Delay for admission of unstable hospitalized patients to intensive care unit: a need for a medical emergency team?

INTRODUCTION. Patients admitted in Intensive Care Unit (ICU) from general wards are more severe and have a higher mortality than those admitted from emergency department as reported [1]. The majority of them develop signs of instability (e.g. tachypnea, tachycardia, hypotension, decreased oxygen saturation and change in conscious state) several hours before ICU admission. Considering this fact and that in-hospital cardiac arrests and unexpected deaths are usually preceded by warning signs, immediate on site intervention by specialists may be effective. This gave an impulse to medical emergency team (MET) implementation, which has been shown to decrease cardiac arrest, morbidity and mortality in several hospitals. OBJECTIVES AND METHODS. In order to verify if the same was true in our hospital and to determine if there was a need for MET, we prospectively collected all non elective ICU admissions of already hospitalized patients (general wards) and of patients remaining more than 3 h in emergency department (considered hospitalized). Instability criteria leading to MET call correspond to those described in the literature. The delay between the development of one criterion and ICU admission was registered. RESULTS. During an observation period of 12 months, 321 patients with our MET criteria were admitted to ICU. 88 patients came from the emergency department, 115 from the surgical and 113 from the medical ward. 65% were male. The median age was 65 years (range 17-89). The delay fromMETcriteria development to ICU admission was higher than 8 h in 155 patients, with a median delay of 32 h and a range of 8.4 h to 10 days. For the remaining 166 patients, an early MET criterion was present up to 8 h (median delay 3 h) before ICU admission. These results are quite concordant with the data reported in the literature (ref 1-8). 122 patients presented signs of sepsis or septic shock, 70 patients a respiratory failure, 58 patients a cardiac emergency. Cardiac arrest represent 5% of our collective of patients. CONCLUSIONS.Similar to others observations, the majority of hospitalized patients admitted on emergency basis in our ICU have warning signs lasting for several hours. More than half of them were unstable for more than 8 h. This shows there is plenty of time for early acute management by dedicated and specialized team such as MET. However, further studies are required to determine if MET implementation can reduce in-hospital cardiac arrests and influence the morbidity, the length of stay and the mortality.

ESCMID postgraduate technical workshop on intracellular bacteria: from biology to clinic.

Infection by intracellular bacteria can lead to several diseases in both veterinary and human medicine. Unfortunately, the biology of these intracellular bacteria is highly complex due to their interactions with their host cells. Thus, it is very important to develop several tools in order to better understand the complex intracellular life of these pathogens, so allowing to improve the diagnosis options and the treatments of infectious diseases that they are causing. The workshop organised in Villars-sur-Ollon (Switzerland) by the ESCMID Study group on intracellular bacteria was a good opportunity to enhance our knowledge on these fastidious pathogens. During 5 days, 15 speakers gave 41 talks, covering all fields, from biology to clinic of different intracellular bacteria such as Bartonella, Chlamydia, Coxiella, Ehrlichia, Listeria, Parachlamydia, Rickettsia, and Waddlia. The format of this postgraduate course, which took place in the Swiss mountains, allowed interactive sessions and living discussions between the participants coming from all around the world. One of the major strength was to gather epidemiologists, clinical microbiologists, infectious diseases specialists, entomologists, veterinarians as well as bioinformaticians, biochemists and biologists to deliver a unique "one-health science" on intracellular bacteria. Here, we summarise the main take-home messages delivered during this meeting.

Advanced nursing role to improve care among breast cancer patients

Background: Breast cancer is a devastating disease for women as it impacts on their intimate, familial, social life. We study the specificities of breast cancer nurse interventions related to demands of support, information and coordination. Material and Methods: More than 300 patients are treated every year in our institution. From 2006 January to 2008 December, the specialist nurse has reported demands of patients and professionals: 1. Patients' needs related to support, information and coordination of care were collected from consultations with her and from their phone calls on using working days help line 2. Demands of breast cancer specialists and general practitioners related to information and coordination for specific patients were collected from their phone calls. Results: The specialist nurse received 679 phone calls respectively 71.5% from patients and 28.5% from professionals. Data are presented in the following table. Table 1: Evolution of number of patients and professionals demands Patients consultations Patients calls Professionals calls 2006 93 45 32 2007 210 200 40 2008 245 240 122 - Seventy percent (70%) of women asked for information about exams and treatments by phone and in nurse consultation. - Forty percent (40%) of women asked for support after announce of diagnosis. The specialist nurse proposed consultations, 2 to 4 consultations were necessary for women to express emotional distress or psychosocial problem. With this specialised nursing support less than 15% of patients were referred to the psycho-oncologist setting. - Forty percent (40%) of professionals asked support for patients and 60% for information and coordination of care. Conclusion: The interventions of the specialist nurse have improved coordination and quality of care. The increase of professionals' demands showed that it was necessary that a nurse assures continuity of information between hospital and extrahospital structures. The breast cancer nurse empowers patients and helps them to get well by providing support to fulfil specific needs.

"INTERMED": a method to assess health service needs. I. Development and reliability.

The purpose of this paper is to describe the development and to test the reliability of a new method called INTERMED, for health service needs assessment. The INTERMED integrates the biopsychosocial aspects of disease and the relationship between patient and health care system in a comprehensive scheme and reflects an operationalized conceptual approach to case mix or case complexity. The method is developed to enhance interdisciplinary communication between (para-) medical specialists and to provide a method to describe case complexity for clinical, scientific, and educational purposes. First, a feasibility study (N = 21 patients) was conducted which included double scoring and discussion of the results. This led to a version of the instrument on which two interrater reliability studies were performed. In study 1, the INTERMED was double scored for 14 patients admitted to an internal ward by a psychiatrist and an internist on the basis of a joint interview conducted by both. In study 2, on the basis of medical charts, two clinicians separately double scored the INTERMED in 16 patients referred to the outpatient psychiatric consultation service. Averaged over both studies, in 94.2% of all ratings there was no important difference between the raters (more than 1 point difference). As a research interview, it takes about 20 minutes; as part of the whole process of history taking it takes about 15 minutes. In both studies, improvements were suggested by the results. Analyses of study 1 revealed that on most items there was considerable agreement; some items were improved. Also, the reference point for the prognoses was changed so that it reflected both short- and long-term prognoses. Analyses of study 2 showed that in this setting, less agreement between the raters was obtained due to the fact that the raters were less experienced and the scoring procedure was more susceptible to differences. Some improvements--mainly of the anchor points--were specified which may further enhance interrater reliability. The INTERMED proves to be a reliable method for classifying patients' care needs, especially when used by experienced raters scoring by patient interview. It can be a useful tool in assessing patients' care needs, as well as the level of needed adjustment between general and mental health service delivery. The INTERMED is easily applicable in the clinical setting at low time-costs.

Delayed referral and gram-negative organisms increase the conversion thoracotomy rate in patients undergoing video-assisted thoracoscopic surgery for empyema

BACKGROUND: The role of video-assisted thoracoscopic surgery in the treatment of pleural empyema was assessed in a consecutive series of 328 patients between 1992 and 2002. An analysis of the predicting factors for conversion thoracotomy in presumed stage II empyema was performed. METHODS: Empyema stage III with pleural thickening and signs of restriction on computer tomography imaging was treated by open decortication, whereas a thoracoscopic debridement was attempted in presumed stage II disease. Conversion thoracotomy was liberally used during thoracoscopy if stage III disease was found at surgery. Predictive factors for conversion thoracotomy were calculated in a multivariate analysis among several variables such as age, sex, time interval between onset of symptoms and surgery, involved microorganisms, and underlying cause of empyema. RESULTS: Of the 328 patients surgically treated for stage II and III empyema, 150 underwent primary open decortication for presumed stage III disease. One hundred seventy-eight patients with presumed stage II empyema underwent a video-assisted thoracoscopic approach. Of these 178 patients, thoracoscopic debridement was successful in 99 of 178 patients (56%), and conversion thoracotomy and open decortication was judged necessary in 79 of 178 patients (44%). The conversion thoracotomy rate was higher in parapneumonic empyema (55%) as compared with posttraumatic (32%) or postoperative (29%) empyema; however, delayed referral (p < 0.0001) and gram-negative microorganisms (p < 0.01) were the only significant predictors for conversion thoracotomy in a multivariate analysis. CONCLUSIONS: Video-assisted thoracoscopic debridement offers an elegant, minimally invasive approach in a number of patients with presumed stage II empyema. However, to achieve a high success rate with the video-assisted thoracoscopic approach, early referral of the patients to surgery is required. Conversion thoracotomy should be liberally used in case of chronicity, especially after delayed referral (> 2 weeks) and in the presence of gram-negative organisms.

Mass casualty incidents with multiple burn victims: rationale for a Swiss burn plan.

INTRODUCTION: Mass casualty incidents involving victims with severe burns pose difficult and unique problems for both rescue teams and hospitals. This paper presents an analysis of the published reports with the aim of proposing a rational model for burn rescue and hospital referral for Switzerland. METHODS: Literature review including systematic searches of PubMed/Medline, reference textbooks and journals as well as landmark articles. RESULTS: Since hospitals have limited surge capacities in the event of burn disasters, a special approach to both prehospital and hospital management of these victims is required. Specialized rescue and care can be adequately met and at all levels of needs by deploying mobile burn teams to the scene. These burn teams can bring needed skills and enhance the efficiency of the classical disaster response teams. Burn teams assist with both primary and secondary triage, contribute to initial patient management and offer advice to non-specialized designated hospitals that provide acute care for burn patients with Total Burn Surface Area (TBSA) <20-30%. The main components required for successful deployments of mobile burn teams include socio-economic feasibility, streamlined logistical implementation as well as partnership coordination with other agencies including subsidiary military resources. CONCLUSIONS: Disaster preparedness plans involving burn specialists dispatched from a referral burn center can upgrade and significantly improve prehospital rescue outcome, initial resuscitation care and help prevent an overload to hospital surge capacities in case of multiple burn victims. This is the rationale behind the ongoing development and implementation of the Swiss burn plan.

Content validation of the dimensions constituting non-adherence to treatment of arterial hypertension

The objective of the study was to validate the content of the dimensions that constituted nonadherence to treatment of arterial systemic hypertension. It was a methodological study of content validation. Initially an integrative review was conducted that demonstrated four dimensions of nonadherence: person, disease/treatment, health service, and environment. Definitions of these dimensions were evaluated by 17 professionals, who were specialists in the area, including: nurses, pharmacists and physicians. The Content Validity Index was calculated for each dimension (IVCi) and the set of the dimensions (IVCt), and the binomial test was conducted. The results permitted the validation of the dimensions with an IVCt of 0.88, demonstrating reasonable systematic comprehension of the phenomena of nonadherence.

Cultural adaptation of the scale Pain Assessment in Advanced Dementia – PAINAD to Brazil

Objective: To translate and culturally adapt to Brazil the scale Pain Assessment in Advanced Dementia(PAINAD).Method: The cultural adaptation process followed the methodology of a theorical reference, in five steps: translation to Brazilian Portuguese, consensual version of translations, back-translation to the original language, revision by a committee of specialists in the field and a equivalency pre-test. The instrument was assessed and applied by 27 health professionals in the last step. Results: The Escala de Avaliação de Dor em Demência Avançada was culturally adapted to Brazil and presented semantic equivalency to the original, besides clarity, applicability and easy comprehension of the instrument items. Conclusion: This process secured the psychometric properties as the reliability and content validity of the referred scale.


Informatics competencies essential to decision making in nursing management

Abstract OBJECTIVE To identify informatics abilities essential to decision making in nursing management. METHOD Survey study with specialist nurses in health informatics and management. An electronic questionnaire was built based on the competencies Information Literacy (five categories; 40 abilities) and Information Management (nine categories; 69 abilities) of the TIGER - Technology Informatics Guiding Education Reform - initiative, with the guiding question: Which informatics abilities are essential to decision making in management? Answers were sorted in a Likert scale, ranging from 1 to 5. Rasch analysis was conducted with the software WINSTEPS ®. Results were presented in logits, with cutoff value zero. RESULTS Thirty-two specialists participated, coming from all regions of Brazil. In the information literacy competency, 18 abilities were considered essential and in Information Management, 38; these were sorted according to their degree of essentiality. CONCLUSION It is believed that the incorporation of these abilities in teaching can support the education of nurse managers and contribute to evidence-based practice, incorporation of information and communication technologies in health and information management.

Welcome To Medicare Physical Exam, September 2007

Medicare will cover a one-time preventive physical exam within the first six months that you have Part B. This benefit is for all Medicare beneficiaries including those under age 65. How much does the exam cost? You pay 20% of the Medicare approved amount after you meet the yearly Part B deductible ($131 for 2007). Since this exam may be your first Medicare-covered service, you could meet your entire Part B deductible for the year. Medicare will cover the exam if performed by a physician, physician assistant, nurse practitioner, or clinical nurse specialist. What should I expect during the exam? The “Welcome to Medicare Physical” will include the following: 1. A review of your medical and social history. 2. A review of your potential risk factors for depression. 3. A review of your functional ability and level of safety. 4. Blood pressure, height, weight and vision test 5. An electrocardiogram (EKG) 6. Education and counseling on the above five items. 7. A written plan explaining screenings and other recommended preventive services. All seven elements must be documented in order for the physical to be covered by Medicare. The exam does not include clinical laboratory tests. Medicare will pay for a one-time ultrasound screening for abdominal aortic aneurysms for beneficiaries who are at risk (has a family history or a man age 65 to 75 who has smoked at least 100 cigarettes in his lifetime.) Only Medicare beneficiaries who receive a referral from the Welcome to Medicare physical exam will be covered for this benefit. There is no Part B deductible, but you or your supplemental insurance will be responsible for the coinsurance. What should I take to the exam? You should bring the following when you go to your “Welcome to Medicare” physical exam: • Medical records, including immunization records (if you are seeing a doctor for the first time) • Family health history • A list of current prescription drugs, how often you take them, and why.

Are gall midge species (Diptera, Cecidomyiidae) host-plant specialists?

Despite the speciose fauna of gall-inducing insects in the Neotropical region, little is known about their taxonomy. On the other hand, gall morphotypes associated with host species have been extensively used as a surrogate of the inducer species worldwide. This study reviewed the described gall midges and their galls to test the generalization on the use of gall morphotypes as surrogates of gall midge species in the Brazilian fauna. We compiled taxonomic and biological data for 196 gall midge species recorded on 128 host plant species. Ninety two percent of those species were monophagous, inducing galls on a single host plant species, whereas only 5.6% species were oligophagous, inducing galls on more than one congeneric host plant species. Only four species induced galls on more than one host plant genus. We conclude that gall morphotypes associated with information on the host plant species and attacked organs are reliable surrogates of the gall-inducing species.

An estimate of the potential number of mayfly species (Ephemeroptera, Insecta) still to be described in Brazil

ABSTRACTThis study reviewed the data on the Brazilian Ephemeroptera, based on the studies published before July, 2013, estimated the number of species still to be described, and identified which regions of the country have been the subject of least research. More than half the species are known from the description of only one developmental stage, with imagoes being described more frequently than nymphs. The Brazilian Northeast is the region with the weakest database. Body size affected description rates, with a strong tendency for the larger species to be described first. The estimated number of unknown Brazilian species was accentuated by the fact that so few species have been described so far. The steep slope of the asymptote and the considerable confidence interval of the estimate reinforce the conclusion that a large number of species are still to be described. This emphasizes the need for investments in the training of specialists in systematics and ecology for all regions of Brazil to correct these deficiencies, given the role of published papers as a primary source of information, and the fundamental importance of taxonomic knowledge for the development of effective measures for the conservation of ephemeropteran and the aquatic ecosystems they depend on.

Motifs de consultation en médecine du travail [Reasons for consultation in occupational medicine].

The inability to characterize more precisely the extent of occupational diseases limits the implementation of an effective preventive policy. Furthermore, not all work-related conditions are reported by the Swiss workers' compensation system. A seven-year (1986 to 1992) retrospective study of medical visits in an Institute of Occupational Health Sciences is presented. The objective of this study is to expand data on occupational diseases for clinical and public health intervention. 298 patients have been examined for a possible work-related condition. In 140 cases (47%), an occupational disease according to the Swiss Law was found. Respiratory tract was the main target of industrial pollutants. Respiratory irritation , solvent intoxications, contact dermatitis and asthma were the most frequent conditions seen. 97 workplace visits (32% of all medical visits) were necessary for diagnostic purposes. Painters (construction, cars) and other solvent exposed workers were at particular risk. Rare alpha-1-antitrypsin phenotypes were found several times in workers with respiratory diseases confirming the value of this test in occupational medicine. Despite many referral biases, direct clinical and public health applications of the data are possible. This study confirms the hypothesis that occupational respiratory diseases and intoxications are probably underreported in the workers' compensation statistics. Activities with an increased risk of work-related diseases have been identified so workplace intervention could be highly targeted. This study shows also that a more intense collaboration between primary care physicians, hospital services and occupational medical specialists is necessary to improve clinical and epidemiological surveillance of work-related health conditions.

How adult specialists deal with the principles of a successful transition.

OBJECTIVES: To evaluate whether adult specialists comply with the basic principles for a successful transition of adolescents with chronic disorders, and to determine whether the characteristics of the adult specialists have an influence on applying these principles. METHODS: Out of 299 adult specialists in four French-speaking Swiss cantons, 209 (70%) answered a paper-and-pencil mailed questionnaire between May and July 2007. Only those having received the transfer of at least one adolescent in the previous 2 years (N=102) were included in the analysis. We analyzed four dependent variables: discussing common concerns of adolescent patients, seeing the patient alone, having a transition protocol, and having a previous contact with the pediatric specialist. A logistic regression was performed for each dependent variable controlling for the physicians' characteristics (number of transfers, age, gender, workplace, and perceived experience). RESULTS: Fifty-four percent of the physicians did not spend time alone with their patients, and sensitive issues such as sexuality or substance use were not widely discussed with their young patients. Most respondents (59%) did not have an established protocol, and 54% did not have any contact with the pediatric specialist. In the multivariate analyses, the adult specialists' characteristics had little impact. CONCLUSIONS: For many adolescents with chronic disorders the transition from pediatric to adult healthcare seems to be limited to a simple transfer, often lacking adequate communication between physicians. Applying simple but basic principles such as a good coordination between providers would probably improve the quality of healthcare of adolescents with chronic illness.

Preliminary report of the first season work of the International Pluridisciplinary Archaeological Expedition to Bactria 2006

The International Pluridisciplinary Archaeological Expedition in Bactria (IPAEB) was created in 2006.The name underlines the international character of the team (which includes Uzbeks, Spanish, French, British and Greek members), the presence of specialists from various fields apart from archaeology and the fame of Bactria1.