Seriously-ill Patients Research Articles

Cefiderocol use in Gram negative infections with limited therapeutic options: Is combination therapy the key?

ObjectivesTo date limited information about cefiderocol use is provided by real life studies. Our aim is to evaluate characteristics and outcome of patients with Gram-negative infections with limited therapeutic options treated with cefiderocol in combination or monotherapy. MethodsWe retrospectively collected data on demographical, clinical characteristics and clinical cure, in-hospital and 30-days mortality, microbiological failure and Clostridioides difficile infections of all patients ≥ 18 years old treated with cefiderocol for ≥ 48 h. ResultsThere were 18 patients of which 14 (77.8%) treated with cefiderocol in combination and 4 (22.2%) with monotherapy. Median age was 54.5 (IQR 35.25–65.75) vs 70.5 (IQR 57.5–78.25) years old, respectively and ward of admission was the ICU in the 78.57% vs 100% of cases. In the 50% vs 100% of cases infections were VAP with concomitant bloodstream infections. Median SOFA score was 10 (IQR 4.5–12.5) vs 5 (IQR 4–6) and APACHE II score was 13.5 (IQR 7.5–18) vs 16 (IQR 8.5–23.5), respectively. Isolated pathogen was carbapenems-resistant Acinetobacter baumannii in 78.57% vs 100% of cases. Median duration of cefiderocol treatment was 9.5 (IQR 7–13.25) vs 9 days (IQR 5.5–12.5) and in 77.8% patients it was used in combination therapy, of which 57.1% were colistin-spairing regimens. Clinical cure was achieved in 64.29% for combination therapy vs 75% of monotherapy treated patients, 30-days mortality rate was 28.57% vs 25% and 30-day ICU admission rate was 14.29% vs 50%, respectively. No statistically significant differences were observed between combination therapy and monotherapy treated patients. ConclusionsTo date, no differences have been demonstrated between cefiderocol monotherapy or combination. Further studies are required to understand whether cefiderocol combination therapy could provide an advantage in outcome in seriously-ill patients.

What’s Race got to do With it? How Palliative Care Consultation may Mitigate Racial Disparities in Future Care

It is unknown if care and cost outcomes differ by race and ethnicity following discharge from a hospitalization involving palliative care consultation to discuss goals-of-care (PCC). In this secondary analysis of 1,390 seriously-ill patients age 18+ alive at discharge who self-identified as Black, Hispanic, Asian, white, or other race and received PCC at an urban, academic medical center, we used binomial logistic regression and multiple linear regression controlling for demographic and clinical variables to identify factors associated with care experiences and costs following discharge from a hospitalization with PCC. In adjusted analyses, discharge to hospice was associated with Medicaid (p=0.016). Thirty-day readmission was associated with age 75+ (P=0.015), Medicaid (P=0.004), admission 30 days prior (P<0.0001), and Black race compared to white (P=0.016). Number of future days hospitalized was associated with Medicaid (P=0.001), admission 30 days prior (P=0.017), and Black race compared to white (P=0.012). Having any future hospitalization cost was associated with patient ages 65-74 (P=0.022) and 75+ (P=0.023), Medicaid (P=0.014), admission 30-days prior (P<0.0001), and Black race compared to white (P=0.021). Total future hospitalization costs were associated with female gender (P=0.025), Medicaid (P=0.009), admission 30 days prior (P=0.040), and Black race compared to white (P=0.037). Race or ethnicity was not a predictor of hospice enrollment. Randomized controlled trials are needed to understand if PCC is an intervention that reduces racial disparities in end-of-life care. Qualitative insights are needed to explain how PCC and socioeconomic factors such as Medicaid may mitigate future acute care use among racial and ethnic groups.

The SHARE study: Pilot study of a communication intervention designed to elicit advanced-stage cancer patients’ preferences and goals.

e24120 Background: Helping seriously-ill cancer patients identify and communicate their preferences for care can increase satisfaction, decrease anxiety and depression, and result in less intensive, hospital-based end-of-life medical care. We developed an intervention designed to elicit patients’ preferences and goals for care and share them with their family and care teams. We sought to pilot-test the feasibility and acceptability of this intervention in advanced cancer patients. Methods: We enrolled advanced-stage cancer patients and their clinicians at an academic and community oncology practice. Eligibility criteria included: patients with metastatic solid tumors and ≥2 prior lines of therapy or patients for whom oncologists indicated that they “would not be surprised” if the patient died within 6 months. Participants watched a 2.5 minute video which prompted them to think about how they define “a good day;” completed a 3-page brief questionnaire, which was shared with their care team; and were given a wallet card with question prompts. The primary outcomes were feasibility (i.e., ≥60% approach-to-consent ratio among eligible patients, ≥60% of participants rated the intervention positively) and acceptability (i.e., ≥60% of participants would recommend the intervention to patients like them). Secondary outcomes, measured pre- and post-intervention, included patient anxiety and distress, hope, quality of life, and therapeutic alliance with their care team. Results: Among 59 potentially eligible patients approached, 53 agreed to participate (90% approach-to-consent ratio). Four patients were non-evaluable because they died before study completion. Among the 49 remaining participants (mean age = 63 years, range 40-86 years), all completed the intervention. Overall, 45 of 49 patients (92%) rated their experience as excellent, very good, or good. Most participants agreed or strongly agreed that they would recommend the video (83%), brief questionnaire (88%), and wallet card (63%) to patients with cancers like theirs. However, only 34% of participants reported having an opportunity to review the questionnaire with their oncologist. There were no increases in patient anxiety or distress associated with the intervention or reductions in hope, quality of life, or therapeutic alliances with oncologists (all P &gt; 0.05). Conclusions: A communication intervention that combined a video, questionnaire, and wallet card was both feasible and acceptable for helping advanced cancer patients identify their care preferences and goals. Future studies should examine combining this with an intervention that primes clinicians to engage in goals of care discussions with advanced-stage cancer patients. Clinical trial information: NCT03392090.

Identification of key biomarkers and immune infiltration in systemic lupus erythematosus by integrated bioinformatics analysis

BackgroundSystemic lupus erythematosus (SLE) is a multisystemic, chronic inflammatory disease characterized by destructive systemic organ involvement, which could cause the decreased functional capacity, increased morbidity and mortality. Previous studies show that SLE is characterized by autoimmune, inflammatory processes, and tissue destruction. Some seriously-ill patients could develop into lupus nephritis. However, the cause and underlying molecular events of SLE needs to be further resolved.MethodsThe expression profiles of GSE144390, GSE4588, GSE50772 and GSE81622 were downloaded from the Gene Expression Omnibus (GEO) database to obtain differentially expressed genes (DEGs) between SLE and healthy samples. The gene ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichments of DEGs were performed by metascape etc. online analyses. The protein–protein interaction (PPI) networks of the DEGs were constructed by GENEMANIA software. We performed Gene Set Enrichment Analysis (GSEA) to further understand the functions of the hub gene, Weighted gene co‐expression network analysis (WGCNA) would be utilized to build a gene co‐expression network, and the most significant module and hub genes was identified. CIBERSORT tools have facilitated the analysis of immune cell infiltration patterns of diseases. The receiver operating characteristic (ROC) analyses were conducted to explore the value of DEGs for SLE diagnosis.ResultsIn total, 6 DEGs (IFI27, IFI44, IFI44L, IFI6, EPSTI1 and OAS1) were screened, Biological functions analysis identified key related pathways, gene modules and co‐expression networks in SLE. IFI27 may be closely correlated with the occurrence of SLE. We found that an increased infiltration of moncytes, while NK cells resting infiltrated less may be related to the occurrence of SLE.ConclusionIFI27 may be closely related pathogenesis of SLE, and represents a new candidate molecular marker of the occurrence and progression of SLE. Moreover immune cell infiltration plays important role in the progession of SLE.

Implementation of palliative care consult Service in Hungary \u2013 integration barriers and facilitators

BackgroundThe Palliative Care Consult Service (PCCS) programme was among the first initiations in Hungary to provide palliative care for patients admitted to hospital. The PCCS team provides palliative care for mainly cancer patients and their family members and manages the patient pathway after being discharged from the hospital. The service started in 2014 with 300–400 patient visits per year. The aim of this study is to give a comprehensive overview of the PCCS programme guided by a conceptual framework designed by SELFIE (“Sustainable intEgrated chronic care modeLs for multi-morbidity: delivery, FInancing, and performancE”), a Horizon2020 funded EU project and to identify the facilitators and barriers to its wider implementation.MethodsPCCS has been selected by the SELFIE consortium for in-depth evaluation as one of the Hungarian integrated care models for persons with multi-morbidity. The qualitative analysis of the PCCS programme was based on available documents of the care provider and interviews with different stakeholders related to the programme.ResultsThe integrated, multidisciplinary and patient-centred approach was well-received among the patients, family members and clinical departments, as verified by the increasing number of requests for consultations. As a result of the patient pathway management across providers (e.g. from inpatient care to homecare) a higher level of coordination could be achieved in the continuity of care for seriously-ill patients. The regulatory framework has only partially been established, policies to integrate care across organizations and sectors and adequate financial mechanism to support the enhancement and sustainability of the PCCS are still missing.ConclusionsThe service integration of palliative care could be implemented successfully in an academic hospital in Hungary. However, the continuation and enhancement of the programme will require further evidence on the performance of the integrated model of palliative care and a more systematic approach particularly regarding the evaluation, financing and implementation process.

It Takes a Village: An Interdisciplinary Effort to Improve the PAL-05 Measure in a Large Academic Medical Center (QI719)

1.Review the Joint Commission PAL-05 measure description and expectations.2.Discuss some of the barriers to meeting the PAL-05 measure.3.Describe an interdisciplinary approach using a step-wise method to improve PLA-05 measure compliance. The National Consensus Project for quality palliative care (2013) guidelines recommend that a patient’s or surrogate’s goals and treatment preferences are used as the foundation for the plan of care. Despite recognition of the value of these conversations by both physicians and patients, there is often hesitancy to initiate these discussions. According to the PEACE project the use of a Treatment Preferences quality measure will promote discussions regarding treatment preferences and goals between seriously-ill patients and their physicians. The Joint Commission’s PAL-05 measure assures that documentation of the patient’s treatment preferences and goals accompanies the patient to the next level of care. Joint Commission certified palliative care programs, however, have found it challenging to develop a feasible and effective approach to meet this measure. Utilizing an interdisciplinary approach along with a step-wised method is crucial to the successful development and execution of the PAL-05 measure Initiative. In order to integrate the important PAL-05 quality measure in our large academic medical center, we developed an interdisciplinary committee encompassing representatives from the palliative care service, nursing leadership, social work, information technology, and quality measure. Several steps were taken, including monthly meetings scheduled over the course of six months, to discuss design, construction, and education of the PAL-05 measure initiative. This initiative encompassed three phases. 1) design and construction; 2) education and training; 3) assessment and impact. Data regarding compliance of the PAL-05 measure was collected at the one month and three month mark. User feedback regarding the practicality and effectiveness of this initiative was assessed via a survey. Data collected showed marked increased in PAL-05 measure compliance, as well as the impact and feasibility of this initiative. Our approach highlights the importance of collaborating with other disciplines, especially when dealing with the complexity of caring for seriously-ill and end-of-life patients.

Facilitating Out-of-the-Box Solutions

Facilitating Out-of-the-Box Solutions

Abstract TP360: The Use of Decision Aids for End-of-Life Surrogate Decision Making for Critically-ill Stroke Patients: A Systematic Review

Background: In severe stroke, prognostic uncertainty creates challenges for surrogates when asked to maintain or forego life-sustaining treatments for seriously-ill patients. Surrogates experience adverse psychological symptoms associated with decisional conflict surrounding end-of-life (EoL) decision making. A 2013 IOM report maintains that quality of care can be improved by integrating patients and caregivers into decision making at every possible level. Purpose: This review was performed to identify levels of evidence in studies of decision aids (DAs) on surrogate decision making in critical illness; determine the feasibility and acceptability of DAs to facilitate EoL surrogate decision making for acutely-ill stroke patients; and evaluate the outcomes of DAs for EoL surrogate decision making for severe stroke patients. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses was used to generate literature pertaining to DAs used to facilitate surrogate decision making in critical illness. Final keywords used included: “decision aid or decision tool”, “surrogate decision making or family decision making”, and “prognosis or outcome or recovery”. The total number of articles produced was 607 via CINAHL and PubMed. Inclusion/exclusion criteria were used to identify articles of relevance. Following screening, nine studies were selected. Monthly searches will continue to identify current literature. Results: Research designs ranged from pilot studies to randomized controlled trials. Four trials provided direction: one was performed in an ICU with patients with prolonged mechanical ventilation; two examined a DA to facilitate goals of care for advanced dementia patients; and one evaluated a video aid to determine the accuracy of surrogate decision making. No studies explored the use of a DA for critically-ill stroke patients. Conclusion: There is a need to investigate the feasibility and acceptability of a DA aimed to reduce psychological symptoms in surrogates for critically-ill stroke patients by promoting shared EoL decision making and reducing decisional conflict as well as regret.

ListeningTime; participatory development of a web-based preparatory communication tool for elderly cancer patients and their healthcare providers

ObjectiveThis paper outlines the participatory development process of a web-based preparatory communication tool for elderly cancer patients and their oncological healthcare providers (HCPs). This tool aims to support them to (better) prepare their encounters. An overarching aim of the project is to develop the tool in a participatory way to increase uptake and use. MethodsScrum, a participatory framework originated from software development, was applied to develop the tool. Using constant feedback loops, elderly (former) cancer patients, oncological HCPs and their representatives were, as end-users, involved. ResultsDuring six ‘sprints’, the communication tool ‘ListeningTime’ was developed with input from end-users. The use of scrum in developing an innovative tool was challenging in this context, because of time constraints of seriously-ill patients and busy HCPs and the co-creation involving non-profit scientific researchers and a for-profit development company. ConclusionsThe collaboration with end-users facilitated the development process of ListeningTime. Early involvement of end-users and flexibility in terms of planning and setup appear to be preconditions for creating a bottom-up inspired development procedure. Several challenges emerged from using scrum as participatory framework. Nevertheless, the ‘pressure cooking situation’, using scrum, resulted in a quick development process and a product ready for implementation.

What Improves Quality of Life for Seriously-Ill Patients and Their Caregivers? From Observation to Intervention to Dissemination (SA510-B)

What Improves Quality of Life for Seriously-Ill Patients and Their Caregivers? From Observation to Intervention to Dissemination (SA510-B)

Do unto others: doctors' personal end-of-life resuscitation preferences and their attitudes toward advance directives.

ObjectiveHigh-intensity interventions are provided to seriously-ill patients in the last months of life by medical sub-specialists. This study was undertaken to determine if doctors' age, ethnicity, medical sub-specialty and personal resuscitation and organ donation preferences influenced their attitudes toward Advance Directives (AD) and to compare a cohort of 2013 doctors to a 1989 (one year before the Patient Self Determination Act in 1990) cohort to determine any changes in attitudes towards AD in the past 23 years.DesignDoctors in two academic medical centers participated in an AD simulation and attitudes survey in 2013 and their responses were compared to a cohort of doctors in 1989.OutcomesResuscitation and organ donation preferences (2013 cohort) and attitudes toward AD (1989 and 2013 cohorts).ResultsIn 2013, 1081 (94.2%) doctors of the 1147 approached participated. Compared to 1989, 2013 cohort did not feel that widespread acceptance of AD would result in less aggressive treatment even of patients who do not have an AD (p<0.001, AUC = 0.77); had greater confidence in their treatment decisions if guided by an AD (p<.001, AUC = 0.58) and were less worried about legal consequences of limiting treatment when following an AD (p<.001, AUC = 0.57). The gender (p = 0.00172), ethnicity (χ2 14.68, DF = 3,p = .0021) and sub-specialty (χ2 28.92, p = .004, DF = 12) influenced their attitudes towards AD. 88.3% doctors chose do-not-resuscitate status and wanted to become organ donors. Those less supportive of AD were more likely to opt for “full code” even if terminally ill and were less supportive of organ donation.ConclusionsDoctors' attitudes towards AD has not changed significantly in the past 23 years. Doctors' gender, ethnicity and sub-specialty influence their attitudes towards AD. Our study raises questions about why doctors continue to provide high-intensity care for terminally ill patients but personally forego such care for themselves at the end of life.

Family Understanding of Seriously-ill Patient Preferences for Family Involvement in Healthcare Decision Making

Surrogate accuracy in predicting patient treatment preferences (i.e., what patients want) has been studied extensively, but it is not known whether surrogates can predict how patients want loved ones to make end-of-life decisions on their behalf. To evaluate the ability of family members to correctly identify the preferences of seriously-ill patients regarding family involvement in decision making. Cross-sectional survey. Twenty-five pancreatic cancer and 27 amyotrophic lateral sclerosis (ALS) patients and their family members (52 dyads total). Patients and family members completed the Decision Control Preferences (DCP) scale regarding patient preferences for family involvement in health care decisions using conscious and unconscious scenarios. Patient and family member agreement was 56% (29/52 dyads) for the conscious scenario (kappa 0.29) and 46% (24/52 dyads) for the unconscious scenario (kappa 0.15). Twenty-four family members identified the patient's preference as independent in the unconscious scenario, but six of these patients actually preferred shared decision making and six preferred reliant decision making. In the conscious scenario, preference for independent decision making was associated with higher odds of patient-family agreement (AOR 5.28, 1.07-26.06). In the unconscious scenario, cancer patients had a higher odds of agreement than ALS patients (AOR 3.86; 95% CI 1.02-14.54). Family members were often unable to correctly identify patient preferences for family involvement in end-of-life decision making, especially when patients desired that decisions be made using the best-interest standard. Clinicians and family members should consider explicitly eliciting patient preferences for family involvement in decision making. Additional research is still needed to identify interventions to improve family member understanding of patient preferences regarding the decision-making process itself.

Compassionate use of medicinal products in Europe: current status and perspectives

The medical treatment of patients with chronic, life-threatening or seriously disabling diseases can be very disappointing both for the suffering patient and their physicians in cases where patients cannot be treated satisfactorily with currently authorized medicines. It may be possible to successfully treat such patients with new pharmaceuticals that have not yet been authorized by suitable clinical trials. But clinical trials are time-consuming and costly, and not every patient meets the enrolment criteria for specific clinical trials. An aggravating factor is that the marketing authorization of promising new pharmaceuticals can take several years, which is valuable time lost from the patient’s perspective. One way to tackle this problem is to allow seriously-ill patients to obtain the medicines through a “compassionate-use” programme. The term “compassionate use” is defined in Article 83 no. 2 of the Regulation (EC) no. 726/2004 of the European Parliament and of the Council1 as “… making a medicinal product belonging to the categories referred to in Article 3 (1) and (2) available for compassionate reasons to a group of patients with a chronically or seriously debilitating disease or whose disease is considered to be life-threatening, and who cannot be treated satisfactorily by an authorized medicinal product. The medicinal product concerned must either be the subject of an application for a marketing authorization in accordance with Article 6 of this Regulation or must be undergoing clinical trials.” This regulatory framework was created by the European Legislature in 2004. Until then, France and Italy were the only two European countries with compassionate-use programmes incorporated into national law. However, the European framework does not include any binding process regulations for countries on how to introduce and implement their own compassionate-use programmes. At present, there is only a nonbinding guideline by the Committee for Medicinal Products for Human Use (CHMP),2 the scientific committee of the European Medicines Agency (EMA). Member States should notify the EMA when they make use of the compassionate-use provision outlined in paragraph 1 of Article 83 of the Regulation (EC) no. 726/2004. The CHMP, after consulting the manufacturer or the applicant, may adopt opinions on the conditions for use and distribution and the patients targeted for compassionate use in a given therapeutic indication. The opinions will be updated on a regular basis. In January 2010, the CHMP published its first opinions on two compassionate-use programmes in the European Union.3 The first opinion was about the compassionate use of intravenous oseltamivir (Tamiflu®), notified to the EMA by Finland.4 The CHMP has also published an assessment report on the compassionate use of this medicinal product.5 The other opinion, which was notified by Sweden and published by the CHMP, was about the compassionate use of intravenous zanamivir.6 Due to the nonbinding nature of the European Regulation and the CHMP guideline, it is up to each Member State to adopt its own corresponding national legal procedures for the introduction and implementation of compassionate-use programmes. Germany introduced its own regulations in July 2010 and has created a quick and efficient procedure for establishing compassionate-use-programmes.7 At time of publication, there were four notifications confirmed by the national pharmaceutical authority in Germany.8 Other European countries, such as the Netherlands, Norway and Spain, have also established national regulations. Austria and the United Kingdom of Great Britain and Northern Ireland plan to present their new procedural rules soon. The strict conditions of the national procedural rules mean that the use of not-yet authorized pharmaceuticals will continue to be an exception. Only a few national cases are expected to meet these conditions in any year but, in these cases, the new regulations may save valuable time for patients who have run out of treatment options. This is exactly why such regulations with clear guidelines and a fast-track procedure were long overdue. It is desirable that the other Member States of the European Union follow these examples, so that seriously ill patients throughout Europe can access promising alternative medical therapies.

Identifying, recruiting, and retaining seriously-ill patients and their caregivers in longitudinal research

Background: In order to improve the state of science in palliative care, we must increase our ability to document the real-time experience of patients and families as they traverse the end of life. Yet, frequently, prospective measurement is impeded by difficulty with patient identification, recruitment, enrollment, and retention. The palliative care literature is replete with descriptions of studies unable to meet enrollment goals, and that as a result, do not have adequate power to test hypotheses or draw conclusions. Objectives: To review the literature describing difficulties associated with ascertainment, enrollment, and attrition. To outline the successful recruitment methods of a new longitudinal study of patients and their caregivers. Design: A two-year longitudinal study of 240 patients with Stage IV cancer (breast, prostate, colorectal, lung), advanced congestive heart failure (CHF) LVEFB < 40 or advanced chronic obstructive pulmonary disease (COPD) pCO2 > 46, and their caregivers, interviewed monthly for up to two years. Patients were identified using clinical and administrative databases from one geographic region. Results: Representative and successful ascertainment was associated with use of clinical criteria and medical record review versus physician or other provider prognostication, use of recruitment letters from personal physician, recruitment letter content, brochure content, small monetary incentives, refined phone scripts, use of matched ethnicity interviewers, in-home and phone interview strategies, measure selection, patient and caregiver rapport, and on-going staff support (including grief and bereavement). Conclusions: Recruitment to prospective longitudinal studies at the end of life is difficult, but possible. The lessons learned from this study are applicable to future investigators conducting prospective research.

High-dose cefepime as an alternative treatment for infections caused by TEM-24 ESBL-producing Enterobacter aerogenes in severely-ill patients

This study evaluated retrospectively the efficacy of treatment with cefepime vs. a carbapenem, in combination with amikacin or ciprofloxacin, for seriously-ill patients infected with ESBL-producing Enterobacter aerogenes who were admitted to an intensive care unit. Forty-four episodes of infection were investigated in 43 patients: 21 treated with cefepime; 23 with a carbapenem. The two treatment groups did not differ statistically in terms of age, APACHE II scores, and infection sites, but the average duration of antibiotic exposure was significantly shorter in the cefepime group (8.5 days vs. 11.4 days; p 0.04). Clinical improvement was seen in 62% of patients receiving cefepime vs. 70% of patients receiving a carbapenem (p 0.59). Bacteriological eradication was achieved in 14% of patients receiving cefepime vs. 22% of patients receiving a carbapenem (p 0.76). The 30-day mortality rates related to infection were 33% in the cefepime group and 26% in the carbapenem group (p 0.44). Thus, outcome parameters did not differ significantly between the two groups. Nevertheless, a statistically significant increase in failure to eradicate ESBL-producing E. aerogenes was observed as the MICs of cefepime rose (p 0.017). Pulsed-field gel electrophoresis revealed three distinct clones, but one predominant clone harbouring the bla(TEM-24) gene was associated with most (42/44) of the episodes of infection. It was concluded that cefepime may be an alternative agent for therapy of severe infections caused by TEM-24 ESBL-producing E. aerogenes, although further studies are required to confirm these observations.

Resultados y factores pronósticos de mortalidad en la intervención de Hartmann

The introduction of one-stage procedures in emergency colonic surgery many years ago has relegated the use of the Hartmann procedure to the most seriously-ill patients, which has led to the high morbidity and mortality rates associated with this surgical technique. The aim of our study was to investigate our results using Hartmanns procedure and to evaluate several prognostic factors of postoperative mortality in this group of patients.From January 1995 to December 2000, 79 patients (34 men and 45 women) with a mean age of 71.5 years underwent Hartmanns operation. Almost all the series (91.1%) had comorbidities. In this group of patients, morbidity and mortality were analyzed retrospectively, and a multivariate logistic regression analysis was performed to study prognostic factors of postoperative mortality.The indications for surgery were acute peritonitis (77.2%), intestinal obstruction (18.9%), and lower gastrointestinal hemorrhage (3.7%). The most frequent etiology was acute diverticulitis (36 patients), followed by complicated colorectal carcinoma (18 patients). In 70.9% of the patients (56 patients) one or more postoperative complications was observed. Reoperation was performed in 15 patients (18.9%) and overall postoperative mortality was 45.5%. Renal failure (creatinine > or = 120 micromol/l) and high surgical ASA score (III or IV) reached statistical significance as predictive factors of mortality in these patients (p=.001 and p=.005, respectively).The patients who underwent Hartmanns procedure with high surgical ASA score and/or renal failure were at significantly higher risk of mortality.

United States: Overview of Cancer Pain and Palliative Care

The growth of the palliative care movement in the United States will have enormous impact on pain specialty in terms of the increasing need for the skills of its professional work force and demand for improved symptom management from our sickest and most vulnerable patients. In this paper, we review the need for palliative care, recent developments in this new field and implications for specialists in pain management.

Insulin resistance and glucose-induced thermogenesis in critical illness.

Critical illness is associated with a marked increase in metabolic rate and progressive wasting, despite aggressive nutritional support. The metabolic events which are responsible for these phenomena are unclear, but are characterised by marked impairment of the anabolic effects of insulin on glucose metabolism and excessive activation of the sympathetic nervous system. It has been suggested that critical illness may be associated with impaired carbohydrate oxidation and a marked increase in the loss of heat energy associated with glucose administration (glucose-induced thermogenesis). This situation may result in impaired efficiency of nutrient assimilation. Studies employing combinations of nutrient infusions both at clinically-relevant rates and in association with euglycaemic hyperinsulinaemia have, however, demonstrated that nutrient-induced thermogenesis is unaffected in critical illness in human subjects, and that defective glucose utilization occurs as a consequence of impaired insulin-mediated glucose storage rather than oxidation. Although the cellular and molecular mechanisms underlying these changes are controversial, the recent validation of a human model of insulin resistance in critical illness should provide a means of studying this response in future, and allow the identification of therapeutic targets. This information should increase the efficacy of nutritional support in some of our most seriously-ill patients.

The role of MRSA (methicillin-resistant Staphylococcus aureus) adherence and colonization in the upper respiratory tract of geriatric patients in nosocomial pulmonary infections.

The mechanism of nosocomial respiratory infections caused by MRSA (methicillin-resistant Staphylococcus aureus) in geriatric patients was investigated. Seriously ill patients (SIP) undergoing naso-gastric tube feeding or intravenous hyperalimentation and moderately ill patients (MIP) who were orally fed, were examined for their colonization and infection by Staphylococcus aureus (S. aureus) in the respiratory tract. Colonization of MRSA in the upper respiratory tract in SIP was from six to ten times higher than that in MIP and was associated with a high incidence of MRSA pulmonary infections. In vitro S. aureus adherence to nasal or oropharyngeal cells demonstrated that bacteria binding to nasal cells was higher, which probably can be interpreted as an elevated occurrence of S. aureus colonization in the nasal cavity than in the throat. The binding activity of MRSA was not superior to that of MSSA (methicillin-sensitive S. aureus). Though MRSA binding to the nasal cells from SIP was not higher than those from MIP, MRSA colonization in the upper respiratory tract was more frequently seen in SIP (P < 0.01). A higher incidence of total infectious episodes (P < 0.02-0.001) and more frequent use of antibiotics (P < 0.02-0.001), which were potent against MSSA might be the basis for selection of MRSA in these patients. In fact, the rate of MRSA colonization on the skin (pressure sores) was also higher in SIP (P < 0.01). A low nutritional state in SIP (P < 0.01-0.02) might also be associated with MRSA colonization.(ABSTRACT TRUNCATED AT 250 WORDS)

Usefulness of color Doppler flow imaging to distinguish ventricular septal defect from acute mitral regurgitation complicating acute myocardial infarction

Several studies have found 2-dimensional echocardiography and conventional spectral Doppler ultrasound useful in the assessment of ventricular septal defect (VSD), but few data exist regarding the usefulness of color Doppler flow imaging in evaluating this problem. Thus, the results of color flow imaging performed in 14 patients who presented with a recent acute myocardial infarction (AMI), hemodynamic instability and a new systolic murmur were evaluated. All patients underwent cardiac catheterization for definitive diagnosis, which proved to be VSD in 7 and acute mitral regurgitation in 7. VSD, identified by turbulent flow traversing the ventricular septum during ventricular systole, was correctly identified in all 7 patients with septal rupture. In the remaining 7 patients with a new murmur after AMI, mitral regurgitation was demonstrated as turbulent systolic flow in the left atrium by both color flow imaging and cine ventriculography. In all 14 patients with new murmurs, color flow imaging was 100% accurate for the presence or absence of VSD. Color flow imaging localized the septal defect to the apical septum (3), inferior septum (3) or both inferior and apical septal regions (1), and was 100% concordant for location compared with cineangiography, surgery and conventional Doppler echocardiographic techniques. Color flow imaging was accurate in identifying the presence and location of VSD complicating AMI, and accurately differentiated VSD from mitral regurgitation. Color flow imaging provides safe, rapid diagnosis of VSD complicating AMI, and may alleviate the need for diagnostic right-sided heart catheterization and preoperative cine ventriculography in these seriouslyill patients.