D serum levels were very low in all patients at all time-points; iPTH serum levels were increased at baseline tending to normalize on 5th week; β-CTx serum levels were significantly increased compared to baseline on 2nd week (peak values), whereas PINP levels were increased significantly after the 4th week. Conclusions. Our data show that critically ill patients had a pattern of hypovitaminosis D, increased iPTH, hypocalcaemia, and BTMs compatible with altered bone metabolism. PMID:28025639
Belopolskaya, O B; Smelaya, T V; Moroz, V V; Golubev, A M; Salnikova, L E
Host genetic variations may influence a changing profile of biochemical markers and outcome in patients with trauma/injury. The objective of this study was to assess clinical associations of single nucleotide polymorphisms (SNPs) in the genes of cytokines in critically ill patients. A total of 430 patients were genotyped for SNPs in the genes of pro- (IL1B, IL6, IL8) and anti-inflammatory (IL4, IL10, IL13) cytokines. The main end-points were sepsis, mortality and adult respiratory distress syndrome (ARDS). We evaluated the dynamic levels of bilirubin, blood urea nitrogen, creatine kinase, creatinine and lactate dehydrogenase in five points of measurements (between 1 and 14 days after admission) and correlated them with SNPs. High-producing alleles of proinflammatory cytokines protected patients against sepsis (IL1B -511A and IL8 -251A) and mortality (IL1B -511A). High-producing alleles of anti-inflammatory cytokines IL4 -589T and IL13 431A (144Gln) were less frequent in ARDS patients. The carriers of IL6 -174C/C genotypes were prone to the increased levels of biochemical markers and acute kidney and liver insufficiency. Genotype-dependent differences in the levels of biochemical indicators gradually increased to a maximal value on the 14th day after admission. These findings suggest that genetic variability in pro- and anti-inflammatory cytokines may contribute to different clinical phenotypes in patients at high risk of critical illness.
Hyphantis, Thomas; Almyroudi, Augustina; Paika, Vassiliki; Goulia, Panagiota; Arvanitakis, Konstantinos
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.
de Medeiros, Gisele Chagas; Sassi, Fernanda Chiarion; Zambom, Lucas Santos; de Andrade, Claudia Regina Furquim
Objective: To determine whether the severity of non-neurological critically ill patients correlates with clinical predictors of bronchial aspiration. Methods: We evaluated adults undergoing prolonged orotracheal intubation (> 48 h) and bedside swallowing assessment within the first 48 h after extubation. We collected data regarding the risk of bronchial aspiration performed by a speech-language pathologist, whereas data regarding the functional level of swallowing were collected with the American Speech-Language-Hearing Association National Outcome Measurement System (ASHA NOMS) scale and those regarding health status were collected with the Sequential Organ Failure Assessment (SOFA). Results: The study sample comprised 150 patients. For statistical analyses, the patients were grouped by ASHA NOMS score: ASHA1 (levels 1 and 2), ASHA2 (levels 3 to 5); and ASHA3 (levels 6 and 7). In comparison with the other patients, those in the ASHA3 group were significantly younger, remained intubated for fewer days, and less severe overall clinical health status (SOFA score). The clinical predictors of bronchial aspiration that best characterized the groups were abnormal cervical auscultation findings and cough after swallowing. None of the patients in the ASHA 3 group presented with either of those signs. Conclusions: Critically ill patients 55 years of age or older who undergo prolonged orotracheal intubation (≥ 6 days), have a SOFA score ≥ 5, have a Glasgow Coma Scale score ≤ 14, and present with abnormal cervical auscultation findings or cough after swallowing should be prioritized for a full speech pathology assessment. PMID:27167432
Jessamine, Peter G; Desjardins, Marc; Gillis, Tom; Scollard, David; Jamieson, Frances; Broukhanski, George; Chedore, Pam; McCarthy, Anne
Here we present the first case of a patient from Ottawa Canada, presenting with leprosy-like illness associated with Mycobacterium lepromatosis. The patient had no history of travel to leprosy-endemic areas or any obvious risk factors. Clinically, the patient presented with an anesthetic maculopapular rash on the trunk, back, and extremities. A skin biopsy of a lesion revealed a dermal lymphohistiocytic infiltration involving the vessels with an inflammatory process extending to the nerves. A neurological exam also identified a severe sensorimotor polyneuropathy. Concurrently, the patient was diagnosed with non-resectable, non small cell carcinoma of the lung, further complicating his clinical presentation. A Kinyoun stain of nasal blows and a Fite stain of the skin biopsy revealed few to moderate acid fast bacilli respectively. Cultures of the skin biopsy and multiple nasal blows were negative. Molecular studies of a skin biopsy sample including sequence analysis of a 765 bp region of the 16s rRNA gene eventually identified the organism with 100% homology to M. lepromatosis. The patient was treated for leprosy and appeared to improve slightly on therapy but died as a result of his malignancy approximately five months after the initiation of therapy. This represents the first case of a patient with M. lepromatosis like illness outside of Mexico and Singapore.
Hyphantis, Thomas; Almyroudi, Augustina; Paika, Vassiliki; Goulia, Panagiota; Arvanitakis, Konstantinos
Based on the psychoanalytic reading of Homer’s Iliad whose principal theme is “Achilles’ rage” (the semi-mortal hero invulnerable in all of his body except for his heel, hence “Achilles’ heel” has come to mean a person’s principal weakness), we aimed to assess whether “narcissistic rage” has an impact on several psychosocial variables in patients with severe physical illness across time. In 878 patients with cancer, rheumatological diseases, multiple sclerosis, inflammatory bowel disease, and glaucoma, we assessed psychological distress (SCL-90 and GHQ-28), quality of life (WHOQOL-BREF), interpersonal difficulties (IIP-40), hostility (HDHQ), and defense styles (DSQ). Narcissistic rage comprised DSQ “omnipotence” and HDHQ “extraverted hostility”. Hierarchical multiple regressions analyses were performed. We showed that, in patients with disease duration less than one year, narcissistic rage had a minor impact on psychosocial variables studied, indicating that the rage was rather part of a “normal” mourning process. On the contrary, in patients with longer disease duration, increased rates of narcissistic rage had a great impact on all outcome variables, and the opposite was true for patients with low rates of narcissistic rage, indicating that narcissistic rage constitutes actually an “Achilles’ Heel” for patients with long-term physical illness. These findings may have important clinical implications. PMID:19936167
Thille, Patricia H; Russell, Grant M
Current visions of family medicine and models of chronic illness management integrate evidence-based medicine with collaborative, patient-centered care, despite critiques that these constructs conflict with each other. With this potential conflict in mind, we applied a critical discursive psychology methodology to present discursive patterns articulated by 13 family physicians in Ontario, Canada, regarding care of patients living with multiple chronic illnesses. Physicians constructed competing versions of the terms "effective chronic illness management" and "patient involvement." One construction integrated individual responsibility for health with primacy of "evidence," resulting in a conceptualization consistent with paternalistic care. The second constructed effective care as involving active partnership of physician and patient, implying a need to foster the ability of both practitioners and patients to respond to complex challenges as they arose. The former pattern is inconsistent with visions of family medicine and chronic illness management, whereas the latter embodies it.
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
Heffner, Alan C.; Horton, James M.; Marchick, Michael R.; Jones, Alan E.
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. PMID:20144044
Fagugli, Riccardo Maria; Patera, Francesco; Battistoni, Sara; Tripepi, Giovanni
Abstract Acute kidney injury requiring dialysis (AKI-D) treatment has significantly increased in incidence over the years, with more than 400 new cases per million population/y, 2/3 of which concern noncritically ill patients. In these patients, there are little data on mortality or on information of care organization and its impact on outcome. Specialty training and integrated teams, as well as a high volume of activity, seem to be linked to better hospital outcome. The study investigates mortality of patients admitted to and in-care of nephrology (NEPHROpts), a closed-staff organization, and to other medical wards (MEDpts), representing a model of open-staff organization. This is a single center, case–control cohort study derived from a prospective epidemiology investigation on patients with AKI-D admitted to or in-care of the Hospital of Perugia during the period 2007 to 2014. Noncritically ill AKI-D patients were analyzed: inclusion and exclusion criteria were defined to avoid possible bias on the cause of hospital admittance and comorbidities, and a propensity score (PS) matching was performed. Six hundred fifty-four noncritically ill patients were observed and 296 fulfilled inclusion/exclusion criteria. PS matching resulted in 2 groups: 100 NEPHROpts and 100 MEDpts. Characteristics, comorbidities, acute kidney injury causes, risk–injury–failure acute kidney injury criteria, and simplified acute physiology score (SAPS 2) were similar. Mortality was 36%, and a difference was reported between NEPHROpts and MEDpts (20% vs 52%, χ2 = 23.2, P < 0.001). Patients who died differed in age, serum creatinine, blood urea nitrogen/s.Creatinine ratio, dialysis urea reduction rate (URR), SAPS 2 and Charlson score; they presented a higher rate of heart disease, and a larger proportion required noradrenaline/dopamine for shock. After correction for mortality risk factors, multivariate Cox analysis revealed that site of treatment (medical vs nephrology wards
Offringa, M; Gemke, R J; Henny, C P
According to the results of a systematic review of randomized clinical studies administration of human albumin to critically ill patients is associated with excess mortality, compared with withholding albumin or administration of crystalloid fluids. The study appears to be well done. Also, there are various explanatory pathophysiological mechanisms supporting the association. However, a favourable effect of albumin in certain patient groups cannot be excluded. Alternatives to albumin are available in most clinical situations, but unfortunately, they are not completely without drawbacks. The use of albumin has to be limited; it might only be abolished when a better effect of other fluids, such as synthetic solutions, is demonstrated.
Pitrowsky, Melissa; Shinotsuka, Cassia Righy; Soares, Márcio; Salluh, Jorge Ibrain Figueira
Glucose control is a major issue in critical care since landmark publications from the last decade leading to widespread use of strict glucose control in the clinical practice. Subsequent trials showed discordant results that lead to several questions and concerns about benefits and risks of implementing an intensive glucose control protocol. In the midst of all recent controversy, we propose that a new glycemic target -150mg/dl) should be aimed. This target glucose level could offer protection against the deleterious effects of hyperglycemia and at the same time keep patient's safety avoiding hypoglicemia. The article presents a critical review of the current literature on intensive insulin therapy in critically ill patients.
Shanmugasegaram, Shamila; Flett, Gordon L; Madan, Mina; Oh, Paul; Marzolini, Susan; Reitav, Jaan; Hewitt, Paul L; Sturman, Edward D
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.
Amerio, A; Tonna, M; Odone, A; Stubbs, B; Ghaemi, S N
Psychiatric comorbidity is extremely common. One of the most common and difficult to manage comorbid conditions is the co-occurrence of bipolar disorder (BD) and obsessive compulsive disorder (OCD). We updated our recent systematic review searching the electronic databases MEDLINE, Embase, and PsycINFO to investigate course of illness in BD-OCD patients. We identified a total of 13 relevant papers which found that the majority of comorbid OCD cases appeared to be related to mood episodes. OC symptoms in comorbid patients appeared more often during depressive episodes, and comorbid BD and OCD cycled together, with OC symptoms often remitting during manic/hypomanic episodes.
Leysen, Marijke; Nijs, Jo; Meeus, Mira; Paul van Wilgen, C; Struyf, Filip; Vermandel, Alexandra; Kuppens, Kevin; Roussel, Nathalie A
Several questionnaires are available to evaluate illness perceptions in patients, such as the illness perception questionnaire revised (IPQ-R) and the brief version (Brief IPQ). This study aims to systematically review the literature concerning the clinimetric properties of the IPQ-R and the Brief IPQ in patients with musculoskeletal pain. The electronic databases Web of Sciences and PubMed were searched. Studies were included when the clinimetric properties of the IPQ-R or Brief IPQ were assessed in adults with musculoskeletal pain. Methodological quality was determined using the COSMIN checklist. Eight articles were included and evaluated. The methodological quality was good for 3 COSMIN boxes, fair for 11 and poor for 3 boxes. None of the articles obtained an excellent methodological score. The results of this review suggest that the IPQ-R is a reliable questionnaire, except for illness coherence. Internal consistency is good, except for the causal domain. The IPQ-R has good construct validity, but the factor structure is unstable. Hence, the IPQ-R appears to be a useful instrument for assessing illness perceptions, but care must be taken when generalizing the results of adapted versions of the questionnaires. The Brief IPQ shows moderate overall test-retest reliability. No articles examining the validity of the Brief IPQ were found. Further research should therefore focus on the content and criterion validity of the IPQ-R and the clinimetric properties of the Brief IPQ.
Oshima, Taku; Heidegger, Claudia-Paula; Pichard, Claude
This review emphasizes the role of a timely supplemental parenteral nutrition (PN) for critically ill patients. It contradicts the recommendations of current guidelines to avoid the use of PN, as it is associated with risk. Critical illness results in severe metabolic stress. During the early phase, inflammatory cytokines and mediators induce catabolism to meet the increased body energy demands by endogenous sources. This response is not suppressed by exogenous energy administration, and the early use of PN to reach the energy target leads to overfeeding. On the other hand, early and progressive enteral nutrition (EN) is less likely to cause overfeeding because of variable gastrointestinal tolerance, a factor frequently associated with significant energy deficit. Recent studies demonstrate that adequate feeding is beneficial during and after the intensive care unit (ICU) stay. Supplemental PN allows for timely adequate feeding, if sufficient precautions are taken to avoid overfeeding. Indirect calorimetry can precisely define the adequate energy prescription. Our pragmatic approach is to start early EN to progressively test the gut tolerance and add supplemental PN on day 3 or 4 after ICU admission, only if EN does not meet the measured energy target. We believe that supplemental PN plays a pivotal role in the achievement of adequate feeding in critically ill patients with intolerance to EN and does not cause harm if overfeeding is avoided by careful prescription, ideally based on energy expenditure measured by indirect calorimetry.
Li, Yue; Glance, Laurent G; Cai, Xueya; Mukamel, Dana B
Context Patients with mental disorders show higher burden of coronary heart disease, and may face special safety issues during in-hospital cardiac care. Objectives To compare the postoperative complication rate between patients with and without mental disorders undergoing isolated coronary artery bypass graft (CABG) surgery. Design, Setting, and Patients Retrospective analyses of New York state hospital claims between 1997 and 2004 (N=135,701). Complications were defined using the Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ PSI). Principal Findings Mental disorders were significantly associated with higher anesthesia complications (adjusted odds ratio [AOR]=6.44, p<.001), decubitus ulcer (AOR=1.42, p=.006), postoperative hip fracture (AOR=3.29, p<.001), and overall complication rate representing nine PSIs (AOR=1.27, p<.001). Conclusions Mentally ill patients undergoing CABG surgery are more likely to experience potentially preventable complications and injuries. The mechanism underlying this observation warrants further study. PMID:18665856
Bridges, K W; Goldberg, D P
The prevalence of psychiatric morbidity in inpatients with neurological disorders and the extent to which it is detected by neurologists were measured by using a two stage model of psychiatric assessment and from information recorded in the patients' medical notes. The prevalence of psychiatric morbidity was estimated as 39%, of which 72% was unrecognised by the neurologists. Only a minority of patients with an uncertain physical diagnosis had a psychiatric illness, showing the error in assuming that a patient's physical symptoms arise from a psychological disturbance if an organic aetiology cannot be determined. When the patients were interviewed on their discharge from hospital they were divided on whether they had wished to discuss their mood with neurologists while they were in hospital. The reasons that they gave suggested that interactions between patients and doctors and the lack of ward facilities for private consultations with doctors are important determinants of hidden psychiatric morbidity in medical inpatients. PMID:6434026
Ventriglio, Antonio; Borelli, Albacenzina; Bellomo, Antonello; Lepore, Alberto
PurposeThis epidemiologic study tested an hypothesized association between the year of birth of persons with major mental illnesses and solar activity over the past century. MethodsWe collected data on diagnoses and birthdates of psychiatric patients born between 1926 and 1975 (N = 1954) in south Italy for comparison to yearly solar activity as registered by the International Observatories. ResultsWe found a strong inverse correlation between high solar activity (HSA) and incidence of schizophrenia and bipolar disorder in a 20-year period whereas the incidence of non-affective/non-psychotic disorders was moderately associated with HSA in the same period. ConclusionsInterpretation of the observed correlations between HSA during years of birth and the incidence of mental illnesses remains unclear, but the findings encourage further study.
Walkey, Allan J.
Rationale: Open lung biopsy may be performed to guide therapy in mechanically ventilated patients with diagnostic uncertainty regarding etiology of pulmonary infiltrates. Current evidence for open lung biopsy in mechanically ventilated patients comes from single-center case series. Objectives: We performed a metaanalysis of case series to determine diagnoses, complications, and changes in therapy after lung biopsy in critically ill patients requiring mechanical ventilation. Methods: We searched Medline for case series of lung biopsies in critically ill patients requiring mechanical ventilation. We pooled results of individual case series using random effects metaanalysis models to obtain summary proportions. Measurements and Main Results: We identified 14 case series including a total of 512 mechanically ventilated patients with 530 histopathological diagnoses. The most common diagnoses were “fibrosis/pneumonitis” (n = 155, 25%; 95% confidence interval [CI], 14–37%) and infection (n = 113, 20%; 95% CI, 15–27%). Viruses were the most commonly identified infectious etiology identified on open lung biopsy, representing 50% of potential pathogens. Diffuse alveolar damage was present in a minority of specimens (n = 100, 16%; 95% CI, 8–25%). Therapeutic changes after lung biopsy occurred in 399 patients (78%; 95% CI, 64–81%). Procedure-related complications occurred in 29% of patients (95% CI, 25–33%), most commonly persistent air leak. Mortality among mechanically ventilated patients after diagnostic open lung biopsy was 54%. Conclusions: Among mechanically ventilated patients with respiratory failure of unclear etiology, lung biopsy yielded a wide range of diagnoses and was associated with a change in therapy in most patients. PMID:26065712
Seymour, Christopher W.; Alotaik, Osama; Wallace, David J.; Elhabashy, Ahmed E.; Chhatwal, Jagpreet; Rea, Thomas D; Angus, Derek C.; Nichol, Graham; Kahn, Jeremy M.
Objective Regionalization may improve critical care delivery, yet stakeholders cite concerns about its feasibility. We sought to determine the operational effects of prehospital regionalization of non-trauma, non-arrest critical illness. Design Discrete event simulation study Patients and setting All 2006 hospital discharge data from King County, Washington, linked to all adult, eligible patients transported by county EMS agencies. Methods We simulated active triage of high-risk patients to designated referral centers using a validated prehospital risk score; we studied three regionalization scenarios: (1) up triage, (2) up & down triage, (3) up & down triage after reducing intensive care unit (ICU) beds by 25%. We determined the effect on patient routing, ICU occupancy at referral and non-referral hospitals, and EMS transport times. Measurements and Main Results 119,117 patients were hospitalized at 11 non-referral centers and 76,817 patients were hospitalized at three referral centers. Among 20,835 EMS patients, 7,817 (43%) patients were eligible for up triage and 10,242 (57%) patients were eligible for down triage. At baseline mean daily ICU bed occupancy was 61% referral and 47% at non-referral hospitals. Up-triage increased referral ICU occupancy to 68%, up and down triage to 64%, and up and down triage with bed reduction to 74%. Mean daily non-referral ICU occupancy did not exceed 60%. Total EMS transport time increased by less than 3% with up and down triage. Conclusions Regionalization based on prehospital triage of the critically ill can allocate high-risk patients to referral hospitals without adversely affecting ICU occupancy or prehospital travel time. PMID:26102251
Taubert, Max; Maier, Barbara; Frechen, Sebastian; Scharf, Christina; Holdt, Lesca-Miriam; Frey, Lorenz; Vogeser, Michael; Fuhr, Uwe; Zander, Johannes
Adequate linezolid blood concentrations have been shown to be associated with an improved clinical outcome. Our goal was to assess new predictors of inadequate linezolid concentrations often observed in critically ill patients. Fifty-two critically ill patients with severe infections receiving standard dosing of linezolid participated in this prospective observational study. Serum samples (median, 32 per patient) were taken on four consecutive days, and total linezolid concentrations were quantified. Covariates influencing linezolid pharmacokinetics were identified by multivariate analysis and a population pharmacokinetic model. Target attainment (area under the concentration-time curve over 12 h [AUC12]/MIC ratio of >50; MIC = 2 mg/liter) was calculated for both the study patients and a simulated independent patient group (n = 67,000). Target attainment was observed for only 36% of the population on both days 1 and 4. Independent covariates related to significant decreases of linezolid concentrations included higher weight, creatinine clearance rates, and fibrinogen and antithrombin concentrations, lower concentrations of lactate, and the presence of acute respiratory distress syndrome (ARDS). Linezolid clearance was increased in ARDS patients (by 82%) and in patients with elevated fibrinogen or decreased lactate concentrations. In simulated patients, most covariates, including fibrinogen and lactate concentrations and weight, showed quantitatively minor effects on target attainment (difference of ≤9% between the first and fourth quartiles of the respective parameters). In contrast, the presence of ARDS had the strongest influence, with only ≤6% of simulated patients reaching this target. In conclusion, the presence of ARDS was identified as a new and strong predictor of insufficient linezolid concentrations, which might cause treatment failure. Insufficient concentrations might also be a major problem in patients with combined alterations of other covariate
Campassi, María Luz; Gonzalez, María Cecilia; Masevicius, Fabio Daniel; Vazquez, Alejandro Risso; Moseinco, Miriam; Navarro, Noelia Cintia; Previgliano, Luciana; Rubatto, Nahuel Paolo; Benites, Martín Hernán; Estenssoro, Elisa; Dubin, Arnaldo
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. PMID:24770684
Sharma, Ankur; Singh, Preet Mohinder; Trikha, Anjan; Rewari, Vimi; Chandralekha
Sedation is routinely used in intensive care units. However due to absence of objective scoring systems like Bispectral Index and entropy our ability to regulate the degree of sedation is limited. This deficiency is further highlighted by the fact that agitation scores used in intensive care units (ICU) have no role in paralyzed patients. The present study compares entropy as a sedation scoring modality with Richmond Agitation Sedation Scale (RASS) in mechanically ventilated, critically ill patients in an ICU. Twenty-seven, mechanically ventilated, critically ill patients of either sex, 16-65 years of age, were studied over a period of 24 h. They received a standard sedation regimen consisting of a bolus dose of propofol 0.5 mg/kg and fentanyl 1 lg/kg followed by infusions of propofol and fentanyl ranging from 1.5 to 5 mg/kg/h and 0.5 to 2.0 lg/kg/h, respectively. Clinically relevant values of RASS for optimal ICU sedation (between 0 and -3) in non-paralyzed patients were compared to corresponding entropy values, to find if any significant correlation exists between the two. These entropy measurements were obtained using the Datex-Ohmeda-M-EntropyTM module. This module is presently not approved by Food and Drug Administration (FDA) for monitoring sedation in ICU. A total of 527 readings were obtained. There was a statistically significant correlation between the state entropy (SE) and RASS [Spearman's rho/rs = 0.334, p\\0.0001]; response entropy (RE) and RASS [Spearman's rho/rs = 0.341, p\\0.0001]). For adequate sedation as judged by a RASS value of 0 to -3, the mean SE was 57.86 ± 16.50 and RE was 67.75 ± 15.65. The present study illustrates that entropy correlates with RASS (between scores 0 and -3) when assessing the level of sedation in mechanically ventilated critically ill patients.
Li, Wen-Gang; Chen, Wei-Wei; Li, Lei; Ji, Dong; Ji, Ying-Jie; Li, Chen; Gao, Xu-Dong; Wang, Li-Fu; Zhao, Min; Duan, Xue-Zhang; Duan, Hui-Juan
During the 2014 Ebola virus disease (EVD) outbreak, less than half of EVD-suspected cases were laboratory tested as Ebola virus (EBOV)-negative, but disease identity remained unknown. In this study we investigated the etiology of EVD-like illnesses in EBOV-negative cases. From November 13, 2014 to March 16, 2015, EVD-suspected patients were admitted to Jui Government Hospital and assessed for EBOV infection by real-time PCR. Of 278 EBOV negative patients, 223 (80.21%), 142 (51.08%), 123 (44.24%), 114 (41.01%), 59 (21.22%), 35 (12.59%), and 12 (4.32%) reported fever, headache, joint pain, fatigue, nausea/vomiting, diarrhea, hemorrhage, respectively. Furthermore, 121 (43.52%), 44 (15.83%), 36 (12.95%), 33 (11.87%), 23 (8.27%), 10 (3.60%) patients were diagnosed as infection with malaria, HIV, Lassa fever, tuberculosis, yellow fever, and pneumonia, respectively. No significant differences in clinical features and symptoms were found between non-EVD and EVD patients. To the best of our knowledge, the present study is the first to explore the etiology of EVD-like illnesses in uninfected patients in Sierra Leone, highlighting the importance of accurate diagnosis to EVD confirmation.
Li, Lei; Ji, Dong; Ji, Ying-Jie; Li, Chen; Gao, Xu-Dong; Wang, Li-Fu; Zhao, Min; Duan, Xue-Zhang; Duan, Hui-Juan
During the 2014 Ebola virus disease (EVD) outbreak, less than half of EVD-suspected cases were laboratory tested as Ebola virus (EBOV)-negative, but disease identity remained unknown. In this study we investigated the etiology of EVD-like illnesses in EBOV-negative cases. From November 13, 2014 to March 16, 2015, EVD-suspected patients were admitted to Jui Government Hospital and assessed for EBOV infection by real-time PCR. Of 278 EBOV negative patients, 223 (80.21%), 142 (51.08%), 123 (44.24%), 114 (41.01%), 59 (21.22%), 35 (12.59%), and 12 (4.32%) reported fever, headache, joint pain, fatigue, nausea/vomiting, diarrhea, hemorrhage, respectively. Furthermore, 121 (43.52%), 44 (15.83%), 36 (12.95%), 33 (11.87%), 23 (8.27%), 10 (3.60%) patients were diagnosed as infection with malaria, HIV, Lassa fever, tuberculosis, yellow fever, and pneumonia, respectively. No significant differences in clinical features and symptoms were found between non-EVD and EVD patients. To the best of our knowledge, the present study is the first to explore the etiology of EVD-like illnesses in uninfected patients in Sierra Leone, highlighting the importance of accurate diagnosis to EVD confirmation. PMID:27058894
Tsai, Danny; Stewart, Penelope; Goud, Rajendra; Gourley, Stephen; Hewagama, Saliya; Krishnaswamy, Sushena; Wallis, Steven C; Lipman, Jeffrey; Roberts, Jason A
There are no available pharmacokinetic data to guide piperacillin dosing in critically ill Australian Indigenous patients despite numerous reported physiological differences. This study aimed to describe the population pharmacokinetics of piperacillin in critically ill Australian Indigenous patients with severe sepsis. A population pharmacokinetic study of Indigenous patients with severe sepsis was conducted in a remote hospital intensive care unit. Plasma samples were collected over two dosing intervals and assayed by validated chromatography. Population pharmacokinetic modeling was conducted using Pmetrics. Nine patients were recruited, and a two-compartment model adequately described the data. The piperacillin clearance (CL), volume of distribution of the central compartment (Vc), and distribution rate constants from the central to the peripheral compartment and from the peripheral to the central compartment were 5.6 ± 3.2 liters/h, 14.5 ± 6.6 liters, 1.5 ± 0.4 h(-1), and 1.8 ± 0.9 h(-1), respectively, where CL and Vc were found to be described by creatinine clearance (CLCR) and total body weight, respectively. In this patient population, piperacillin demonstrated high interindividual pharmacokinetic variability. CLCR was found to be the most important determinant of piperacillin pharmacokinetics.
Cardoso, Yolanda; Oliveira, Erika; Vasconcelos, Jocelyne; Cohen, Adam L; Francisco, Moises
There are no published data on influenza trends in Angola, where pneumonia is a leading cause of death among young children. This study aims to describe the seasonal trends, types, and subtypes of influenza virus recovered from patients with respiratory illness who were admitted to the major children's hospital in Angola from May 2009 through April 2011. Nasal and oral swabs were collected from patients seen in the outpatient clinic with influenza-like illness (ILI) or hospitalized with severe acute respiratory illness (SARI) and tested for influenza virus by polymerase chain reaction assays. Of 691 samples collected, 334 (48%) were from case patients with ILI, and 357 (52%) were from case patients with SARI. Most (86%) of these children were <5 years of age. Thirty-nine samples (47% SARI, 53% outpatient) tested positive for influenza virus, including 2009 pandemic influenza A virus subtype H1N1 (A[H1N1]pdm09; n = 9), influenza A virus subtype H3, likely H3N2 (n = 12), and influenza B virus (n = 18). The proportion of specimens positive for influenza virus was 5% for ILI cases and 6% for SARI cases. After the peak of A(H1N1)pdm09 infection from May through September of 2009, additional peaks of ILI and SARI were seen, especially during February-April 2010. Influenza virus causes a small but preventable number of pneumonia cases among children in Angola.
Linna, Miika; Rönkkö, Ilona; Kröger, Virpi
Background Electronic patient portals may enhance effective interaction between the patient and the health care provider. To grasp the full potential of patient portals, health care providers need more knowledge on which patient groups prefer electronic services and how patients should be served through this channel. Objective The objective of this study was to assess how chronically ill patients’ state of health, comorbidities, and previous care are associated with their adoption and use of a patient portal. Methods A total of 222 chronically ill patients, who were offered access to a patient portal with their health records and secure messaging with care professionals, were included in the study. Differences in the characteristics of non-users, viewers, and interactive users of the patient portal were analyzed before access to the portal. Patients’ age, gender, diagnoses, levels of the relevant physiological measurements, health care contacts, and received physiological measurements were collected from the care provider’s electronic health record. In addition, patient-reported health and patient activation were assessed by a survey. Results Despite the broad range of measures used to indicate the patients’ state of health, the portal user groups differed only in their recorded diagnosis for hypertension, which was most common in the non-user group. However, there were significant differences in the amount of care received during the year before access to the portal. The non-user group had more nurse visits and more measurements of relevant physiological outcomes than viewers and interactive users. They also had fewer referrals to specialized care during the year before access to the portal than the two other groups. The viewers and the interactive users differed from each other significantly in the number of nurse calls received, the interactive users having more calls than the viewers. No significant differences in age, gender, or patient activation were
Adebowale, T O; Ogunlesi, A O
A survey of 70 insightful clinically stable out-patients with functional psychotic disorders and 70 accompanying relatives was carried out. They were interviewed about their beliefs concerning the cause of the illness, and their awareness of other possible aetiological factors. Relevant sociodemographic and clinical information were also elicited. Twelve (17.1%) patients and relatives, respectively, gave "medical" causal explanations; 16 (22.9%) patients and 13 (18.6%) relatives gave "psychosocial" causal explanations; 27 (38.6%) patients and 38 (54.3%) relatives were "uncertain" about the cause of their/relatives' illness (X2 = 5.08; df = 3: P = 0.16). Relatives reported a greater relevance of "heredity" (X2 = 11.58; P = 0.0006) and "supernatural" factors (X2 = 4.72: P = 0.029) as other possible causal factors, than patients. Patients with previous psychiatric hospitalisation reported higher prevalence of "psychosocial" and "supernatural" causal beliefs than those without (X2 = 9.15; P = 0.027). Also, patients with "medical" causal belief reported better treatment compliance than those with other beliefs (P = 0.031). Among relatives, "psychosocial" causal belief in comparison with other beliefs was associated with a longer duration of treatment in the hospital (h = 8.29; P = 0.04). For patients, knowledge about possible causal role of "heredity was significantly more prevalent among male than female patients (X2 = 6.55; P = 0.01) and admission of possible "supernatural" causation was associated with education below the secondary level (X2 = 6.68; P = 0.008). For relatives, knowledge about possible causal role of brain dysfunction was associated with longer duration of treatment (u = 3.93; P = 0.047), and knowledge of possible causal role of "psychosocial" stress was associated with urban place of residence rather than rural (X2 = 10.52; P = 0.0012). For both patients and relatives, the most acceptable aetiological proposition was the "supernatural" while the least
Stockton, Winifred M.; Padilla-Tolentino, Eimeira
OBJECTIVES Children have decreased levels of antithrombin III (AT III) compared to adults. These levels may be further decreased during acute illness. Administration of exogenous AT III can increase anticoagulant efficacy. The objective of this study was to evaluate AT III doses rounded to available vial sizes compared to partial vial doses in critically ill pediatric patients, including patients receiving extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). METHOD This retrospective review evaluated pediatric patients 0–18 years of age admitted to a 24-bed medical/surgical pediatric intensive care unit between June 1, 2012, and December 31, 2014, who received plasma-derived AT III. Patients received unfractionated heparin, low-molecular-weight heparin, or no anticoagulation. This review included patients who received ECMO and CRRT. RESULTS Eighty doses of AT III were administered to 24 patients (38 full vial size doses and 42 partial vial size doses). The AT III level following dose administration was ≥80% for 26 full vial doses (70%) and 16 partial vial doses (41%; p = 0.010). For patients who received multiple doses of AT III, the median time between doses was 45 hours following full vial doses, and 23 hours following partial vial doses (p = 0.011). Seven patients (29%) had documentation of new or increased bleeding. The median waste prevented from rounding doses to full vial sizes was 363 units. CONCLUSIONS After receiving AT III doses rounded to full vial sizes, patients were more likely to have a therapeutic AT III level and a longer interval between administrations. Rounding AT III doses to full vial sizes reduces waste and can result in cost savings.
Anderson, Brian J.; Mangalmurti, Nilam S.; Nguyen, Tam D.; Holena, Daniel N.; Wu, Qufei; Nguyen, Ethan T.; Reilly, Muredach P.; Lanken, Paul N.; Christie, Jason D.; Meyer, Nuala J.; Shashaty, Michael G.S.
Background and objective ABO blood types are determined by antigen modifications on glycoproteins and glycolipids and associated with altered plasma levels of inflammatory and endothelial injury markers implicated in AKI pathogenesis. We sought to determine the association of ABO blood types with AKI risk in critically ill patients with trauma or sepsis. Design, setting, participants, & measurements We conducted two prospective cohort studies at an urban, academic, level I trauma center and tertiary referral center; 497 patients with trauma admitted to the surgical intensive care unit between 2005 and 2010 with an injury severity score >15 and 759 patients with severe sepsis admitted to the medical intensive care unit between 2008 and 2013 were followed for 6 days for the development of incident AKI. AKI was defined by Acute Kidney Injury Network creatinine and dialysis criteria. Results Of 497 patients with trauma, 134 developed AKI (27%). In multivariable analysis, blood type A was associated with higher AKI risk relative to type O among patients of European descent (n=229; adjusted risk, 0.28 versus 0.14; risk difference, 0.14; 95% confidence interval, 0.03 to 0.24; P=0.02). Of 759 patients with sepsis, AKI developed in 326 (43%). Blood type A again conferred higher AKI risk relative to type O among patients of European descent (n=437; adjusted risk, 0.53 versus 0.40; risk difference, 0.14; 95% confidence interval, 0.04 to 0.23; P=0.01). Findings were similar when analysis was restricted to those patients who did not develop acute respiratory distress syndrome or were not transfused. We did not detect a significant association between blood type and AKI risk among individuals of African descent in either cohort. Conclusions Blood type A is independently associated with AKI risk in critically ill patients with trauma or severe sepsis of European descent, suggesting a role for ABO glycans in AKI susceptibility. PMID:26342043
Córdova-Sánchez, Bertha M; Herrera-Gómez, Ángel; Ñamendys-Silva, Silvio A
Acute kidney injury (AKI) is common in critically ill patients and is associated with higher mortality. Cancer patients are at an increased risk of AKI. Our objective was to determine the incidence of AKI in our critically ill cancer patients, using the criteria of serum creatinine (SCr) and urine output (UO) proposed by the Kidney Disease: Improving Global Outcomes (KDIGO). Methods. We performed a retrospective cohort analysis of a prospectively collected database at the intensive care unit (ICU) of the Instituto Nacional de Cancerología from January 2013 to March 2015. Results. We classified AKI according to the KDIGO definition. We included 389 patients; using the SCr criterion, 192 (49.4%) had AKI; using the UO criterion, 219 (56.3%) had AKI. Using both criteria, we diagnosed AKI in 69.4% of patients. All stages were independently associated with six-month mortality; stage 1 HR was 2.04 (95% CI 1.14-3.68, p = 0.017), stage 2 HR was 2.73 (95% CI 1.53-4.88, p = 0.001), and stage 3 HR was 4.5 (95% CI 2.25-8.02, p < 0.001). Patients who fulfilled both criteria had a higher mortality compared with patients who fulfilled just one criterion (HR 3.56, 95% CI 2.03-6.24, p < 0.001). Conclusion. We diagnosed AKI in 69.4% of patients. All AKI stages were associated with higher risk of death at six months, even for patients who fulfilled just one AKI criterion.
Kaldjian, L; Jekel, J; Bernene, J; Rosenthal, G; Vaughan-Sarrazin, M; Duffy, T
Objective: To describe the frequency of support for terminal sedation among internists, determine whether support for terminal sedation is accompanied by support for physician assisted suicide (PAS), and explore characteristics of internists who support terminal sedation but not assisted suicide. Design: A statewide, anonymous postal survey. Setting: Connecticut, USA. Participants: 677 Connecticut members of the American College of Physicians. Measurements: Attitudes toward terminal sedation and assisted suicide; experience providing primary care to terminally ill patients; demographic and religious characteristics. Results: 78% of respondents believed that if a terminally ill patient has intractable pain despite aggressive analgesia, it is ethically appropriate to provide terminal sedation (diminish consciousness to halt the experience of pain). Of those who favoured terminal sedation, 38% also agreed that PAS is ethically appropriate in some circumstances. Along a three point spectrum of aggressiveness in end of life care, the plurality of respondents (47%) were in the middle, agreeing with terminal sedation but not with PAS. Compared with respondents who were less aggressive or more aggressive, physicians in this middle group were more likely to report having more experience providing primary care to terminally ill patients (p = 0.02) and attending religious services more frequently (p<0.001). Conclusions: Support for terminal sedation was widespread in this population of physicians, and most who agreed with terminal sedation did not support PAS. Most internists who support aggressive palliation appear likely to draw an ethical line between terminal sedation and assisted suicide. PMID:15467087
Coleman, Albert M E
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.
unit (ICU) patients re-mains high despite numerous clinical and technologic advances supporting the care of critically ill patients. Sepsis continues...From 83 subjects in both studies, 13 met the criteria for inclusion. The subjects varied in their mechanisms of injury/ illness, indication for...Characteristics of Study Subjects Receiving Piperacillin/Tazobactam Included in This Study Subject Age, y Sex Mechanism Indication Dose* eGFR** SOFA† APACHE II
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
Stuck, Anna K; Spirk, David; Schaudt, Jil; Kucher, Nils
Although the use of thromboprophylaxis is recommended for acutely ill medical patients at increased risk of venous thromboembolism (VTE), it remains unclear which risk assessment model (RAM) should be routinely used to identify at-risk patients requiring thromboprophylaxis. We therefore aimed to describe existing RAMs, and to compare these tools in terms of validity and applicability for clinical decision-making. We performed a comprehensive systematic search in MEDLINE from the date of initiation until May 2016 for studies in acutely ill medical patients investigating validity of RAMs for VTE. Two reviewers independently screened the title, abstract, and full text, and evaluated the characteristics of studies, and the composition, evidence of validation, and results on validity of the RAMs. We included 11 studies assessing eight RAMs: 4-Element RAM, Caprini RAM, a full logistic model, Geneva risk score, IMPROVE-RAM, Kucher Model, a "Multivariable Model", and Padua Prediction Score. The 4-Element RAM, IMPROVE-RAM, Multivariable Model, and full logistic model had derivation by identifying factors with predictive power. The other four RAMs were empirically generated based on consensus guidelines, published data, and clinical expertise. The Kucher Model, the Padua Prediction Score, the Geneva Risk Score and the IMPROVE-RAM underwent multicenter external validation. The Kucher Model, the Padua Prediction Score, and the Geneva Risk Score improved rates of thromboprophylaxis or clinical outcomes. In conclusion, existing RAMs to evaluate the need of thromboprophylaxis in acutely ill medical patients are difficult to compare and none fulfills the criteria of an ideal RAM. Nevertheless, the adequacy of thromboprophylaxis may be improved by implementing one of the validated RAMs.
Zander, Johannes; Döbbeler, Gundula; Nagel, Dorothea; Scharf, Christina; Huseyn-Zada, Mikayil; Jung, Jette; Frey, Lorenz; Vogeser, Michael; Zoller, Michael
Therapeutic drug monitoring for critically ill patients receiving piperacillin/tazobactam is described as a useful tool. However, the minimum inhibitory concentration of piperacillin depends on a sufficiently high concentration of tazobactam in case of β-lactamase-producing strains. Therefore, the relationship between piperacillin and tazobactam concentrations was assessed in a heterogeneous group of critically ill patients. Sixty patients with severe infections receiving 4.5 g of piperacillin/tazobactam 2-3 times daily by intermittent infusion were included in this prospective observational study (NCT01793012). Over 4 days, multiple serum samples were obtained to determine the total piperacillin and tazobactam concentrations. The target ranges were defined as trough levels >16 mg/L (>22.5 mg/L) and >4 mg/L (>5.7 mg/L) for the calculated unbound concentrations (measured total concentrations) of piperacillin and tazobactam, respectively. Despite a high correlation coefficient (r = 0.93) comparing piperacillin and tazobactam trough levels, the piperacillin/tazobactam quotients varied between ca. 1 and 10. From linear regression analysis of piperacillin versus tazobactam values, it follows that a piperacillin trough level of 22.5 mg/L might be associated with tazobactam trough levels ranging from 1.5 mg/L to 10.1 mg/L. A 70 mg/L threshold for total piperacillin trough levels would be necessary to ensure that tazobactam concentrations are >5.7 mg/L. Because of the observed variability of piperacillin/tazobactam quotients, defining the total piperacillin target range ≥70 mg/L might be useful to ensure that tazobactam concentrations do not fall below 5.7 mg/L. Further studies are necessary to confirm that the used therapeutic ranges are associated with optimal outcomes in critically ill patients.
Knight, Patrick H; Maheshwari, Neelabh; Hussain, Jafar; Scholl, Michael; Hughes, Michael; Papadimos, Thomas J; Guo, Weidun Alan; Cipolla, James; Stawicki, Stanislaw P; Latchana, Nicholas
Intrahospital transportation of critically ill patients is associated with significant complications. In order to reduce overall risk to the patient, such transports should well organized, efficient, and accompanied by the proper monitoring, equipment, and personnel. Protocols and guidelines for patient transfers should be utilized universally across all healthcare facilities. Care delivered during transport and at the site of diagnostic testing or procedure should be equivalent to the level of care provided in the originating environment. Here we review the most common problems encountered during transport in the hospital setting, including various associated adverse outcomes. Our objective is to make medical practitioners, nurses, and ancillary health care personnel more aware of the potential for various complications that may occur during patient movement from the intensive care unit to other locations within a healthcare facility, focusing on risk reduction and preventive strategies. PMID:26807395
Díaz, Magda C; Ospina-Tascón, Gustavo A; Salazar C, Blanca C
Respiratory muscle dysfunction, particularly of the diaphragm, may play a key role in the pathophysiological mechanisms that lead to difficulty in weaning patients from mechanical ventilation. The limited mobility of critically ill patients, and of the diaphragm in particular when prolonged mechanical ventilation support is required, promotes the early onset of respiratory muscle dysfunction, but this can also be caused or exacerbated by other factors that are common in these patients, such as sepsis, malnutrition, advanced age, duration and type of ventilation, and use of certain medications, such as steroids and neuromuscular blocking agents. In this review we will study in depth this multicausal origin, in which a common mechanism is altered protein metabolism, according to the findings reported in various models. The understanding of this multicausality produced by the same pathophysiological mechanism could facilitate the management and monitoring of patients undergoing mechanical ventilation.
Anders, Robert L; Olson, Tom; Bader, Julia
The relationship between quality of care and patient satisfaction has been documented. The specific research aim related to this study is to determine if differences exist among Caucasians, Asians, and Pacific Islanders who are hospitalized for an acute mental illness with regard to their perceived satisfaction with the care. The results of the overall study have been reported elsewhere. The sample was composed of 138 patients, of whom 34.7% were Caucasian, 31.2% Pacific Islanders, and 34.8% Asians. Within 24 hours of discharge, patients completed the Perceptions of Care instrument. Caucasians were over-represented in our sample in comparison to their percentage in the general population of Hawaii. These patients were significantly more satisfied (p = .04) with their care than the other ethnic groups. No single variable was found to specifically indicate why they were more satisfied than Pacific Islanders and Asians.
Lester, Helen; Tritter, Jonathan Q; Sorohan, Helen
Objective To explore the experience of providing and receiving primary care from the perspectives of primary care health professionals and patients with serious mental illness respectively. Design Qualitative study consisting of six patient groups, six health professional groups, and six combined focus groups. Setting Six primary care trusts in the West Midlands. Participants Forty five patients with serious mental illness, 39 general practitioners (GPs), and eight practice nurses. Results Most health professionals felt that the care of people with serious mental illness was too specialised for primary care. However, most patients viewed primary care as the cornerstone of their health care and preferred to consult their own GP, who listened and was willing to learn, rather than be referred to a different GP with specific mental health knowledge. Swift access was important to patients, with barriers created by the effects of the illness and the noisy or crowded waiting area. Some patients described how they exaggerated symptoms (“acted up”) to negotiate an urgent appointment, a strategy that was also employed by some GPs to facilitate admission to secondary care. Most participants felt that structured reviews of care had value. However, whereas health professionals perceived serious mental illness as a lifelong condition, patients emphasised the importance of optimism in treatment and hope for recovery. Conclusions Primary care is of central importance to people with serious mental illness. The challenge for health professionals and patients is to create a system in which patients can see a health professional when they want to without needing to exaggerate their symptoms. The importance that patients attach to optimism in treatment, continuity of care, and listening skills compared with specific mental health knowledge should encourage health professionals in primary care to play a greater role in the care of patients with serious mental illness. PMID:15843427
Markianos, Manolis; Panas, Marios; Kalfakis, Nikos; Vassilopoulos, Dimitrios
Huntington's disease (HD) is a neurodegenerative disorder characterized by motor, cognitive, and psychiatric symptoms and by a progressive loss among other, of dopaminergic receptors in striatum, cortex, and hypothalamus. Central dopaminergic activity has been implicated in the regulation of sex hormones. Several features of testosterone deficiency, such as reduced muscle mass, depressive mood, and cognitive impairment, are often present in HD patients, but data on their testosterone levels are lacking. We assessed plasma levels of testosterone, LH, and FSH in 42 male patients with HD, confirmed by molecular genetic analysis, and searched for differences from age-matched healthy male subjects and for relations to CAG repeat number, age, age range, 26 to 76 (mean, 50.7 +/- 12.3) years; duration of illness range, 1 to 23 (mean, 6.7 +/- 6.3) years; and CAG repeat numbers from 40 to 65 (45.1 +/- 3.8). Disease symptomatology was assessed using the Unified Huntington's Disease Rating Scale. Testosterone and LH levels of the patients were significantly lower compared to the levels of 44 age-matched (mean age, 48.9 +/- 13.0, range, 26-76 years) healthy men. Severity of illness was negatively related to plasma testosterone levels. Further, low testosterone levels were associated with dementia but not with depression or psychotic features. Clinical studies with selected HD patients are needed to evaluate possible beneficial effects of androgen substitution therapy on cognitive functions, depression, muscle mass and strength, general well-being, and, eventually, neuroprotective effects.
Kreiner, Meta J.; Hunt, Linda M.
Preventive health care has become prominent in clinical medicine in the United States, emphasizing risk assessment and control, rather than addressing the signs and symptoms of pathology. Current clinical guidelines, reinforced by evidence-based decision aids and quality of care assessment, encourage clinicians to focus on maintaining rigid test thresholds which are based on population norms. While achieving these goals may benefit the total population, this may be of no benefit or even harmful to individual patients. In order to explore how this phenomenon is manifest in clinical care, and consider some factors that promote and sustain this trend, we analyze observations of over 100 clinical consultations, and open-ended interviews with 58 primary care clinicians and 70 of their patients. Both clinicians and patients equated at-risk states with illness, and viewed the associated interventions not as prevention, but as treatment. This conflation of risk and disease redefines clinical success such that reducing the threat of anticipated future illness requires acceptance of aggressive treatments and any associated adverse effects in the present. While the expanding emphasis on preventive medicine may improve the health profile of the total population, the implications of these innovations for the well-being of individual patients merits careful reconsideration. PMID:24372285
Jochems, Eline C; van Dam, Arno; Duivenvoorden, Hugo J; Scheffer, Sylvia C M; van der Feltz-Cornelis, Christina M; Mulder, Niels L
The present study assessed motivation for engaging in treatment as rated by clinicians (n = 57) and patients with severe mental illness (SMI, n = 294) using measures based on three different motivation theories. Questionnaires were derived from self-determination theory, the transtheoretical model and the integral model of treatment motivation. It was investigated to which extent clinicians of patients with SMI were able to estimate their patient's perspective on motivation for engaging in treatment, to which extent they agreed on the patient's motivation and which factors were associated with estimation and agreement on treatment motivation. It was found that clinicians were poorly to moderately capable of estimating their patient's type of motivation and readiness for change. Further, agreement on the level of motivation between patients and clinicians was moderate. These findings were consistent across diagnostic groups (psychotic and personality disorders). A higher quality therapeutic relationship was generally associated with higher clinician-rated motivation. The patient's ethnicity and socially desirable responding were factors that differentiated between scales of different motivation theories. It is concluded that patients with SMI and their clinicians have different perceptions on the patient's motivation for engaging in psychiatric treatment, regardless of the theoretical framework that is used to measure motivation. The findings imply that a negotiated approach is needed where both perceptions of clinicians and patients on motivation for treatment are considered to ensure effective mental health interventions. Copyright © 2015 John Wiley & Sons, Ltd.
Pandya, Urmil; Polite, Nathan; Wood, Teresa; Lieber, Michael
Dysfunction in the hypothalamopituitary adrenal axis is thought to exist; however, there continues to be controversy about what level of serum cortisol corresponds to adrenal insufficiency. Few studies have focused on the significance of serum random cortisol in the critically ill trauma patient. Trauma patients with total serum random cortisol levels drawn in the intensive care unit within the first seven days of hospitalization were retrospectively reviewed. The primary outcome measured was in-hospital mortality. Two hundred forty-two patients were analyzed. Nonsurvivors had significantly higher mean cortisol levels than survivors (28.7 ± 15.80 μg/dL vs 22.9 ± 12.35 μg/dL, P = 0.01). Patients with cortisol 30 μg/dL or greater were more likely to die with odds ratio of 2.7 (95% confidence interval [CI], 1.5 to 5). The odds ratio increased to 4.0 and 3.8 (95% CI, 1.4 to 11.4 and 1.3 to 10.9) when cortisol was drawn on hospital Day 2 and Days 3 through 7, respectively. Among nonsurvivors, patients with an injury severity score less than 25 had significantly higher cortisol levels than patients with an Injury Severity Score 25 or higher (35.3 ± 19.21 μg/dL vs 25.7 ± 13.21 μg/dL, P = 0.009). Patients with massive transfusion, traumatic brain injury, spinal cord injury, or solid organ injury did not have significantly different cortisol levels. The covariate-adjusted area under the receiver operating characteristic curve indicated that cortisol level has a 77 per cent accuracy in differentiating survivors from nonsurvivors. Higher cortisol levels were predictive of mortality in critically ill trauma patients. Whether serum cortisol level is a marker that can be modified remains an area of interest for future study.
Georgopoulos, Dimitris; Matamis, Dimitris; Routsi, Christina; Michalopoulos, Argiris; Maggina, Nina; Dimopoulos, George; Zakynthinos, Epaminondas; Nakos, George; Thomopoulos, George; Mandragos, Kostas; Maniatis, Alice
Introduction The aim of this study was to assess the efficacy of two dosing schedules of recombinant human erythropoietin (rHuEPO) in increasing haematocrit (Hct) and haemoglobin (Hb) and reducing exposure to allogeneic red blood cell (RBC) transfusion in critically ill patients. Method This was a prospective, randomized, multicentre trial. A total of 13 intensive care units participated, and a total of 148 patients who met eligibility criteria were enrolled. Patients were randomly assigned to receive intravenous iron saccharate alone (control group), intravenous iron saccharate and subcutaneous rHuEPO 40,000 units once per week (group A), or intravenous iron saccharate and subcutaneous rHuEPO 40,000 units three times per week (group B). rHuEPO was given for a minimum of 2 weeks or until discharge from the intensive care unit or death. The maximum duration of therapy was 3 weeks. Results The cumulative number of RBC units transfused, the average numbers of RBC units transfused per patient and per transfused patient, the average volume of RBCs transfused per day, and the percentage of transfused patients were significantly higher in the control group than in groups A and B. No significant difference was observed between group A and B. The mean increases in Hct and Hb from baseline to final measurement were significantly greater in group B than in the control group. The mean increase in Hct was significantly greater in group B than in group A. The mean increase in Hct in group A was significantly greater than that in control individuals, whereas the mean increase in Hb did not differ significantly between the control group and group A. Conclusion Administration of rHuEPO to critically ill patients significantly reduced the need for RBC transfusion. The magnitude of the reduction did not differ between the two dosing schedules, although there was a dose response for Hct and Hb to rHuEPO in these patients. PMID:16277712
Although early and appropriate antibiotic therapy remains the most important intervention for successful treatment of septic shock, data guiding optimization of beta-lactam prescription in critically ill patients prescribed with continuous renal replacement therapy (CRRT) are still limited. Being small hydrophilic molecules, beta-lactams are likely to be cleared by CRRT to a significant extent. As a result, additional variability may be introduced to the per se variable antibiotic concentrations in critically ill patients. This article aims to describe the current clinical scenario for beta-lactam dosing in critically ill patients with septic shock and CRRT, to highlight the sources of variability among the different studies that reduce extrapolation to clinical practice, and to identify the opportunities for future research and improvement in this field. Three frequently prescribed beta-lactams (meropenem, piperacillin and ceftriaxone) were chosen for review. Our findings showed that present dosing recommendations are based on studies with drawbacks limiting their applicability in the clinical setting. In general, current antibiotic dosing regimens for CRRT follow a one-size-fits-all fashion despite emerging clinical data suggesting that drug clearance is partially dependent on CRRT modality and intensity. Moreover, some studies pool data from heterogeneous populations with CRRT that may exhibit different pharmacokinetics (for example, admission diagnoses different to septic shock, such as trauma), which also limit their extrapolation to critically ill patients with septic shock. Finally, there is still no consensus regarding the %T>MIC (percentage of dosing interval when concentration of the antibiotic is above the minimum inhibitory concentration of the pathogen) value that should be chosen as the pharmacodynamic target for antibiotic therapy in patients with septic shock and CRRT. For empirically optimized dosing, during the first day a loading dose is required
Ulldemolins, Marta; Vaquer, Sergi; Llauradó-Serra, Mireia; Pontes, Caridad; Calvo, Gonzalo; Soy, Dolors; Martín-Loeches, Ignacio
Although early and appropriate antibiotic therapy remains the most important intervention for successful treatment of septic shock, data guiding optimization of beta-lactam prescription in critically ill patients prescribed with continuous renal replacement therapy (CRRT) are still limited. Being small hydrophilic molecules, beta-lactams are likely to be cleared by CRRT to a significant extent. As a result, additional variability may be introduced to the per se variable antibiotic concentrations in critically ill patients. This article aims to describe the current clinical scenario for beta-lactam dosing in critically ill patients with septic shock and CRRT, to highlight the sources of variability among the different studies that reduce extrapolation to clinical practice, and to identify the opportunities for future research and improvement in this field. Three frequently prescribed beta-lactams (meropenem, piperacillin and ceftriaxone) were chosen for review. Our findings showed that present dosing recommendations are based on studies with drawbacks limiting their applicability in the clinical setting. In general, current antibiotic dosing regimens for CRRT follow a one-size-fits-all fashion despite emerging clinical data suggesting that drug clearance is partially dependent on CRRT modality and intensity. Moreover, some studies pool data from heterogeneous populations with CRRT that may exhibit different pharmacokinetics (for example, admission diagnoses different to septic shock, such as trauma), which also limit their extrapolation to critically ill patients with septic shock. Finally, there is still no consensus regarding the %T>MIC (percentage of dosing interval when concentration of the antibiotic is above the minimum inhibitory concentration of the pathogen) value that should be chosen as the pharmacodynamic target for antibiotic therapy in patients with septic shock and CRRT. For empirically optimized dosing, during the first day a loading dose is required
de Andrade, Cristiani Garrido; da Costa, Solange Fátima Geraldo; Lopes, Maria Emília Limeira
Palliative care involves an approach in the field of care for terminal patients and their families that seeks to assure them better quality of life by establishing good communication. The scope of this study was to verify how nurses use communication in the field of palliative care when assisting patients in the terminal phase. This is exploratory research of a qualitative nature in which 28 nurses working in wards of a hospital in the city of Joao Pessoa in the State of Paraíba participated in the period from August to October 2012. A form was used for data collection that was then analyzed using the content analysis technique. Three categories emerged from the analysis of the material: "palliative care and communication - interpersonal relationship between the nurse and the terminal patient"; "communication in palliative care as a strategy for strengthening the bond between the nurse and the terminal patient"; and "the importance of communication between the nurse and the family of the terminal patient under palliative care." The conclusion reached was that communication is seen to be an effective element of care for the patient in the terminal phase and it is extremely important for the promotion of palliative care.
Yeo, Hye Ju; Cho, Woo Hyun; Park, Jong Myung; Kim, Dohyung
Background Extracorporeal membrane oxygenation (ECMO) has been successfully used as a method for the interhospital transportation of critically ill patients. In South Korea, a well-established ECMO interhospital transport system is lacking due to limited resources. We developed a simplified ECMO transport system without mechanical ventilation for use by public emergency medical services. Methods Eighteen patients utilized our ECMO transport system from December 2011 to September 2015. We retrospectively analyzed the indications for ECMO, the patient status during transport, and the patient outcomes. Results All transport was conducted on the ground by ambulance. The distances covered ranged from 26 to 408 km (mean, 65.9±88.1 km) and the average transport time was 56.1±57.3 minutes (range, 30 to 280 minutes). All patients were transported without adverse events. After transport, 4 patients (22.2%) underwent lung transplantation because of interstitial lung disease. Eight patients who had severe acute respiratory distress syndrome showed recovery of heart and lung function after ECMO therapy. A total of 13 patients (70.6%) were successfully taken off ECMO, and 11 patients (61.1%) survived. Conclusion Our ECMO transport system without mechanical ventilation can be considered a safe and useful method for interhospital transport and could be a good alternative option for ECMO transport in Korean hospitals with limited resources. PMID:28180097
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.
Acute kidney injury (AKI) is common in critically ill patients. Diuretics are used without any evidence demonstrating a beneficial effect on renal function. The objective of the present study is to determine the incidence of AKI in an intensive care unit (ICU) and if there is an association between the use of furosemide and the development of AKI. The study involved a hospital cohort in which 344 patients were consecutively enrolled from January 2010 to January 2011. A total of 132 patients (75 females and 57 males, average age 64 years) remained for analysis. Most exclusions were related to ICU discharge in the first 24 h. Laboratory, sociodemographic and clinical data were collected until the development of AKI, medical discharge or patient death. The incidence of AKI was 55% (95%CI = 46-64). The predictors of AKI found by univariate analysis were septic shock: OR = 3.12, 95%CI = 1.36-7.14; use of furosemide: OR = 3.27, 95%CI = 1.57-6.80, and age: OR = 1.02, 95%CI = 1.00-1.04. Analysis of the subgroup of patients with septic shock showed that the odds ratio of furosemide was 5.5 (95%CI = 1.16-26.02) for development of AKI. Age, use of furosemide, and septic shock were predictors of AKI in critically ill patients. Use of furosemide in the subgroup of patients with sepsis/septic shock increased (68.4%) the chance of development of AKI when compared to the sample as a whole (43.9%) PMID:22641414
Grégoire, N; Mimoz, O; Mégarbane, B; Comets, E; Chatelier, D; Lasocki, S; Gauzit, R; Balayn, D; Gobin, P; Marchand, S; Couet, W
Colistin is an old antibiotic that has recently gained a considerable renewal of interest as the last-line defense therapy against multidrug-resistant Gram-negative bacteria. It is administered as colistin methanesulfonate (CMS), an inactive prodrug, and it was shown that due to slow CMS conversion, colistin plasma concentrations increase very slowly after treatment initiation, which constitutes the rationale for a loading dose in critically ill patients. However, faster CMS conversion was observed in healthy volunteers but using a different CMS brand, which may also have a major impact on colistin pharmacokinetics. Seventy-three critically ill patients not undergoing dialysis received multiple doses of CMS. The CMS concentrations were measured by liquid chromatography-tandem mass spectrometry (LC-MS/MS), and a pharmacokinetic analysis was conducted using a population approach. We confirmed that CMS renal clearance and colistin concentrations at steady state are mostly governed by creatinine clearance, but we predict a typical maximum concentration of drug in serum (Cmax) of colistin close to 2 mg/liter, occurring 3 h after an initial dose of 2 million international units (MIU) of CMS. Accordingly, the estimated colistin half-life (t1/2) was relatively short (3.1 h), with rapid attainment of steady state. Our results are only partially consistent with other recently published results. We confirm that the CMS maintenance dose should be adjusted according to renal function in critically ill patients. However, much higher than expected colistin concentrations were observed after the initial CMS dose, with rapid steady-state achievement. These discrepancies challenge the pharmacokinetic rationale for a loading dose, which may still be appropriate for rapid bacterial eradication and an improved clinical cure rate.
Qi, S Y; Wang, W T; Chen, C Y; Chu, Z D; Liu, X J; Liu, X J
This study was designed to investigate the influence of early enteral and parenteral nutrition on immune functions of neurocritically ill patients. Patients who were admitted to the neurological intensive care unit (ICU) of The Second Affiliated Hospital of Zhengzhou University between May 2014 and January 2016 were selected. They had been hospitalized for more than one week and received enteral nutrition (EN) via nasogastric tube, with a gross energy of 25 kcal/(Kg d). Patients were divided into EN group, EN + early PN (EPN) group and EN + supplemental PN (SPN) group according to the time of PN support. Differences in patients general information and changes in serum protein and immune indexes were compared between the three groups. On admission, patients Glasgow coma scale (GCS), age, immune functions and protein indexes had no obvious differences between the three groups. After nutritional support, serum protein level reduced in the EN group while prealbumin (PALB) and retinol binding protein (RBP) increased in the EN + EPN group and EN + SPN group after one week of admission to hospital, and the differences were statistically significant (p less than 0.05). Total protein (TP), albumin (ALB), PALB and transferrin (TRF) increased significantly in the EN + EPN group and EN + SPN group compared with the EN group (p < 0.05); before and after treatment, an increase was found in ALB in the EN + EPN group in comparison with EN + SPN group, with a notable difference (p < 0.05); C3, C4, immunoglobulin M (IgM) and immunoglobulin A (IgA) increased in the EN + SPN group after nutritional support compared with before treatment, and the difference was statistically significant (p < 0.05). Moreover, immunoglobulin G (IgG) and IgA in the EN + EPN group increased after nutritional support comparing to prior to nutritional support, and the difference was statistically significant (p < 0.05). After nutritional treatment, IgA and IgG increased markedly in the EN + EPN group
Jayasinghe, Upali W; Proudfoot, Judith; Barton, Christopher A; Amoroso, Cheryl; Holton, Chris; Davies, Gawaine Powell; Beilby, Justin; Harris, Mark F
Background To study health-related quality of life (HRQOL) in a large sample of Australian chronically-ill patients and investigate the impact of characteristics of patients and their general practices on their HRQOL and to assess the construct validity of SF-12 in Australia. Methods Cross sectional study with 96 general practices and 7606 chronically-ill patients aged 18 years or more using standard SF-12 version 2. Factor analysis was used to confirm the hypothesized component structure of the SF-12 items. SF-12 physical component score (PCS-12) and mental component score (MCS-12) were derived using the standard US algorithm. Multilevel regression analysis (patients at level 1 and practices at level 2) was applied to relate PCS-12 and MCS-12 to patient and practice characteristics. Results There were significant associations between lower PCS-12 or MCS-12 score and poorer general health (10.8 (regression coefficient) lower for PCS-12 and 7.3 lower for MCS-12), low socio-economic status (5.1 lower PCS-12 and 2.9 lower MCS-12 for unemployed, 0.8 lower PCS-12 and 1.7 lower MCS-12 for non-owner-occupiers, 1.0 lower PCS-12 for less well-educated) and having two or more chronic conditions (up to 2.7 lower PCS-12 and up to 1.5 lower MCS-12 than those having a single disease). Younger age was associated with lower MCS-12 (2.2 and 6.0 lower than middle age and older age respectively) but higher PCS-12 (4.7 and 7.6 higher than middle age and older age respectively). Satisfaction with quality of care (regression coefficient = 1.2) and patients who were married or cohabiting (regression coefficient = 0.6) was positively associated with MCS-12. Patients born in non-English-speaking countries were more likely to have a lower MCS-12 (1.5 lower) than those born in Australia. Employment had a stronger association with the quality of life of males than that of females. Those attending smaller practices had lower PCS-12 (1.0 lower) and MCS-12 (0.6 lower) than those attending larger
Mandeville, Justin C.; Colebourn, Claire L.
Introduction. We systematically evaluated the use of transthoracic echocardiography in the assessment of dynamic markers of preload to predict fluid responsiveness in the critically ill adult patient. Methods. Studies in the critically ill using transthoracic echocardiography (TTE) to predict a response in stroke volume or cardiac output to a fluid load were selected. Selection was limited to English language and adult patients. Studies on patients with an open thorax or abdomen were excluded. Results. The predictive power of diagnostic accuracy of inferior vena cava diameter and transaortic Doppler signal changes with the respiratory cycle or passive leg raising in mechanically ventilated patients was strong throughout the articles reviewed. Limitations of the technique relate to patient tolerance of the procedure, adequacy of acoustic windows, and operator skill. Conclusions. Transthoracic echocardiographic techniques accurately predict fluid responsiveness in critically ill patients. Discriminative power is not affected by the technique selected. PMID:22400109
Grasso, Rosario Francesco Quattrocchi, Carlo Cosimo; Crucitti, Pierfilippo; Carboni, Giampiero; Coppola, Roberto; Zobel, Bruno Beomonte
A 71-year-old man affected by cardio- and cerebrovascular disease experienced an accidental fall and trauma to the fronto-temporal area of the head. A few weeks later a growing mass appeared on his scalp. A diagnosis of superficial temporal artery pseudoaneurysm was made following CT and color Doppler ultrasound. His clinical condition favoured a conservative approach by ultrasound-guided compression and subsequent surgical resection. A conservative approach should be considered the treatment of choice in critically ill patients affected by superficial temporal artery pseudoaneurysm.
Wilson, W. H.; Diamond, R. J.; Factor, R. M.
This paper presents a conceptual approach for leading various types of groups of chronically mentally ill patients. Although these groups may have a concrete, task-oriented purpose, with skillful leadership they also function as psychotherapy groups. The developmental deficits in ego functions, object relations, and social skills that severely impair such groups can be compensated by non-interpretative actions of the therapists. The group leader must actively work to provide for the structure, stability, and safety of the group when group members are unable to provide these for themselves. PMID:4049917
Kilbourne, Amy M; Greenwald, Devra E; Bauer, Mark S; Charns, Martin P; Yano, Elizabeth M
Integrated care for medical conditions is essential for persons with serious mental illness (SMI). This qualitative study describes mental health provider perspectives regarding barriers and facilitators of integrated care for patients with SMI. We interviewed providers from a national sample of Veterans Health Administration facilities that scored in the top or bottom percentile in medical care quality. Providers from high-performing sites reported substantial in-person contacts with general medical providers, while providers from low-performing sites reported stigma and limited communication with medical providers as major concerns. Interventions to improve mental health and medical provider communication may facilitate integrated care for persons with SMI.
Zielske, J; Bohne, S; Axer, H; Brunkhorst, F M; Guntinas-Lichius, O
Dysphagia is a severe complication in critically ill patients and affects more than half the patients in an intensive care unit. Dysphagia also has a strong impact on morbidity and mortality. Risk factors for the development of dysphagia are neurological diseases, age >55-70 years, intubation >7 days and sepsis. With increasing numbers of long-term survivors chronic dysphagia is becoming an increasing problem. There is not much knowledge on the influence of specific diseases, including the direct impact of sepsis on the development of dysphagia. Fiberoptic evaluation of swallowing is a standardized tool for bedside evaluation, helping to plan swallowing training during the acute phase and to decrease the rate of chronic dysphagia. For evaluation of chronic dysphagia even more extensive diagnostic tools as well as several options of stepwise rehabilitation using restitution, compensation and adaption strategies for swallowing exist. Currently it seems that these options are not being sufficiently utilized. In general, there is a need for controlled clinical trials analyzing specific swallowing rehabilitation concepts for former critically ill patients and long-term survivors.
Sanches, Ana Cláudia Soncini; Góes, Cassiana Regina de; Bufarah, Marina Nogueira Berbel; Balbi, André Luiz; Ponce, Daniela
Patients on intensive care present systemic, metabolic, and hormonal alterations that may adversely affect their nutritional condition and lead to fast and important depletion of lean mass and malnutrition. Several factors and medical conditions can influence the energy expenditure (EE) of critically ill patients, such as age, gender, surgery, serious infections, medications, ventilation modality, and organ dysfunction. Clinical conditions that can present with EE change include acute kidney injury, a complex disorder commonly seen in critically ill patients with manifestations that can range from minimum elevations in serum creatinine to renal failure requiring dialysis. The nutritional needs of this population are therefore complex, and determining the resting energy expenditure is essential to adjust the nutritional supply and to plan a proper diet, ensuring that energy requirements are met and avoiding complications associated with overfeeding and underfeeding. Several evaluation methods of EE in this population have been described, but all of them have limitations. Such methods include direct calorimetry, doubly labeled water, indirect calorimetry (IC), various predictive equations, and, more recently, the rule of thumb (kcal/kg of body weight). Currently, IC is considered the gold standard.
Sehgal, Vishal; Bajwa, Sukhminder Jit Singh; Sehgal, Rinku; Bajaj, Anurag
Context: Articles in various international and national bibliographic indices were extensively searched with an emphasis on thyroid and hypothyroid disorders, hypothyroidism in elderly hospitalized patients, hypothyroidism in critically ill geriatric population, thyroxine in elderly hypothyroid, drug interactions and thyroid hormones, and thyroid functions in elderly. Evidence acquisition: Entrez (including PubMed), NIH.gov, Medscape.com, WebMD.com, MedHelp.org, Search Medica, MD consult, yahoo.com, and google.com were searched. Manual search was performed on various textbooks of medicine, critical care, pharmacology, and endocrinology. Results: Thyroid function tests in elderly hospitalized patients must be interpreted with circumspection. The elderly are often exposed to high iodide content and critical care settings. This may occur because of either decreased iodine excretion or very high intake of iodine. This is especially true for elderly population with underlying acute or chronic kidney diseases or both. Amiodarone, with a very high iodine content, is also often used in this set of population. Moreover, other medications including iodinated contrast are often used in the critical care settings. These may affect different steps of thyroid hormone metabolism, and thereby complicate the interpretation of thyroid function tests. Conclusions: The current review is aimed at analyzing and managing various clinical aspects of hypothyroidism in hospitalized elderly, and critically ill geriatric patients. PMID:24719636
Penesova, A; Galusova, A; Vigas, M; Vlcek, M; Imrich, R; Majek, M
The critically ill subjects are represented by a heterogeneous group of patients suffering from a life-threatening event of different origin, e.g. trauma, cardiopulmonary failure, surgery or sepsis. The majority of these patients are dependent on the artificial lung ventilation, which means a life-saving chance for them. However, the artificial lung ventilation may trigger ventilation-associated lung injury (VALI). The mechanical ventilation at higher volumes (volutrauma) and pressure (barotrauma) can cause histological changes in the lungs including impairments in the gap and adherens junctions and desmosomes. The injured lung epithelium may lead to an impairment of the surfactant production and function, and this may not only contribute to the pathophysiology of VALI but also to acute respiratory distress syndrome. Other components of VALI are atelectrauma and toxic effects of the oxygen. Collectively, all these effects may result in a lung inflammation associated with a subsequent profibrotic changes, endothelial dysfunction, and activation of the local and systemic endocrine responses such as the renin-angiotensin system (RAS). The present review is aimed to describe some of the pathophysiologic aspects of VALI providing a basis for novel therapeutic strategies in the critically ill patients.
Madan, Alok; Fowler, J Christopher; Patriquin, Michelle A; Salas, Ramiro; Baldwin, Philip R; Velasquez, Kenia M; Viswanath, Humsini; Molfese, David L; Sharp, Carla; Allen, Jon G; Hardesty, Susan; Oldham, John M; Frueh, B Christopher
Serious mental illness (SMI) is disabling, and current interventions are ineffective for many. This exploratory study sought to demonstrate the feasibility of applying topological data analysis (TDA) to resting-state functional connectivity data obtained from a heterogeneous sample of 235 adult inpatients to identify a biomarker of treatment response. TDA identified two groups based on connectivity between the prefrontal cortex and striatal regions: patients admitted with greater functional connectivity between these regions evidenced less improvement from admission to discharge than patients with lesser connectivity between them. TDA identified a potential biomarker of an attenuated treatment response among inpatients with SMI. Insofar as the observed pattern of resting-state functional connectivity collected early during treatment is replicable, this potential biomarker may indicate the need to modify standard of care for a small, albeit meaningful, percentage of patients.
CHLAN, LINDA; HEIDERSCHEIT, ANNIE
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. PMID:24489432
Dickerson, Roland N; Maish, George O; Minard, Gayle; Brown, Rex O
Glycemic control is an important component of the metabolic management of the critically ill patient. Nutrition support teams are frequently challenged by complicated patients who exhibit multiple concurrent etiologies for hyperglycemia. Nutrition support teams can serve in a pivotal role in the development and evaluation of safe and effective techniques for achieving glycemic control. This review describes the efforts of a nutrition support team in achieving safe and effective glycemic control at their institution. Identification of target blood glucose concentration range, development, initiation, monitoring of a continuous intravenous insulin infusion algorithm, nursing adherence to the algorithm, modification of the algorithm based on the presence of conditions that alter insulin metabolism and glucose homeostasis, and transition of the patient who receives continuous enteral nutrition from a continuous intravenous insulin infusion to intermittent subcutaneous insulin therapy are discussed.
Porcher, Raphaël; Argaud, Laurent; Piquilloud, Lise; Guitton, Christophe; Tamion, Fabienne; Hraiech, Sami; Mira, Jean-Paul
Context Health-related Internet utilization is common but its use by proxies of critically ill patients is unknown. Our objective was to describe the prevalence and the Internet utilization characteristics among surrogates of critically ill septic patients. We conducted a prospective observational study in French ICUs. Three survey instruments were used to describe ICU organization regarding information delivery, patients and surrogates characteristics. Results 169 surrogates of 146 septic patients hospitalized in 19 ICUs were included. One sixth of ICUs (n = 3, 16%) had their own website. Majority of patients were males (n = 100, 68%), aged 64±1 years old, with a SAPS2 score at 53±17 and required vasopressors (n = 117, 83%), mechanical ventilation (n = 116, 82%). More than one quarter required renal replacement therapy (n = 36, 26%). Majority of surrogates were female, in their fifties. Only one in five knew the word sepsis (n = 27, 16%). Majority of proxies internet users (n = 77; 55%) search on the internet about sepsis. The main motivation was curiosity. Majority of surrogates found the information online reliable, suitable for request and concordant. Prior use of health-related Internet (OR = 20.7 [4.30–100.1]), the presence of a nursing staff during family-physician meetings (OR = 3.33 [1.17–9.53]), a younger patient age (OR = 1.32 [1.01–1.72]) and renal replacement therapy requirement (OR = 2.58 [1.06–6.26]) were associated with health-related Internet use. Neither satisfaction with medical care or information provision, neither presence of anxiety-depression symptoms, were associated with health-related Internet use. Majority of surrogates (N = 76 (52%)) would have like receiving a list of selected websites on sepsis. Conclusions Majority of proxies of critically ill patients with sepsis use Internet to learn more about sepsis. Internet utilization is independent of satisfaction with global ICU care, perceived quality of information delivery by
Bartholomée, Yvette; Maarse, Hans
On January 1, 2006, the Dutch government instituted major reforms to the country's health insurance scheme. One of the features of the new system is the opportunity for groups to form collectives that may negotiate and enter into group contracts with health insurers. This article discusses one particular type of collective, namely patient collectives. The purpose of this paper is to investigate if, and to what extent, patient collectives empower chronically ill patients. The results of the study show that some patient groups were able to contract collective agreements with health insurers, whereas others were not. The eligibility of a group's disease for compensation through the risk equalisation fund (which subsidises the costs for many but not all disorders) seems to determine whether or not a patient organisation is able to successfully negotiate a collective contract for its members. Another key factor for success is the presence of a large membership whose constituents have similar healthcare needs. If both of these factors are present, insurers are more likely to develop specific products for particular groups of patients, as is the case for people with diabetes. Furthermore, the presence of patient collectives accords patient associations with a new role. It may be possible for them to become powerful players in the health insurance market. However, this new role may also lead to tensions, both within and between associations.
Risør, Mette Bech
Patients with medically unexplained symptoms (MUS) are often considered to be strictly confined to thinking about their symptoms as having only a physical etiology. However, several studies have shown, that the patients also apply other explanations for their sufferings. The aim of this study is to analyse the social construction of illness explanations among patients with MUS, and to illustrate the use of explanatory idioms as being dependent on space, time and setting, legitimizing each idiom. The study is based on repeated, semi-structured, qualitative interviews with nine informants during a period of 1.5 years. A thematic content analysis was performed on a pragmatic and phenomenological basis. We found, that patients with MUS employ at least four different explanatory idioms defined as: (1) the symptomatic idiom; (2) the personal idiom; (3) the social idiom; and (4) the moral idiom. All idioms play an important role in the process of creating meaning in the patients' everyday life. The symptomatic idiom is mainly used at clinical consultations in primary care, but it is not the only idiom of significance for the patients. Simultaneously other idioms exist and gradually become important for especially patients with MUS due to the lack of valid diagnoses and treatment opportunities. Clinical settings, however, call for the employment of the symptomatic idiom and a discrepancy is found between the general practitioners' notion of the bio-psycho-social model and the patients' everyday life idioms.
Sarnecka, Agnieszka; Dąbrowska, Aleksandra; Kosałka, Katarzyna; Wachowska, Ewelina; Bałan, Barbara J.; Jankowska, Marta; Korta, Teresa; Niewiński, Grzegorz; Kański, Andrzej; Mikaszewska-Sokolewicz, Małgorzata; Omidi, Mohammad; Majewska, Krystyna; Słotwińska, Sylwia M.
The aim of this study was an attempt to determine whether the expression of genes involved in innate antibacterial response (TL R2, NOD 1, TRAF6, HMGB 1 and Hsp70) in peripheral blood leukocytes in critically ill patients, may undergo significant changes depending on the severity of the infection and the degree of malnutrition. The study was performed in a group of 128 patients with infections treated in the intensive care and surgical ward. In 103/80.5% of patients, infections had a severe course (sepsis, severe sepsis, septic shock, mechanical ventilation of the lungs). Clinical monitoring included diagnosis of severe infection (according to the criteria of the ACC P/SCC M), assessment of severity of the patient condition and risk of death (APACHE II and SAPS II), nutritional assessment (NRS 2002 and SGA scales) and the observation of the early results of treatment. Gene expression at the mRNA level was analyzed by real-time PCR. The results of the present study indicate that in critically ill patients treated in the IC U there are significant disturbances in the expression of genes associated with innate antimicrobial immunity, which may have a significant impact on the clinical outcome. The expression of these genes varies depending on the severity of the patient condition, severity of infection and nutritional status. Expression disorders of genes belonging to innate antimicrobial immunity should be diagnosed as early as possible, monitored during the treatment and taken into account during early therapeutic treatment (including early nutrition to support the functions of immune cells). PMID:26648775
Connolly, Bronwen; O'Neill, Brenda; Salisbury, Lisa; Blackwood, Bronagh
Background Physical rehabilitation interventions aim to ameliorate the effects of critical illness-associated muscle dysfunction in survivors. We conducted an overview of systematic reviews (SR) evaluating the effect of these interventions across the continuum of recovery. Methods Six electronic databases (Cochrane Library, CENTRAL, DARE, Medline, Embase, and Cinahl) were searched. Two review authors independently screened articles for eligibility and conducted data extraction and quality appraisal. Reporting quality was assessed and the Grading of Recommendations Assessment, Development and Evaluation approach applied to summarise overall quality of evidence. Results Five eligible SR were included in this overview, of which three included meta-analyses. Reporting quality of the reviews was judged as medium to high. Two reviews reported moderate-to-high quality evidence of the beneficial effects of physical therapy commencing during intensive care unit (ICU) admission in improving critical illness polyneuropathy/myopathy, quality of life, mortality and healthcare utilisation. These interventions included early mobilisation, cycle ergometry and electrical muscle stimulation. Two reviews reported very low to low quality evidence of the beneficial effects of electrical muscle stimulation delivered in the ICU for improving muscle strength, muscle structure and critical illness polyneuropathy/myopathy. One review reported that due to a lack of good quality randomised controlled trials and inconsistency in measuring outcomes, there was insufficient evidence to support beneficial effects from physical rehabilitation delivered post-ICU discharge. Conclusions Patients derive short-term benefits from physical rehabilitation delivered during ICU admission. Further robust trials of electrical muscle stimulation in the ICU and rehabilitation delivered following ICU discharge are needed to determine the long-term impact on patient care. This overview provides recommendations for
Disturbances in sodium concentration are common in the critically ill patient and associated with increased mortality. The key principle in treatment and prevention is that plasma [Na+] (P-[Na+]) is determined by external water and cation balances. P-[Na+] determines plasma tonicity. An important exception is hyperglycaemia, where P-[Na+] may be reduced despite plasma hypertonicity. The patient is first treated to secure airway, breathing and circulation to diminish secondary organ damage. Symptoms are critical when handling a patient with hyponatraemia. Severe symptoms are treated with 2 ml/kg 3% NaCl bolus infusions irrespective of the supposed duration of hyponatraemia. The goal is to reduce cerebral symptoms. The bolus therapy ensures an immediate and controllable rise in P-[Na+]. A maximum of three boluses are given (increases P-[Na+] about 6 mmol/l). In all patients with hyponatraemia, correction above 10 mmol/l/day must be avoided to reduce the risk of osmotic demyelination. Practical measures for handling a rapid rise in P-[Na+] are discussed. The risk of overcorrection is associated with the mechanisms that cause hyponatraemia. Traditional classifications according to volume status are notoriously difficult to handle in clinical practice. Moreover, multiple combined mechanisms are common. More than one mechanism must therefore be considered for safe and lasting correction. Hypernatraemia is less common than hyponatraemia, but implies that the patient is more ill and has a worse prognosis. A practical approach includes treatment of the underlying diseases and restoration of the distorted water and salt balances. Multiple combined mechanisms are common and must be searched for. Importantly, hypernatraemia is not only a matter of water deficit, and treatment of the critically ill patient with an accumulated fluid balance of 20 litres and corresponding weight gain should not comprise more water, but measures to invoke a negative cation balance. Reduction of
Introduction Research on co-enrollment practices and their impact are limited in the ICU setting. The objectives of this study were: 1) to describe patterns and predictors of co-enrollment of patients in a thromboprophylaxis trial, and 2) to examine the consequences of co-enrollment on clinical and trial outcomes. Methods In an observational analysis of an international thromboprophylaxis trial in 67 ICUs, we examined the co-enrollment of critically ill medical-surgical patients into more than one study, and examined the clinical and trial outcomes among co-enrolled and non-co-enrolled patients. Results Among 3,746 patients enrolled in PROTECT (Prophylaxis for ThromboEmbolism in Critical Care Trial), 713 (19.0%) were co-enrolled in at least one other study (53.6% in a randomized trial, 37.0% in an observational study and 9.4% in both). Six factors independently associated with co-enrollment (all P < 0.001) were illness severity (odds ratio (OR) 1.35, 95% confidence interval (CI) 1.19 to 1.53 for each 10-point Acute Physiology and Chronic Health Evaluation (APACHE) II score increase), substitute decision-makers providing consent, rather than patients (OR 3.31, 2.03 to 5.41), experience of persons inviting consent (OR 2.67, 1.74 to 4.11 for persons with > 10 years' experience compared to persons with none), center size (all ORs > 10 for ICUs with > 15 beds), affiliation with trials groups (OR 5.59, 3.49 to 8.95), and main trial rather than pilot phase (all ORs > 8 for recruitment year beyond the pilot). Co-enrollment did not influence clinical or trial outcomes or risk of adverse events. Conclusions Co-enrollment was strongly associated with features of the patients, research personnel, setting and study. Co-enrollment had no impact on trial results, and appeared safe, acceptable and feasible. Transparent reporting, scholarly discourse, ethical analysis and further research are needed on the complex topic of co-enrollment during critical illness. PMID:23298553
Overgaard-Steensen, Christian; Ring, Troels
Disturbances in sodium concentration are common in the critically ill patient and associated with increased mortality. The key principle in treatment and prevention is that plasma [Na+] (P-[Na+]) is determined by external water and cation balances. P-[Na+] determines plasma tonicity. An important exception is hyperglycaemia, where P-[Na+] may be reduced despite plasma hypertonicity. The patient is first treated to secure airway, breathing and circulation to diminish secondary organ damage. Symptoms are critical when handling a patient with hyponatraemia. Severe symptoms are treated with 2 ml/kg 3% NaCl bolus infusions irrespective of the supposed duration of hyponatraemia. The goal is to reduce cerebral symptoms. The bolus therapy ensures an immediate and controllable rise in P-[Na+]. A maximum of three boluses are given (increases P-[Na+] about 6 mmol/l). In all patients with hyponatraemia, correction above 10 mmol/l/day must be avoided to reduce the risk of osmotic demyelination. Practical measures for handling a rapid rise in P-[Na+] are discussed. The risk of overcorrection is associated with the mechanisms that cause hyponatraemia. Traditional classifications according to volume status are notoriously difficult to handle in clinical practice. Moreover, multiple combined mechanisms are common. More than one mechanism must therefore be considered for safe and lasting correction. Hypernatraemia is less common than hyponatraemia, but implies that the patient is more ill and has a worse prognosis. A practical approach includes treatment of the underlying diseases and restoration of the distorted water and salt balances. Multiple combined mechanisms are common and must be searched for. Importantly, hypernatraemia is not only a matter of water deficit, and treatment of the critically ill patient with an accumulated fluid balance of 20 litres and corresponding weight gain should not comprise more water, but measures to invoke a negative cation balance. Reduction of
Hasanin, Ahmed; Mohamed, Sabah Abdel Raouf; El-Adawy, Akram
Pain is a common and undertreated problem in critically ill patients. Pain assessment in critically ill patients is challenging and relies on complex scoring systems. The aim of this work was to find out the possible role of the perfusion index (PI) measured by a pulse oximeter (Masimo Radical 7; Masimo Corp., Irvine, CA, USA) in pain assessment in critically ill patients. A prospective observational study was carried out on 87 sedated non-intubated patients in a surgical intensive care unit. In addition to routine monitoring, a Masimo pulse oximeter probe was used for PI measurement. The sedation level of the patients was assessed by using the Richmond Agitation-Sedation Scale (RASS). The pain intensity was determined by applying the behavioral pain scale for non-intubated (BPS-NI) patients. The PI, arterial blood pressure, heart rate, RASS, and BPS-NI values before and after the application of a standard painful stimulus (changing the patient position) were reported. Correlation between the PI and other variables was carried out at the two measurements. Correlation between changes in the PI (delta PI) and in the hemodynamic variables, RASS, and BPS-NI was also done. Changing the patient position resulted in a significant increase in SBP (128 ± 20 vs 120.4 ± 20.6, P = 0.009), DBP (71.3 ± 11.2 vs 68.7 ± 11.3, P = 0.021), heart rate (99.5 ± 19 vs 92.7 ± 18.2, P = 0.013), and BPS-NI (7[6-8] vs 3[3-3], P < 0.001) values and a significant decrease in the PI (1[0.5-1.9] vs 2.2[0.97-3.6], P < 0.001) value compared to the baseline readings. There was no correlation between the values of the PI and the ABP, BPS-NI, and RASS at the two measurements. A good correlation was found between the delta PI and delta BPS-NI (r = -0.616, P < 0.001). A weak correlation was observed between the PI and heart rate after the patient positioning (r = -0.249, P < 0.02). In surgical critically ill non-intubated patients, the application of a painful
Mandelbaum, Tal; Scott, Daniel J; Lee, Joon; Mark, Roger G.; Malhotra, Atul; Waikar, Sushrut S.; Howell, Michael D.; Talmor, Daniel
Objective Acute kidney injury (AKI) affects 5–7% of all hospitalized patients with a much higher incidence in the critically ill. The Acute Kidney Injury Network proposed a definition in which serum creatinine rises (>0.3mg/dl) and/or oliguria (<0.5/ml/kg/h) for a period of 6 hours are used to detect AKI. Accurate urine output measurements as well as serum creatinine values from our database were used to detect patients with AKI and calculate their corresponding mortality risk and length of stay. Design Retrospective cohort study. Setting 7 intensive care units at, a large, academic, tertiary medical center. Patients Adult patients without evidence of end stage renal disease, with more than 2 creatinine measurements and at least a 6 hours urine output recording, who were admitted to the ICU between 2001 and 2007. Interventions Medical records of all the patients were reviewed. Demographic information, lab results, charted data, discharge diagnoses, physiological data and patient outcomes were extracted from the MIMIC-II database using a SQL query. Measurements and main results From 19,677 adult patient records, 14,524 patients met the inclusion criteria. 57% developed AKI during their ICU stay. In-hospital mortality rates were: 13.9%, 16.4%, 33.8% for AKI 1, 2 and 3 respectively compared to only 6.2% in patients without AKI (p<0.0001). After adjusting for multiple covariates AKI was associated with increased hospital mortality (OR 1.4 and 1.3 for AKI1 and AKI2 and 2.5 for AKI3; p<0.0001). Using multivariate logistic regression, we found that in patients who developed AKI, urine output alone was a better mortality predictor than creatinine alone or the combination of both. Conclusions More than 50% of our critically ill patients developed some stage of AKI resulting in stage-wise increased mortality risk. However, the mortality risk associated with AKI stages 1 and 2 does not differ significantly. In light of these findings reevaluation of the AKIN staging
Yang, Chun-Chieh; Chan, Khee-Siang; Tseng, Kuei-Ling; Weng, Shih-Feng
Lactic acidosis is common in critical care; by contrast, a subtype called alcohol-associated lactic acidosis (AALA) is rarely encountered. The primary purpose of this study was to determine the prognosis of AALA in critically ill patients and the second aim was to determine whether the survival was associated to the peak blood lactate concentration. An 8-year retrospective analysis of adult patients admitted to the intensive care unit (ICU) with AALA between January 2007 and December 2014 was considered in a tertiary care hospital. In total, 23 patients were analyzed and the median peak blood lactate level was 15.9 mmol/L. Only 2 patients (8.7%) presented peak blood lactate levels <10 mmol/L. In this study, 21 patients survived from ICU and hospital, the mortality rate was 8.7%. The result indicted the survival of AALA was not associated with peak blood lactate concentration although survivors still had a better lactate clearance rate per hour than non-survivors. Moreover, AALA patients with coexisting sepsis presenting higher lactate clearance rate and shorter lactate clearance time than those of AALA patients with solely sepsis-related lactic acidosis. PMID:27748410
Masakhwe, Clement; Ochanda, Horace; Nyakoe, Nancy; Ochiel, Daniel; Waitumbi, John
Background Most acute febrile illnesses (AFI) are usually not associated with a specific diagnosis because of limitations of available diagnostics. This study reports on the frequency of EBV viremia and viral load in children and adults presenting with febrile illness in hospitals in Kenya. Methodology/Principal Findings A pathogen surveillance study was conducted on patients presenting with AFI (N = 796) at outpatient departments in 8 hospitals located in diverse regions of Kenya. Enrollment criterion to the study was fever without a readily diagnosable infection. All the patients had AFI not attributable to the common causes of fever in Kenyan hospitals, such as malaria or rickettsiae, leptospira, brucella and salmonella and they were hence categorized as having AFI of unknown etiology. EBV was detected in blood using quantitative TaqMan-based qPCR targeting a highly conserved BALF5 gene. The overall frequency of EBV viremia in this population was 29.2%, with significantly higher proportion in younger children of <5years (33.8%, p = 0.039) compared to patients aged ≥5 years (26.3% for 5–15 years or 18.8% for >15 years). With respect to geographical localities, the frequency of EBV viremia was higher in the Lake Victoria region (36.4%), compared to Kisii highland (24.6%), Coastal region (22.2%) and Semi-Arid region (25%). Furthermore, patients from the malaria endemic coastal region and the Lake Victoria region presented with significantly higher viremia than individuals from other regions of Kenya. Conclusions/Significance This study provides profiles of EBV in patients with AFI from diverse eco-regions of Kenya. Of significant interest is the high frequency of EBV viremia in younger children. The observed high frequencies of EBV viremia and elevated viral loads in residents of high malaria transmission areas are probably related to malaria induced immune activation and resultant expansion of EBV infected B-cells. PMID:27163791
Namendys-Silva, S A; Silva-Medina, M A; Vásquez-Barahona, G M; Baltazar-Torres, J A; Rivero-Sigarroa, E; Fonseca-Lazcano, J A; Domínguez-Cherit, G
The purpose of the present study was to explore the usefulness of the Mexican sequential organ failure assessment (MEXSOFA) score for assessing the risk of mortality for critically ill patients in the ICU. A total of 232 consecutive patients admitted to an ICU were included in the study. The MEXSOFA was calculated using the original SOFA scoring system with two modifications: the PaO2/FiO2 ratio was replaced with the SpO2/FiO2 ratio, and the evaluation of neurologic dysfunction was excluded. The ICU mortality rate was 20.2%. Patients with an initial MEXSOFA score of 9 points or less calculated during the first 24 h after admission to the ICU had a mortality rate of 14.8%, while those with an initial MEXSOFA score of 10 points or more had a mortality rate of 40%. The MEXSOFA score at 48 h was also associated with mortality: patients with a score of 9 points or less had a mortality rate of 14.1%, while those with a score of 10 points or more had a mortality rate of 50%. In a multivariate analysis, only the MEXSOFA score at 48 h was an independent predictor for in-ICU death with an OR = 1.35 (95%CI = 1.14-1.59, P < 0.001). The SOFA and MEXSOFA scores calculated 24 h after admission to the ICU demonstrated a good level of discrimination for predicting the in-ICU mortality risk in critically ill patients. The MEXSOFA score at 48 h was an independent predictor of death; with each 1-point increase, the odds of death increased by 35%.
Mafra, José Marcelo e Souza; Maria da Silva, Janete; Yamada da Silveira, Leda Tomiko; Fu, Carolina; Tanaka, Clarice
[Purpose] To evaluate the quality of life of critical illness survivors in a developing country over the time after hospital discharge and to assess the influence of clinical variables on quality of life. [Subjects and Methods] A prospective longitudinal study was conducted in a large, tertiary, public hospital in Sao Paulo, Brazil. We included patients ≥18 years old, hospitalized in the intensive care unit with ≥24 hours of invasive mechanical ventilation. Quality of life was assessed using the Medical Outcomes Study 36-Item Short Form Health Survey, which was applied by telephone interview at the first, third and sixth months after hospital discharge. [Results] 75 patients were included in the study. Quality of life improved progressively after hospital discharge; role-physical was the most compromised domain. The physical component was influenced by the age. Quality of life was not influenced by Apache II categorization, length of invasive mechanical ventilation, intensive care unit stay or hospital stay. [Conclusion] Survivors of critical illness in a developing country present poor quality of life, which improves over time. Age influenced the physical component of quality of life. PMID:27821961
Eukel, Heidi N.; Frenzel, Jeanne E.; Werremeyer, Amy; McDaniel, Becky
Objective. To increase student pharmacist empathy through the use of an auditory hallucination simulation. Design. Third-year professional pharmacy students independently completed seven stations requiring skills such as communication, following directions, reading comprehension, and cognition while listening to an audio recording simulating what one experiencing auditory hallucinations may hear. Following the simulation, students participated in a faculty-led debriefing and completed a written reflection. Assessment. The Kiersma-Chen Empathy Scale was completed by each student before and after the simulation to measure changes in empathy. The written reflections were read and qualitatively analyzed. Empathy scores increased significantly after the simulation. Qualitative analysis showed students most frequently reported feeling distracted and frustrated. All student participants recommended the simulation be offered to other student pharmacists, and 99% felt the simulation would impact their future careers. Conclusions. With approximately 10 million adult Americans suffering from serious mental illness, it is important for pharmacy educators to prepare students to provide adequate patient care to this population. This auditory hallucination simulation increased student pharmacist empathy for patients with mental illness. PMID:27899838
Gray-Toft, Pamela; Anderson, James G.
Investigated sources of stress experienced by hospice nurses. Stress sources included: physical characteristics of the unit as well as staffing policies designed to improve the quality of care; procedures followed in admitting patients; policies related to the preparation of meals and open visitation; and greater involvement with the patient and…
Hinshaw, Daniel B.
Patients with advanced illness such as advanced stage cancer presenting with the need for possible surgical intervention can be some of the most challenging cases for a surgeon. Often there are multiple factors influencing the decisions made. For patients they are facing not just the effects of the disease on their body, but the stark realization that the disease will also limit their life. Not only are these factors a consideration when patients are making decisions, but also the desire to make the decision that is best for themselves, the autonomous decision. Also included in this process for the patient facing the possible need for an intervention is the surgeon. While patient autonomy remains one of the main principles within medicine, guiding treatment decisions, there is also the surgeon’s autonomy to be considered. Surgeons determine if there is even a possible intervention to be offered to patients, a decision making process that respects surgeons’ autonomous choices and includes elements of paternalism as surgeons utilize their expertise to make decisions. Included in the treatment decisions that are made and the care of the patient is the impact patients’ outcomes have on the surgeon, the inherent drive to be the best for the patient and desire for good outcomes for the patient. While both the patient’s and surgeon’s autonomy are a dynamic interface influencing decision making, the main goal for the patient facing a palliative procedure is that of making treatment decisions based on the concept of shared decision making, always giving primary consideration to the patient’s goals and values. Lastly, regardless of the decision made, it is the responsibility of surgeons to their patients to be a source of support through this challenging time. PMID:27004224
Hensel, Jennifer M; Flint, Alastair J
There is evidence to suggest that people with serious mental illness (SMI) have lower access to tertiary care than patients without SMI, particularly when care is complex. Barriers are present at the level of the individual, providers, and the health care system. High levels of co-morbidity and the associated health care costs, along with a growing focus on facilitating equal access to quality care for all, urges health care systems to address existing gaps. Some interventions have been successful at improving access to primary care for patients with SMI, but relatively little research has focused on access to complex interventions. This paper summarizes the scope of the problem regarding access to complex tertiary medical care among people with SMI. Barriers are discussed and potential solutions are proposed. Policies and programs must be developed, implemented, and evaluated to determine cost-effectiveness and impact on outcomes.
Zaragoza, Rafael; Ramírez, Paula; Borges, Marcio; Pemán, Javier
Invasive candidiasis in non-neutropenic critically ill patients remains a challenge for clinicians due to its association with high morbidity and mortality rates, increased incidence, and health-care costs. It is well known that early diagnosis and treatment are associated with a better prognosis. For these reasons a thorough update has been performed in this setting focused on recent Spanish epidemiology, new predictive scores and microbiological tests such as mannan antigen, mannan antibodies, Candida albicans germ-tube antibodies or (1→3)-β-D-glucan detection, molecular techniques for the detection of fungal-specific DNA, advances in antifungal treatment and educational programs in Spain. An early diagnostic and therapeutic algorithm is proposed based on the combination of scores and microbiological test. The aim of this review is to provide physicians with the best information available in order to improve the prognosis of these patients.
Jansen, J O; Turner, S; Johnston, A McD
The role of nutritional support in critical illness is well established. This article reviews the nutritional management of military trauma patients in the deployed setting, which poses special challenges for the surgeon and intensivist. There is little direct evidence relating to the nutritional management of trauma patients in general, and military trauma patients in particular, but much of the evidence accrued in the civilian and non-trauma critical care setting can be extrapolated to military practice. There is strong consensus that feeding should be commenced as soon possible after injury. Enteral nutrition should be used in preference to parenteral nutrition whenever possible. If available, supplemental parenteral feeding can be considered if enteral delivery is insufficient. Gastrointestinal anastomoses and repairs, including those in the upper gastrointestinal tract, are not a contraindication to early enteral feeding. Intragastric delivery is more physiological and usually more convenient than postpyloric feeding, and thus the preferred route for the initiation of nutritional support. Feeding gastrostomies or jejunostomies should not be used for short-term nutritional support. Enteral feeding of patients with an open abdomen does not delay closure and may reduce the incidence of pneumonia, and enteral nutrition should be continued for schedule