Patients's satisfaction concerning postoperative analgesia after caesarean section: a comparison of 4 alternative analgesic regimen

Introduction: Different routes of postoperative analgesia may be used after cesarean section: systemic, spinal or epidural [1]. Although the efficacy of these alternative analgesic regimen has already been studied [2, 3], very few studies have compared patients' satisfaction between them. Methodology: After ethical committee acceptation, 100 ASA 1 patients scheduled for an elective cesarean section were randomized in 4 groups. After a standardized spinal anesthesia (hyperbaric bupivacaine 10 mg and fentanyl 20 &#956;g), each group had a different postoperative analgesic regimen: - Group 1: oral paracetamol 4x1 g/24 h, oral ibuprofene 3x600 mg/24 h and subcutaneous morphine on need (0.1 mg/kg 6x/24 h) - Group 2: intrathecal morphine (100 &#956;g) and then same as Group 1 - Group 3: oral paracetamol 4x1 g/24 h, oral ibuprofene 3x600 mg/24 h and PCEA with fentanyl 5 &#956;g/ml epidural solution - Group 4: oral paracetamol 4x1g/24 h, oral ibuprofene 3x600 mg/ 24 h and PCEA with bupivacaine 0.1% and fentanyl 2 &#956;g/ml epidural solution After 48 hours, a specific satisfaction questionnaire was given to all patients which permitted to obtain 2 different scores concerning postoperative analgesia: a global satisfaction score (0-10) and a detailed satisfaction score (5 questions scored 0-10 with a summative score of 0-50). Both scores, expressed as mean ± SD, were compared between the 4 groups with a Kruskall-Wallis test and between each group with a Mann-Whitney test. A P-value <0.05 was considered significant. Results: Satisfaction scores Gr. 1 (n = 25) Gr. 2 (n = 25) Gr. 3 (n = 25) Gr. 4 (n = 25) P-value global (0-10) 8.2 ± 1.2 9.0 ± 1.0 7.8 ± 2.1 6.5 ± 2.5 0.0006 detailed (0-50) 40 ± 6 43 ± 5 38 ± 6 34 ± 8 0.0002 Conclusion: Satisfaction scores were significantly better in patients who received a systemic postoperative analgesia only (Groups 1 and 2) compared to patients who received systemic and epidural postoperative analgesia (Groups 3 and 4). The best scores were achieved with the combination of intrathecal morphine and multimodal systemic analgesia (Group 2) which allowed early ambulation without significant pain. Patients treated with postoperative epidural analgesia with combined local anesthetics and opioids (Group 4) obtained the worse scores (more restrictive nursing with less mobility, frequent asymmetrical block with insufficient analgesia on one side and motor block on the other)

Teaching cardiac auscultation to trainees in internal medicine and family practice: does it work?

BACKGROUND: The general proficiency in physical diagnostic skills seems to be declining in relation to the development of new technologies. The few studies that have examined this question have invariably used recordings of cardiac events obtained from patients. However, this type of evaluation may not correlate particularly well with bedside skills. Our objectives were 1) To compare the cardiac auscultatory skills of physicians in training with those of experienced cardiologists by using real patients to test bedside diagnostic skills. 2) To evaluate the impact of a five-month bedside cardiac auscultation training program. METHODS: 1) In an academic primary care center, 20 physicians (trainees in internal medicine and family practice) and two skilled academic cardiologists listened to 33 cardiac events in 13 patients directly at bedside and identified the cardiac events by completing an open questionnaire. Heart sounds, murmurs and diagnosis were determined beforehand by an independent skilled cardiologist and were validated by echocardiography. Thirteen primary cardiologic diagnoses were possible.2) Ten of the physicians agreed to participate in a course of 45-minute sessions once a week for 5 months. After the course they listened again to the same patients (pre/post-interventional study). RESULTS: 1) The experts were the most skillful, achieving 69% recognition of heart sounds and murmurs and correct diagnoses in 62% of cases. They also heard all of the diastolic murmurs. The residents heard only 40% of the extra heart sounds and made a correct diagnosis in 24% of cases. 2) After the weekly training sessions, their mean percentage for correct diagnosis was 35% [an increase of 66% (p &lt; 0.05)]. CONCLUSIONS: The level of bedside diagnostic skills in this relatively small group of physicians in training is indeed low, but can be improved by a course focusing on realistic bedside teaching.

Assessment of needs, health-related quality of life, and satisfaction with care in breast cancer patients to better target supportive care.

BACKGROUND: This study assessed whether breast cancer (BC) patients express similar levels of needs for equivalent severity of symptoms, functioning difficulties, or degrees of satisfaction with care aspects. BC patients who did (or not) report needs in spite of similar difficulties were identified among their sociodemographic or clinical characteristics. PATIENTS AND METHODS: Three hundred and eighty-four (73% response rate) BC patients recruited in ambulatory or surgery hospital services completed the European Organisation for Research and Treatment of Cancer Quality of Life questionnaire (EORTC QLQ)-C30 quality of life [health-related quality of life (HRQOL)], the EORTC IN-PATSAT32 (in-patient) or OUT-PATSAT35 (out-patient) satisfaction with care, and the supportive care needs survey short form 34-item (SCNS-SF34) measures. RESULTS: HRQOL or satisfaction with care scale scores explained 41%, 45%, 40% and 22% of variance in, respectively, psychological, physical/daily living needs, information/health system, and care/support needs (P &lt; 0.001). BC patients' education level, having children, hospital service attendance, and anxiety/depression levels significantly predicted differences in psychological needs relative to corresponding difficulties (adjusted R(2) = 0.11). Medical history and anxiety/depression levels significantly predicted differences in information/health system needs relative to degrees of satisfaction with doctors, nurses, or radiotherapy technicians and general satisfaction (adjusted R(2) = 0.12). Unmet needs were most prevalent in the psychological domains across hospital services. CONCLUSIONS: Assessment of needs, HRQOL, and satisfaction with care highlights the subgroups of BC patients requiring better supportive care targeting.

Mandatory communication skills training for oncologists: enforcement does not substantially impact satisfaction.

PURPOSE: Even though there is evidence that both patients and oncology clinicians are affected by the quality of communication and that communication skills can be effectively trained, so-called Communication Skills Trainings (CSTs) remain heterogeneously implemented. METHODS: A systematic evaluation of the level of satisfaction of oncologists with the Swiss CST before (2000-2005) and after (2006-2012) it became mandatory. RESULTS: Levels of satisfaction with the CST were high, and satisfaction of physicians participating on a voluntary or mandatory basis did not significantly differ for the majority of the items. CONCLUSIONS: The evaluation of physicians' satisfaction over the years and after introduction of mandatory training supports recommendations for generalized implementation of CST and mandatory training for medical oncologists.

Work values as predictors of entrepreneurial career intentions: A longitudinal analysis of gender effects

Purpose - Work values are an important characteristic to understand gender differences in career intentions, but how gender affects the relationship between values and career intentions is not well established. The purpose of this paper is to investigate whether gender moderates the effects of work values on level and change of entrepreneurial intentions (EI). Design/methodology/approach - In total, 218 German university students were sampled regarding work values and with EI assessed three times over the course of 12 months. Data were analysed with latent growth modelling. Findings - Self-enhancement and openness to change values predicted higher levels and conservation values lower levels of EI. Gender moderated the effects of enhancement and conservation values on change in EI. Research limitations/implications - The authors relied on self-reported measures and the sample was restricted to university students. Future research needs to verify to what extent these results generalize to other samples and different career fields, such as science or nursing. Practical implications - The results imply that men and women are interested in an entrepreneurial career based on the same work values but that values have different effects for men and women regarding individual changes in EI. The results suggest that the prototypical work values of a career domain seem important regarding increasing the career intent for the gender that is underrepresented in that domain. Originality/value - The results enhance understanding of how gender affects the relation of work values and a specific career intention, such as entrepreneurship.