Family satisfaction in the intensive care unit: what makes the difference?

PURPOSE: To assess family satisfaction in the ICU and to identify parameters for improvement. METHODS: Multicenter study in Swiss ICUs. Families were given a questionnaire covering overall satisfaction, satisfaction with care and satisfaction with information/decision-making. Demographic, medical and institutional data were gathered from patients, visitors and ICUs. RESULTS: A total of 996 questionnaires from family members were analyzed. Individual questions were assessed, and summary measures (range 0-100) were calculated, with higher scores indicating greater satisfaction. Summary score was 78 +/- 14 (mean +/- SD) for overall satisfaction, 79 +/- 14 for care and 77 +/- 15 for information/decision-making. In multivariable multilevel linear regression analyses, higher severity of illness was associated with higher satisfaction, while a higher patient:nurse ratio and written admission/discharge criteria were associated with lower overall satisfaction. Using performance-importance plots, items with high impact on overall satisfaction but low satisfaction were identified. They included: emotional support, providing understandable, complete, consistent information and coordination of care. CONCLUSIONS: Overall, proxies were satisfied with care and with information/decision-making. Still, several factors, such as emotional support, coordination of care and communication, are associated with poor satisfaction, suggesting the need for improvement. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s00134-009-1611-4) contains supplementary material, which is available to authorized users.

Respiratory distress syndrome in near-term babies after caesarean section

OBJECTIVE: Severe respiratory distress syndrome (RDS) caused by surfactant deficiency is described not only in preterm infants but also in (near-) term babies after caesarean section (CS), especially when carried out before the onset of labour. The aim of the present study was to document the severity of this theoretically avoidable entity in order to improve obstetric and perinatal care. PATIENTS: All neonates admitted to the paediatric intensive care unit of the University Hospital of Bern between 1988 and 2000 with RDS on the basis of hyaline membrane disease (HMD) needing mechanical ventilation (MV) after CS and with a birthweight > or = 2500 g were analysed. HMD was diagnosed when respiratory distress and the typical radiological signs were present. Patients were grouped into elective CS before onset of labour and before rupture of membranes (group 1, n = 34) and patients delivered by emergency CS or CS after onset of labour or rupture of membranes (group 2, n = 22). Analysed indices for severity of illness were duration of stay in intensive care unit and MV, ventilation mode, worst oxygenation index (OI), presence of pulmonary air leak, and systemic hypotension. RESULTS: Mean gestational age (GA) was 37 2/7 weeks in group 1 and 36 2/7 weeks in group 2; no patient had a GA of > or = 39 0/7 weeks. Duration of MV was 4.4 days in group 1 and 3.9 days in group 2. Thirteen patients (38%) of group 1 and 7 (32%) of group 2 had to be managed by rescue high-frequency ventilation. A total of 7 patients had an OI>40. Eight patients (24%) in group 1 and 4 (18%) in group 2 developed a pulmonary air leak. Fourteen neonates (41%) in group 1 had to be supported by catecholamines versus 5 (22%) in group 2. There was one death in group 1. CONCLUSION: Severe RDS on the basis of HMD can also occur in near-term babies after CS; even a fatal outcome can not be excluded. The severity of illness in elective CS without labour may be quite high and is comparable to newborns delivered by CS (after onset of labour and/or rupture of the membranes) who were 1 week younger. No case of HMD was found in our population when CS was carried out after completion of 39 post-menstrual weeks of gestation.

What Ethanol metabolites as biological markers tell us about alcohol use

Alcohol and tobacco related disorders are the two leading and most expensive causes of illness in central Europe. In addition to self reports and questionnaires, biomarkers are of relevance in diagnosis and therapy of alcohol use disorders.Traditional biomarkers such as gamma glutamyl transpeptidase or mean corpuscualr volume are indirect biomarkers and are subject to influence of age, gender and non alcohol related diseases, among others.Direct ethanol metabolites such as ethyl glucuronide (EtG), ethyl sulphate (EtS) and phosphatidylethanol (PEth) are direct metabolites of ethanol, that are positive after intake of ethyl alcohol. They represent useful diagnostic tools for identifying alcohol use even more accurately than traditional biomarkers. Each of these drinking indicators remains positive in serum and urine for a characteristic time spectrum after the cessation of ethanol intake-EtG and EtS in urine up to 7 days, EtG in hair for months after ethanol has left the body. Applications include clinical routine use, emergency room settings, proof of abstinence in alcohol rehabilitation programs, driving under influence offenders, workplace testing, assessment of alcohol intake in the context of liver transplantation and fetal alcohol syndrome.

A Health- and Resource-Oriented Perspective on NSLBP

Nonspecific low back pain (NSLBP) is an important health issue of our time. Personal as well as economic factors, like suffering pain and experiencing disability on the one hand and enormous and still increasing costs to the economy and society on the other hand, display the importance of the matter. Tremendous research has been conducted in the last few decades on NSLBP. A PubMed search (June 17, 2013) on “low back pain” provided 22,980 hits, and when specifying for “low back pain, systematic review,” 3,134 hits were still generated. Most research has been done examining the development, risk factors, or therapeutic measures of NSLBP, but hardly any literature exists on resources related to NSLBP. The aims of this review are twofold. In order to shade light on the salutogenetic approach of NSLBP, and thus to focus on health instead of illness, the first aim is to facilitate the understanding of which therapeutic measures enhance the ability to cope with chronic NSLBP and enable (more) normal functioning in life. The second aim is to stimulate the understanding of resources protecting against the onset of NSLBP or against the development of chronic NSLBP and its resulting work absence.

Angiotensin receptor agonistic autoantibody is highly prevalent in preeclampsia: correlation with disease severity.

Preeclampsia (PE), a syndrome affecting 5% of pregnancies, characterized by hypertension and proteinuria, is a leading cause of maternal and fetal morbidity and mortality. The condition is often accompanied by the presence of a circulating maternal autoantibody, the angiotensin II type I receptor agonistic autoantibody (AT(1)-AA). However, the prevalence of AT(1)-AA in PE remains unknown, and the correlation of AT(1)-AA titers with the severity of the disease remains undetermined. We used a sensitive and high-throughput luciferase bioassay to detect AT(1)-AA levels in the serum of 30 normal, 37 preeclamptic (10 mild and 27 severe), and 23 gestational hypertensive individuals. Here we report that AT(1)-AA is highly prevalent in PE ( approximately 95%). Next, by comparing the levels of AT(1)-AA among women with mild and severe PE, we found that the titer of AT(1)-AA is proportional to the severity of the disease. Intriguingly, among severe preeclamptic patients, we discovered that the titer of AT(1)-AA is significantly correlated with the clinical features of PE: systolic blood pressure (r=0.56), proteinuria (r=0.70), and soluble fms-like tyrosine kinase-1 level (r=0.71), respectively. Notably, only AT(1)-AA, and not soluble fms-like tyrosine kinase-1, levels are elevated in gestational hypertensive patients. These data serve as compelling clinical evidence that AT(1)-AA is highly prevalent in PE, and its titer is strongly correlated to the severity of the disease.

Deep gray matter atrophy in multiple sclerosis: a tensor based morphometry.

Tensor based morphometry (TBM) was applied to determine the atrophy of deep gray matter (DGM) structures in 88 relapsing multiple sclerosis (MS) patients. For group analysis of atrophy, an unbiased atlas was constructed from 20 normal brains. The MS brain images were co-registered with the unbiased atlas using a symmetric inverse consistent nonlinear registration. These studies demonstrate significant atrophy of thalamus, caudate nucleus, and putamen even at a modest clinical disability, as assessed by the expanded disability status score (EDSS). A significant correlation between atrophy and EDSS was observed for different DGM structures: (thalamus: r=-0.51, p=3.85 x 10(-7); caudate nucleus: r=-0.43, p=2.35 x 10(-5); putamen: r=-0.36, p=6.12 x 10(-6)). Atrophy of these structures also correlated with 1) T2 hyperintense lesion volumes (thalamus: r=-0.56, p=9.96 x 10(-9); caudate nucleus: r=-0.31, p=3.10 x 10(-3); putamen: r=-0.50, p=6.06 x 10(-7)), 2) T1 hypointense lesion volumes (thalamus: r=-0.61, p=2.29 x 10(-10); caudate nucleus: r=-0.35, p=9.51 x 10(-4); putamen: r=-0.43, p=3.51 x 10(-5)), and 3) normalized CSF volume (thalamus: r=-0.66, p=3.55 x 10(-12); caudate nucleus: r=-0.52, p=2.31 x 10(-7), and putamen: r=-0.66, r=2.13 x 10(-12)). More severe atrophy was observed mainly in thalamus at higher EDSS. These studies appear to suggest a link between the white matter damage and DGM atrophy in MS.

The adolescent response to pregnancy: Accepting the reality

The research literature on adolescent pregnancy indicates a relationship between early prenatal care and positive pregnancy outcomes, yet fewer than half of pregnant teenagers seek prenatal care in the first trimester of pregnancy. Although social support theory speculates that there should be a relationship between support and health outcomes, available studies do not reflect the processes by which pregnant adolescents use their social resources in making decisions about their pregnancies. This study describes the processes by which the adolescent comes to accept the reality of her pregnancy.^ Drawing from the social-psychological theories of illness behavior and symbolic interactionism, this study examines the symptom diagnosis and help seeking behavior of the pregnant adolescent. This approach describes how the adolescent interprets events and draws conclusions based on her social reality.^ Interviews were conducted with ten young women, aged 15-17, who had recently delivered a first child. Onset of prenatal care ranged from the third month to the seventh month. None were married, and all but two lived with a parent. All but one were currently in school. Initial unstructured interviews were attempted to construe the modes of expression of the young women regarding the event of pregnancy. Subsequent interviews elicited the processes of recognition and explanation of symptoms of pregnancy.^ Analysis revealed a consistent natural history in the subjects' experiences as they come to accept the reality of pregnancy. Symptom appraisal and definition involves noticing changes in themselves, and evaluating and attempting to find suitable explanations for these symptoms. Lay consultation from friends and family aids in identifying the symptoms and to receive suggestions for treatment. It is at this point that prenatal care is usually initiated. Finally the young women describe the integration of pregnancy into their belief systems. ^

Severity assessment tools in ICU patients with 2009 influenza A (H1N1) pneumonia.

The aim of this study was to determine if severity assessment tools (general severity of illness and community-acquired pneumonia specific scores) can be used to guide decisions for patients admitted to the intensive care unit (ICU) due to pandemic influenza A pneumonia. A prospective, observational, multicentre study included 265 patients with a mean age of 42 (±16.1) years and an ICU mortality of 31.7%. On admission to the ICU, the mean pneumonia severity index (PSI) score was 103.2 ± 43.2 points, the CURB-65 score was 1.7 ± 1.1 points and the PIRO-CAP score was 3.2 ± 1.5 points. None of the scores had a good predictive ability: area under the ROC for PSI, 0.72 (95% CI, 0.65-0.78); CURB-65, 0.67 (95% CI, 0.59-0.74); and PIRO-CAP, 0.64 (95% CI, 0.56-0.71). The PSI score (OR, 1.022 (1.009-1.034), p 0.001) was independently associated with ICU mortality; however, none of the three scores, when used at ICU admission, were able to reliably detect a low-risk group of patients. Low risk for mortality was identified in 27.5% of patients using PIRO-CAP, but above 40% when using PSI (I-III) or CURB65 (<2). Observed mortality was 13.7%, 13.5% and 19.4%, respectively. Pneumonia-specific scores undervalued severity and should not be used as instruments to guide decisions in the ICU.

Früherkennung und integrierte Versorgung von Jugendlichen und jungen Erwachsenen mit schweren psychotischen Erkrankungen

Prospektive 1-Jahres-Follow-up-Untersuchung in der kombinierte multidimensionale Früherkennung und alters- und fachübergreifende integrierte Versorgung (Interventionsbedingung, n = 120) mit einer Standardbehandlung (historische Kontrollgruppe, n = 105) bei Jugendlichen und jungen Erwachsenen in der frühen Phase einer psychotischen Störung verglichen wird. Daten bei Aufnahme in die Studie weisen auf eine hohe Komplexität und Schwere der Erkrankung hin. Primäres Zielkriterium ist die Rate einer 6-monatigen kombiniert symptomatischen und funktionalen Remission zum Studienendpunkt.

Improving Communication in Adolescent Cancer Care: A Multiperspective Study.

BACKGROUND Professionals treating adolescents with cancer must communicate well with them and their parents. Evidence suggests that the communication needs of this population are rarely met. Skills training can improve professional communication, but has been criticized for not being based on the experience of the participants in the clinical encounter. We took a multiperspective approach, drawing on perspectives of former adolescents with cancer, patients' parents, physicians, and nurses with the aim to provide suggestions for improvement in communication in adolescent cancer care. METHODS Adolescent cancer survivors (n = 16), parents (n = 8), pediatric oncologists (n = 12), and pediatric oncology nurses (n = 18) participated in 11 focus groups. They discussed their experiences communicating with each other. Transcripts were analyzed by thematic analysis. RESULTS We identified themes within the following sections: (1) The framework in which professionals communicate with adolescents with cancer (regression in a time of detachment, adolescents' perception and knowledge of illness, cognitive versus legal maturity, "lost in transition" between pediatric and adult oncology); (2) communication difficulties between professionals and patients and parents (professionals and patients/parents identified the other party as the source of difficulties), and (3) effective professional communication (there was some overlap on how doctors and nurses should communicate, along with substantially different expectations for the two professions). CONCLUSIONS The framework within which professionals communicate, the different perspectives on the factors that make communication difficult, and the different expectations regarding good communication by doctors and nurses should be considered when communication skills training courses are developed for professionals who work in adolescent oncology.

A Tort for Risk and Endogenous Bankruptcy

Conventional tort law bars victims of exposure to a toxic substance from filing suit until they actually develop symptoms of illness. Practically speaking, this rule often bars recovery due to bankruptcy and causal uncertainty. One solution is to allow victims to file at exposure for expected damages (a tort for risk). The trade-off is that such a rule may trigger a race to file among exposure victims, thereby itself inducing bankruptcy. This paper characterizes the conditions under which such a race will occur in equilibrium and examines the implications for social welfare.

Minority preferences and disease types for non-emergent emergency department usage in a CHIP population

Background. Of the over five million annual pediatric visits to U.S. emergency departments, one-third to one-half are for non-emergent conditions. Minorities are more likely to utilize the emergency department (ED) for non-emergent conditions. Very little research has analyzed the role of illness type, perceived need, or family preferences in explaining this disparity. ^ Objectives. This study examined racial-ethnic differences in preferences for care among non-emergent users of the ED. ^ Research design. A random selection of pediatric non-emergent ED users within a single CHIP managed care plan were surveyed regarding attitudes and health care preferences. Preferences for ED utilization were analyzed by racial-ethnic category, controlling for illness type, child and guardian age, education level, language, and perceived need. ^ Results. A total of 250 families were surveyed. Most respondents reported having a regular doctor, satisfaction with their physician, and ready access to their physician. Fifteen percent of White, 39% of Hispanic, and 38% of Black families reported they preferred the emergency department for ill care. In multivariate analysis, Whites families were significantly less likely to prefer the emergency department for ill visits (odds ratio, 0.12; 95% confidence interval 0.03-0.55) compared to Blacks and Hispanics. ^ Conclusions. Racial-ethnic disparities in non-emergent ED utilization may be partially explained by different preferences for care. ^ Key words: children, emergency department, preferences for care, disparities ^

Infectious diseases, immune status, and health insurance among child care providers in Houston, Texas

The objectives of this study were to compare female child-care providers with female university workers and with mothers of children in child-care centers for: (1) frequency of illness and work loss days due to infectious diseases, (2) prevalence of antibodies against measles, rubella, mumps, hepatitis B, hepatitis A, chickenpox and cytomegalovirus (CMV), and (3) status regarding health insurance and job benefits.^ Subjects from twenty child-care centers and twenty randomly selected departments of a university in Houston, Texas were studied in a cross-sectional fashion.^ A cluster sample of 281 female child-care providers from randomly selected child-care centers, a cluster sample of 286 university workers from randomly selected departments and a systematic sample of 198 mothers of children from randomly selected child-care centers.^ Main outcome measures were: (1) self-reported frequency of infectious diseases and number of work-days lost due to infectious diseases; (2) presence of antibodies in blood; and (3) self-reported health insurance and job benefits.^ In comparison to university workers, child-care providers reported a higher prevalence of infectious diseases in the past 30 days; lost three times more work-days due to infectious diseases; and were more likely to have anti-core antibodies against hepatitis B (odds ratio = 3.16 95% CI 1.27-7.85) and rubella (OR 1.88, 95% CI 1.02-3.45). Child-care providers had less health insurance and job-related benefits than mothers of children attending child-care centers.^ Regulations designed to reduce transmission of vaccine and non-vaccine preventable diseases in child-care centers should be strictly enforced. In addition policies to improve health insurance and job benefits of child-care providers are urgently needed. ^

Myanmar migrant laborers in Ranong, Thailand

Thailand is the major destination for migrants in mainland Southeast Asia, and Myanmar (Burmese) migrants account for the dominant share. This paper sheds light on the actual working conditions and the life of Myanmar migrants in Thailand, based on our intensive survey in Ranong in southern Thailand in 2009. We found a wide range of serious problems that Myanmar migrants face in everyday life: very harsh working conditions, low income, heavy indebtedness, risk of being human-trafficking victims, harassment by the police and military (especially of sex workers), high risk of illness including malaria and HIV/AIDS and limited access to affordable medical facilities, and a poor educational environment for their children.

Fundamentos antropológicos de las tecnologías biomédicas no terapéuticas

The important developments in technology in all areas of human life have generated high expectations and hopes with regard to the health sector. Science and technology have favored the development of incredible therapeutic treatments to help resolve numerous problems relating to illness and disability. Nonetheless, many developments in the therapeutic realm have given rise to discussions over the possibility of whether this same scientific and technological progress could be beneficial even for those who may not be sick. One may ask: why not apply the same knowledge and technology used for treatment of illness for conditions where therapy is not necessary, but there is a desire to care for, improve and enhance human person? These new horizons offered by biomedical technologies undoubtedly express a deep desire of every person for health, happiness, and a long life. In order to offer a response to these questions, current biomedical technologies and those in development offer a wide range of possibilities. Therefore, in this investigation we attempt to identify and define four areas of non-therapeutic treatment: illness prevention, health promotion, improving human nature, and human enhancement. These four areas, which do not directly regard illness, give rise to a series of questions, which range from those regarding the meaning of health and illness to those concerning anthropological questions, such as situations and conditions that must be taken into account so human dignity is respected. The treatment, improvement and enhancement of the human being imply clarifying in scientific and technological terms the truth and meaning of the human person as such. This research identifies and looks at the relationship between the four anthropological cornerstones which non-therapeutic biomedical technologies should be based upon so as not to impact or violate the dignity of the human person. This research presents the anthropological boundaries which non-therapeutic biomedical technologies should take into consideration so as not to alter or violate the dignity of the human person. At the same time, the research proposes an anthropological foundation on which to build a code of ethics for non-therapeutic biomedical technologies. El gran desarrollo de las tecnologías en todos los ámbitos de la vida del hombre ha generado una gran expectativa y esperanza en lo que se refiere a la salud. Ciencia y técnica están aportando grandes beneficios en materia terapéutica, ayudando a resolver muchos problemas concernientes a la enfermedad y a la discapacidad. Pero este desarrollo que se ha producido en el ámbito terapéutico nos conduce a la formulación de preguntas sobre las posibilidades que esos avances técnico-científicos pueden aportar en beneficio del hombre, cuando no se encuentra enfermo: ¿por qué no pueden aplicarse los conocimientos y tecnologías usados en terapia a un ámbito diferente, no terapéutico, con el fin de mantener, mejorar o incluso potenciar al hombre? Ciertamente los nuevos horizontes que abren las Tecnologías Biomédicas encuentran repercusión en el deseo de bienestar, de felicidad e incluso de prolongación de la vida presente en todos los hombres. Para responder a esta pregunta las Tecnologías Biomédicas han desarrollado y están desarrollando una gama muy amplia de posibilidades. En este trabajo intentamos organizar en cuatro áreas los conceptos de los tratamientos no-terapéuticos: prevención de la enfermedad, promoción de la salud, mejoramiento de la naturaleza humana y potenciación del hombre. Estas cuatro áreas, que no se refieren directamente a la enfermedad, generan una serie de interrogantes que van desde las preguntas sobre el significado de salud y enfermedad, hasta las cuestiones antropológicas relativas a la posibilidad y las condiciones que se han de dar para que tales acciones respeten la dignidad humana. Cuidar, mejorar y potenciar al hombre implica que los objetivos de la ciencia y de la técnica mantengan siempre claros los valores y la realidad del hombre en cuanto tal. ... Este Trabajo de Investigación presenta los límites antropológicos dentro de los cuales deben moverse las Tecnologías Biomédicas no-terapéuticas para no alterar el ser ni menoscabar la dignidad del hombre. Y ofrece los fundamentos antropológicos sobre los cuales se pueda construir un código ético y deontológico para las Tecnologías Biomédicas no-terapéuticas.