Childhood community-acquired pneumonia

Background: Community-acquired pneumonia is a leading cause of morbidity and mortality in children worldwide. New, rapid methods are needed to improve the microbiologic diagnosis of pneumonia in clinical practice. The increasing incidence of parapneumonic empyema in children accentuates the importance of the identification of the causative agent and clinical predictors of empyema. Aims and methods: Two prospective studies were conducted to find feasible diagnostic methods for the detection of causative agents of pneumonia. The usefulness of pneumolysin-targeted real-time PCR in the diagnosis of pneumococcal disease was studied in children with pneumonia and empyema, and the clinical utility of induced sputum analysis in the microbiologic diagnosis of pneumonia was investigated in children with pneumonia. In addition, two retrospective clinical studies were performed to describe the frequency and clinical profile of influenza pneumonia in children and the frequency, clinical profile and clinical predictors of empyema in children. Results: Pneumolysin-PCR in pleural fluid significantly improved the microbiologic diagnosis of empyema by increasing the detection rate of pneumococcus almost tenfold to that of pleural fluid culture (75 % vs. 8 %). In whole blood samples, PCR detected pneumococcus in only one child with pneumonia and one child with pneumococcal empyema. Sputum induction provided good-quality sputum specimens with high microbiologic yield. <i>Streptococcus pneumoniae</i> (46 %) and rhinovirus (29 %) were the most common microbes detected. The quantification results of the paired sputum and nasopharyngeal aspirate specimens provided support that the majority of the bacteria (79 %) and viruses (55 %) found in sputum originated from the lower airways. Pneumonia was detected in 14 % of children with influenza infection. A history of prolonged duration of fever, tachypnea, and pain on abdominal palpation were found to be independently significant predictors of empyema. Conclusions: Pneumolysin-targeted real-time PCR is a useful and rapid method for the diagnosis of pneumococcal empyema in children. Induced sputum analysis with paired nasopharyngeal aspirate analysis can be of clinical value in the microbiologic diagnosis of pneumonia. Influenza pneumonia is an infrequent and generally benign disease in children with rare fatalities. Repeat chest radiograph and ultrasound imaging are recommended in children with pneumonia presenting with clinical predictors of empyema and in children with persistent fever and high CRP levels during hospitalization.

The Quality of Paediatric Nursing Care - Children���s Perspective

<b>Hoitoty��n laatu - lasten n��k��kulma</b> T��m��n kolmivaiheisen tutkimuksen tarkoituksena oli kuvailla lasten odotuksia ja arviointeja lasten hoitoty��n laadusta sek�� kehitt���� mittari kouluik��isille sairaalassa oleville lapsille laadun arviointiin. Perimm��isen�� tavoitteena oli lasten hoitoty��n laadun kehitt��minen sairaalassa. Ensimm��isess�� vaiheessa 20 alle kouluik��ist�� (4-6v) sek�� 20 kouluik��ist�� (7-11v) lasta kuvailivat odotuksiaan lasten hoitoty��n laadusta. Aineisto ker��ttiin haastattelulla ja lasten piirustusten avulla, sek�� analysoitiin sis��ll��n analyysilla. Lasten odotukset lasten hoitoty��n laadusta kohdistuivat hoitajaan, hoitoty��n toimintoihin ja ymp��rist����n, fyysinen ymp��rist�� korostui piirustuksissa. Ensimm��isen vaiheen tulosten, aikaisemman kirjallisuuden sek�� Leino-Kilven ���HYV�� HOITO��� mittarin pohjalta kehitettiin ���Lasten Hoidon Laatu Sairaalassa��� (LHLS) mittari ja testattiin sen psykometrisi�� ominaisuuksia tutkimuksen toisessa vaiheessa. Mittaria kehitettiin ja testattiin kolmen vaiheen kautta. Aluksi asiantuntijapaneeli (n=7) arvioi mittarin sis��lt����. Seuraavaksi mittari esitestattiin kahdesti kouluik��isill�� sairaalassa olevilla lapsilla (n=41 ja n=16), samassa vaiheessa my��s viiden lastenosaston hoitajat (n=19) yhdess�� arvioivat mittarin sis��lt���� sek�� 8 lasta. Lopuksi mittaria testattiin kouluik��isill�� lapsilla (n=388) sairaalassa sek�� hoitajat (n=198) arvioivat mittarin sis��ll��n validiteettia. Mittarin kehitt��misen aikana p����laatuluokkien: hoitajan ominaisuudet, hoitoty��n toiminnot ja hoitoty��n ymp��rist�� Cronbachin alfa kertoimet paranivat. P����komponentti analyysi tuki mittarin hoitoty��n toimintojen ja ymp��rist��n alaluokkien teoreettista rakennetta. Kolmannessa vaiheessa ���Lasten Hoidon Laatu Sairaalassa��� (LHLS III, versio nelj��) mittarilla ker��ttiin aineisto Suomen yliopistosairaaloiden lastenosastoilta kouluik��isilt�� 7-11 -vuotiailta lapsilta (n=388). Mittarin lopussa lapsia pyydettiin lis��ksi kuvailemaan kivointa ja ik��vint�� kokemustaan sairaalahoidon aikana lauseen t��ydennysteht��v��n��. Aineisto analysoitiin tilastollisesti sek�� sis��ll��n analyysilla. Lapset arvioivat fyysisen hoitoymp��rist��n, hoitajien inhimillisyyden ja luotettavuuden sek�� huolenpidon ja vuorovaikutustoiminnot kiitett��viksi. Lapset arvioivat hoitajien viihdytt��mistoiminnot kaikkein alhaisimmiksi. Lapsen ik�� ja sairaalantulotapa olivat yhteydess�� lasten saamaan tiedon m����r����n. Lasten kivoimmat kokemukset liittyiv��t ihmisiin ja heid��n ominaisuuksiinsa, toimintoihin, ymp��rist����n sek�� lopputuloksiin. Ik��vimm��t kokemukset liittyiv��t potilaana oloon, tuntemuksiin sairauden oireista sek�� erossaoloon, hoitoty��n fyysisiin toimintoihin sek�� ymp��rist����n. Tutkimuksen tulokset osoittavat lasten olevan kykenevi�� arvioimaan omaa hoitoaan ja heid��n n��k��kulmansa tulisi n��hd�� osana koko laadun kehitt��misprosessia parannettaessa laatua k��yt��nn��ss�� todella lapsil��ht��isemm��ll�� l��hestymistavalla. ���Lasten Hoidon Laatu Sairaalassa��� (LHLS) mittari on mahdollinen v��line saada tietoa lasten arvioinneista lasten hoitoty��n laadusta, mutta mittarin testaamista tulisi jatkaa tulevaisuudessa

Community-acquired pneumonia in adult patients with special reference to rapid methods for etiological diagnosis

<b>Aikuispotilaan kotisyntyisen keuhkokuumeen etiologinen diagnostiikka mikrobiologisilla pikamenetelmill��</b> <b>Tausta. </b>Keuhkokuume on vakava sairaus, johon sairastuu Suomessa vuosittain n. 60 000 aikuista. Huolimatta siit��, ett�� taudin hoito on kehittynyt, siihen liittyy yh�� merkitt��v��, 6-15%:n kuolleisuus. Alahengitystieinfektion aiheuttajamikrobien tunnistaminen on my��s edelleen haasteellista. <b>Tavoitteet. </b>T��m��n ty��n tavoitteena oli tutkia Turun yliopistollisessa keskussairaalassa hoidettujen aikuispotilaiden keuhkokuumeen etiologiaa sek�� selvitt���� uusien mikrobiologisten pikamenetelmi��en hy��dyllisyytt�� taudinaiheuttajan toteamisessa. <b>Aineisto. </b>Osat��iden I ja III aineisto koostui 384 Turun yliopistollisen keskussairaalaan infektio-osastolla hoidetusta keuhkokuumepotilaasta. Osaty��ss�� I tutkittiin keuhkokuumeen aiheuttaja��mikrobeja k��ytt��m��ll�� perinteisten menetelmien lis��ksi antigeeniosoitukseen ja PCR-tekniikkaan perustuvia pikamenetelmi��. Osaty�� II k��sitti 231 potilaasta koostuvan alaryhm��n, jossa tutkittiin potilaiden nielun liman��ytteest�� rinovirusten ja enterovirusten esiintyvyytt��. Osaty��ss�� III potilailta tutkittiin plasman C-reaktiivisen proteiinin (CRP) pitoisuus ensimm��isten viiden sairaalahoitop��i��v��n aikana. Laajoja tilastotieteellisi�� analyysej�� k��ytt��m��ll�� selvitettiin CRP:n k��ytt��kelpoisuutta sairauden vaikeusasteen arvioinnissa ja komplikaatioiden kehittymisen ennustamisessa. Osaty��ss�� IV 68 keuhkokuumepotilaan sairaalaan tulovaiheessa otetuista n��ytteist�� m����ritettiin neutrofiilien pintareseptorien ekspressio. Osaty��ss�� V analysoitiin sis��tautien vuodeosastoilla vuosina 1996-2000 keuhkokuumepotilaille tehtyjen keuhkohuuhtelun��ytteiden laboratoriotutkimustulokset. <b>Tulokset. </b>Keuhkokuumeen aiheuttaja l��ytyi 209 potilaalta, aiheuttajamikrobeja l��ydettiin kaikkiaan 230. N��ist�� aiheuttajista 135 (58.7%) l��ydettiin antigeenin osoituksella tai PCR-menetelmill��. Suu��rin osa, 95 (70.4%), todettiin pelk��st����n kyseisill�� pikamenetelmill��. Respiratorinen virus todettiin antigeeniosoituksella 11.1% keuhkokuumepotilaalla. Eniten respiratorisia viruksia l��ytyi vakavaa keuhkokuumetta sairastavilta potilailta (20.3%). 231 keuhkokuumepotilaan alaryhm��ss�� todettiin PCR-menetelm��ll�� picornavirus 19 (8.2%) potilaalla. Respiratorinen virus l��ytyi t��ss�� potilasryh��m��ss�� kaiken kaikkiaan 47 (20%) potilaalta. N��ist�� 17:ll�� (36%) l��ytyi samanaikaisesti bakteerin aiheuttama infektio. CRP-tasot olivat sairaalaan tulovaiheessa merkitsev��sti korkeammat vakavaa keuhkokuumetta (PSI-luokat III-V) sairastavilla potilailla kuin liev���� keuhkokuumetta (PSI-luokat I-II) sairastavilla potilailla (p <0.001). Yli 100 mg/l oleva CRP-taso nelj��n p��iv��n kuluttua sairaa��laan tulosta ennusti keuhkokuumeen komplikaatiota tai huonoa hoitovastetta. Neutrofiilien komple��menttireseptorin ekspressio oli pneumokokin aiheuttamaa keuhkokuumetta sairastavilla merkitse��v��sti korkeampi kuin influenssan aiheuttamaa keuhkokuumetta sairastavilla. BAL-n��ytteist�� vain yhdess�� 71:st�� (1.3%) todettiin diagnostinen bakteerikasvu kvantitatiivisessa viljelyss��. Uusilla menetelmill��kin keuhkokuumeen aiheuttaja l��ytyi vain 9.8% BAL-n��ytteist��. <b>P����telm��t.</b> Uusilla antigeeniosoitus- ja PCR-menetelmill�� keuhkokuumeen etiologia voidaan saada selvitetty�� nopeasti. Lis��ksi n��it�� menetelmi�� k��ytt��m��ll�� taudin aiheuttajamikrobi l��ytyi huomattavasti suuremmalta osalta potilaista kuin pelk��st����n tavanomaisia menetelmi�� k��ytt��m��ll��. Pikamenetelmien hy��dyllisyys vaihteli taudin vaikeusasteen mukaan. Respiratorinen virus l��ytyi huomattavan usein keuhkokuumetta sairastavilta potilailta, ja n��iden potilaiden taudinkuva oli usein vaikea. Tulovaiheen korkeaa CRP-tasoa voidaan k��ytt���� lis��keinona arvioitaessa keuhkokuumeen vaikeutta. CRP on erityisen hy��dyllinen arvioitaessa hoitovastetta ja riski�� komplikaatioiden ke��hittymiseen. Neutrofiilien komplementtireseptorin ekspression tutkiminen n��ytt���� lupaavalta pi��kamenetelm��lt�� erottamaan bakteerien ja virusten aiheuttamat taudit toisistaan. Antimikrobihoitoa saavilla potilailla BAL-tutkimuksen l��yd��kset olivat v��h��iset ja vaikuttivat hoitoon vain harvoin.

First-Line Chemotherapy with Anthracycline and Taxane Combination in Metastatic Breast Cancer. Detection of bone metastases with TRACP 5b

<b>Background:</b> In Finland, breast cancer (BC) is the most common cancer among women, and prostate cancer (PC) that among men. At the metastatic stage both cancers remain essentially incurable. The goals of therapy include palliation of symptoms, improvement or maintenance of quality of life (QoL), delay of disease progression, and prolongation of survival. Balancing between efficacy and toxicity is the major challenge. With increasing costs of new treatments, appropriate use of resources is paramount. When new treatment regimes are introduced into clinical practice a comprehensive assessment of clinical benefit, adverse effects and cost is necessary. Both BC and PC show a predilection to metastasize to bone. Bone metastases cause significant morbidity impairing the patients�� QoL. Diagnosis of bone metastases relies mainly on radiological methods, which however lack optimal sensitivity and specificity. New tools are needed for detection and follow-up of bone metastases. <b>Aims:</b> Anthracyclines and taxanes are effective chemotherapeutic agents in the treatment of metastatic breast cancer (MBC) with different mechanisms of action. Therefore, evaluation of the combination of anthracyclines with taxanes was a justifiable approach in the treatment of MBC patients. We assessed the efficacy, toxicity, cost of treatment and QoL of BC patients treated with first-line chemotherapy for metastatic disease with the combination epirubicin and docetaxel. We also evaluated the diagnostic potential of tartrate-resistant acid phosphatase 5b (TRACP 5b) and carboxyterminal telopeptides of type I collagen (ICTP) in the diagnosis of bone metastases in BC and TRACP 5b in PC patients. <b>Results: </b>The combination of epirubicin and docetaxel was effective in this phase II study, but required individual dose adjustment to avoid neutropenic infections, and the use of growth factors to maintain a feasible dose level. The response rate was 54 % (95 % CI 37-71) and the median overall survival (OS) was 26 months. Of the patients, 87 % were treated for infections. The treatment of adverse events required additional use of health resources mainly due to neutropenic infections, thereby raising direct treatment costs by 20 %. Despite adverse events, the global QoL was not significantly compromised during the treatment. Clinically evident acute cardiac toxicity was not observed. The combination of serum TRACP 5b and ICTP was at least equally sensitive and specific in detection of of bone metastases as commonly used total alkaline phosphatise (tALP) in BC patients. In contrast, TRACP 5b was less specific and sensitive than tALP as a marker of skeletal changes in PC patients. <b>Conclusions:</b> Treatment with epirubicin and docetaxel showed high efficacy in first-line chemotherapy of MBC. The relatively high incidence of neutropenic infections requiring hospitalization increased the treatment costs. Despite adverse events, the global QoL of the patients was not significantly compromised. The combination of TRACP 5b and ICTP showed similar activity as tALP in detecting bone metastases in MBC. In contrast, TRACP 5b was less specific and sensitive than tALP as a marker of skeletal changes in PC.

Quality of Abdominal Surgical Nursing Care

The study evaluates the quality of abdominal surgical nursing care. The data were collected from patients (n=1208) having undergone abdominal surgical operations on their last day of hospitalization and nurses (n=218) working in the same wards. Three instruments originally created in Finland and adapted to the Lithuanian context were used: (1) Good Nursing Care Scale for patients and nurses (GNCS-P, GNCS-N), (2) Nurse Competence Scale (NCS), and (3) Nurse Empowerment Scale (NES). Patient and nurses��� perceptions of the quality of nursing care were evaluated. In addition, nurses��� perceptions of their competence and empowerment were evaluated. The patient and nurses' perceptions of the quality of abdominal surgical nursing care were positive, with more criticism in the nurses��� perceptions. Both patients and nurses gave the lowest evaluation to the quality in the progress of nursing care and the co-operation with significant others. The nurses gave the highest evaluation to the self-assessed level of their competence and the frequency of using competences in practice, with the highest assessment given to situation management and their role at work and the lowest to teaching-coaching and ensuring quality. The nurse perceptions of their empowerment were positive in the qualities and performance of an empowered nurse and empowerment promoting factors, with the highest evaluation in moral principles and sociability and the lowest evaluation in the future-orientedness and expertise. The empowerment-impeding factors were evaluated as negative. The perceptions of the quality of nursing care of both patients and nurses had significant correlations with patient and nurse satisfaction and nurse job independence. The nurse perceptions of their competence and empowerment correlated with their education, the type of the nurse license, completed courses of development of their knowledge and skills, nurse job independence, and nurse satisfaction. The nurse perceptions of the quality of nursing care had a positive correlation with their perceptions of competence and empowerment. Generally, the quality of nursing care was evaluated as high and had correlations with the patients' demographic and satisfaction factors and with the nurse demographic, work-related, and satisfaction factors. The study produced the knowledge that the quality in co-operation with significant others and the progress of nursing process, surgical nurse competence in teaching-coaching, and future-orientedness of surgical nurse empowerment need to be improved in order to develop the quality of abdominal surgical nursing care. The knowledge may be used to offer better services for abdominal surgical patients and increase their satisfaction with nursing care, as well as to increase nurses' satisfaction with work and independence at work. The study suggests implications for clinical practice and management, nursing education, and nursing research.

Burden of Influenza in Children

Background: Most children with influenza are treated as outpatients but, especially among young children, influenza-attributable illnesses often result in hospitalization. However, relatively scarce data exist on the clinical picture and the full disease burden of pediatric influenza. Prompt diagnosis of influenza could enable the institution of antiviral therapy and adequate cohorting of patients. Data are needed to help clinicians correctly suspect influenza at the time of hospital admission. Aims and methods: We conducted a prospective 2-year cohort study of respiratory infections in children aged ���13 years to determine the incidence of influenza in outpatient children and to assess the clinical presentation of influenza in various age groups seen in primary care. We also determined the rates of different complications attributable to influenza and the absenteeism of the children and their parents due to the child���s influenza infection. We then conducted a further 16-year retrospective study of children ���16 years of age, hospitalized with virologically confirmed influenza. We estimated the population-based rates of hospitalizations and determined the primary admission diagnoses of the hospitalized children in different age groups. Results: The average annual rate of influenza was highest (179 / 1000) among children <3 years old. In this age group, acute otitis media was diagnosed as a complication of influenza in 40% of children. High fever was the most prominent sign of influenza, and 20% of children <3 years of age had a fever ���40oC. Most children had rhinitis already during the first days of the illness. The average annual incidence of influenzarelated hospitalization was highest (276 / 100,000) among infants <6 months of age, of whom 52% were primarily admitted due to sepsis-like illnesses. Respiratory symptoms accounted for 38% of the hospitalizations. Conclusions: Influenza causes a substantial burden of illness on outpatient children and their families. The clinical presentation of influenza is most severe in children <3 years of age. The high incidence of influenza-associated hospitalizations among infants aged <6 months calls for more effective ways to prevent influenza in this age group. The clinical manifestations of influenza vary widely in different age groups of children at the time of hospital admission. Awareness of this phenomenon is important for the early recognition of the illness and the potential initiation of effective antiviral treatment of these patients.

Coercion, Perceived Care and Quality of Life Among Patients in Psychiatric Hospitals

The goals of the study were to describe patients��� perceptions of care after experiencing seclusion/restraint and their quality of life. The goal was moreover to identify methodological challenges related to studies from the perspective of coerced patients. The study was conducted in three phases between September 2008 and April 2012. In the first phase, the instrument Secluded/ Restrained Patients��� Perception of their Treatment (SR-PPT) was developed and validated in Japan in cooperation with a Finnish research group (n = 56). Additional data were collected over one year from secluded/restrained patients using the instrument (n = 90). In the second phase, data were collected during the discharge process (n = 264). In the third phase, data were collected from electronic databases. Methodological and ethical issues were reviewed (n = 32) using systematic review method. Patients perceived that co-operation with the staff was poor; patients��� opinions were not taken into account, treatment targets collated and treatment methods were seen in different ways. Patients also felt that their concerns were not well enough understood. However, patients received getting nurses��� time. In particular, seclusion/restraint was considered unnecessary. The patients felt that they benefited from the isolation in treating their problems more than they needed it, even if the benefit was seen to be minor. Patients treated on forensic wards rated their treatment and care significantly lower than in general units. During hospitalization secluded/restrained patients evaluated their quality of life, however, better than did non-secluded/restrained patients. However, no conclusion is drawn to the effect that the better quality of life assessment is attributable to the seclusion/restraint because patients��� treatment period after the isolation was long and because of many other factors, as rehabilitation, medication, diagnostic differences, and adaptation. According to the systematic mixed studies review variation between study designs was found to be a methodological challenge. This makes comparison of the results more difficult. A research ethical weakness is conceded as regards descriptions of the ethical review process (44 %) and informed consent (32 %). It can be concluded that patients in psychiatric hospital care and having a voice as an equal expert require special attention to clinical nursing, decision-making and service planning. Patients and their family members will be consulted in plans of preventive and alternative methods for seclusion and restraint. The study supports the theory that in ethical decision-making situations account should be taken of medical indications, in addition to the patients��� preferences, the effect of treatment on quality of life, and this depends on other factors. The connection between treatment decisions and a patient���s quality of life should be evaluated more structurally in practice. Changing treatment culture towards patients��� involvement will support daily life in nursing and service planning taking into account improvements in patients��� quality of life.

Children at psychiatric risk and their families in Bucharest, in the context of 25 years of changes after December 89��� Romanian Revolution

The aim of the present dissertation was to capture a picture of child and adolescent mental health in Romania, in the context of almost 25 years of changes following the Romanian Revolution of December ���89. A three-part study was carried out in order to provide consistent answers to the pre-defined objectives: to appraise the development of child and adolescent mental health services in Romania (Part I), to explore the characteristics of clinically-referred patients in a Romanian child and adolescent psychiatry department (Part II), to examine the children���s mental health state and its connections with family functioning and associated risk factors (Part III). A multi-method research approach was used, comprising one qualitative analysis and two quantitative research studies. Part I consisted of a comparative qualitative analysis of the answers given by 10 mental health professionals at a 12-questions open ended interview about the current situation in child and adolescent mental health in Romania, on three topics: changes, challenges, solutions. Part II involved a descriptive quantitative analysis of certain variables (e.g. age, gender, primary diagnosis, co-morbidities, time of hospitalization) conducted on the patients who had been admitted to the Child and Adolescent Psychiatry Department at ���Prof. Dr. Alexandru Obregia��� Psychiatry Hospital, Bucharest in 1991 and in 2013. Part III was conducted on 342 subjects enrolled in two clinical groups and one school group, this study being performed through a cross-sectional analysis on multi-informant child and adolescent mental health problems and competencies (CBCL, YSR, SDQ P, SDQ SR) and their interrelation with household information (HQ) and family functioning (FAD). Outlining the results it can be stated that: 1) The CAMH System in Romania is definitely set on the path of reorganization, including a higher involvement of beneficiaries and of the community. 2) The characteristics of the admitted patients have changed significantly during the last almost 25 years since `89 December Revolution, under the influence of word wide trends in child psychiatry and of administrative aspects of the mental health network in Romania. 3) The rates of main diagnoses and co-morbidities confirm the reports in literature, with Autism Spectrum Disorder being the most frequent childhood psychiatric disorders in this study. 4) The children���s mental health problems in the psychiatry group are comparable to those reported for other clinical populations. 5) Significant score differences were observed according to various household features and also meaningful associations between a child���s clinical status and different aspects of family functioning. The Romanian Child and Adolescent Psychiatry has started to adopt the norms and standards of the European Union. In the 25 years that have elapsed after the 1989 Revolution, many changes have occurred in Romanian CAMH, but many unresolved issues have also risen. Therefore, the major contribution of this thesis is that it provides a coherent and updated overview of the present-day situation from three different perspectives- those of mental healthcare professionals, the one observed in clinical patients and the one reported by children���s families.