Cost and reimbursement analysis of end-of-life cancer inpatients. The case of the Greek public healthcare sector

BACKGROUND

While hospital-based Palliative Care services are usually covered through the main funding healthcare framework, traditional reimbursement methods have been criticized for their appropriateness. The present study investigates for the first time the case of treating end-of-life cancer patients in a Greek public hospital in terms of cost and reimbursement.

METHODS

This retrospective observational study used health administrative data of 135 deceased cancer patients who were hospitalized in the end of their lives. Following the cost estimation procedure, which indentified both the individual patient and overhead costs, we compared the relevant billing data and reimbursement requests to the estimated costs.

RESULTS

The average total cost per patient per day was calculated to be 97 EUR, with equal participation of individual patient's and overhead costs. Length of stay was identified as the main cost driver. Reimbursement was performed either by per-diem fees or by Diagnosis Related Groups' (DRGs), which were correspondingly associated with under or over reimbursement risks. In the case of the combined use of the two available reimbursement alternatives a cross-subsidization phenomenon was described.

CONCLUSION

Although the cost of end-of-life care proved to be quite low, the national per-diem rate fails to cover it. DRGs designed for acute care needs are rather unsuitable for such sub acute hospitalizations.

POLICY SUMMARY

There is a concrete need for reconsidering the current reimbursement schemes for this group of patients as part of any national plan concerning the integration and reformation of Palliative Care services. Otherwise, there is a serious danger for public institutions' reluctance to admit them with a serious impact on access and equity of end-of-life cancer care.

Scales for assessing medication adherence in patients with hypertension

BACKGROUND

the choice of the appropriate tool for assessing level of medication adherence is a significant barrier in scientific research.

AIMS

to translate into Greek and test the reliability of the Hill-Bone and A-14 scales among patients with hypertension. Also, to compare patients' responses in the Hill-Bone scale, A-14 scale and Morisky Medication Adherence Scale (MMAS).

METHODS

data collection occurred between February 2016 and March 2016 at a general hospital in Athens, Greece. The sample consisted of hypertensive patients (n=34) and non-hypertensive patients (n=34).

FINDINGS

the coefficient alpha in hypertensive patients was 0.76 for Hill-Bone, 0.64 for MMAS and 0.91 for the A-14 scale. In non-hypertensive patients, the Cronbach's alpha for MMAS was 0.81 and 0.78 for A-14. A statistically significant difference was found among the mean scores of the scales, whereas strong correlation was found only between two pairs of questions with similar meaning.

CONCLUSION

all tools are appropriate to assess the level of medication adherence in Greek hypertensive patients. However, careful translation of the scales is essential since items with the same meaning could be understudied in a different way.

Necessity of the Periodical Ultrasound Assessment of the Peripheral Venous System in Intensive Care Unit Patients

The utility of periodic sonographic assessment and monitoring for early diagnosis of deep vein thrombosis (DVT) in patients hospitalized in intensive care units (ICUs) was investigated. Of 314 patients hospitalized in an ICU over a 24-mo period, 248 were examined. The first examination of the patients was carried out within the first 48 h of ICU admission, and weekly examination followed until discharge. Peripheral veins were examined according to the general principles of the ultrasound study using the compression test in B-mode imaging (image to gray scale). The criterion for the absence or presence of a clot within the lumen was the presence or absence of full compressibility of the venous lumen, respectively. Intermittent compression was applied to multiple cross sections along the entire extent of the limbs. Three patients (1.2%) were diagnosed with sub-clinical DVT. The diagnoses were made on the third (sapheno-femoral junction), fourth (right internal jugular) and fifth (left gastrocnemius) weeks of hospitalization, respectively, although patients received full anticoagulation prophylaxis. DVT in a general-population ICU patient on anticoagulation prophylaxis did not seem to occur very frequently, and hence, regular ultrasound monitoring is not recommended. However, it may have value after the third week or in a selected population of ICU patients with very severe and/or multiple predisposing factors or who are not undergoing anticoagulant treatment because of contraindications.

Clinical factors affecting costs in patients receiving systemic antifungal therapy in intensive care units in Greece: Results from the ESTIMATOR study

Invasive fungal infections are common in intensive care units (ICUs) but there is a great variability in factors affecting costs of different antifungal treatment strategies in clinical practice. To determine factors affecting treatment cost in adult ICU patients with or without documented invasive fungal infection receiving systemic antifungal therapy (SAT) we have performed a prospective, multicentre, observational study enrolling patients receiving SAT in participating ICUs in Greece. During the study period, 155 patients received SAT at 14 participating ICUs: 37 (23.9%) for proven fungal infection before treatment began, 10 (6.5%) prophylactically, 77 (49.7%) empirically and 31 (20.0%) pre-emptively; 66 patients receiving early SAT (55.9%) were subsequently confirmed to have proven infection with Candida spp. (eight while on treatment). The most frequently used antifungal drugs were echinocandins (89/155; 57.4%), fluconazole (31/155; 20%) and itraconazole (20/155; 12.9%). Mean total cost per patient by SAT strategy was €20 458 (proven), €15 054 (prophylaxis), €23 594 (empiric) and €22 184 (pre-emptive). Factors associated with significantly increased cost were initial treatment failure, length of stay (LOS) in ICU before starting SAT (i.e. from admission until treatment start), fever and proven candidaemia (all P≤.05).

CONCLUSION

Early administration of antifungal drugs was not a substantial component of total hospital costs. However, there was a significant adverse impact on costs with increasing LOS in febrile patients in ICU for whom diagnosis of fungaemia was delayed before starting SAT, and with initial treatment failure. Awareness of potential candidaemia and initiation of pre-emptive or empirical strategy as early appropriate treatment may improve ICU patient outcomes while reducing direct medical costs.

Variable cost of ICU care, a micro-costing analysis

Intensive care unit (ICU) costs account for a great part of a hospital's expenses. The objective of the present study was to measure the patient-specific cost of ICU treatment, to identify the most important cost drivers in ICU and to examine the role of various contributing factors in cost configuration. A retrospective cost analysis of all ICU patients who were admitted during 2011 in a Greek General, seven-bed ICU and stayed for at least 24hours was performed, by applying bottom-up analysis. Data collected included demographics and the exact cost of every single material used for patients' care. Prices were yielded from the hospital's purchasing costs and from the national price list of the imaging and laboratory tests, which was provided by the Ministry of Health. A total of 138 patients were included. Variable cost per ICU day was €573.18. A substantial cost variation was found in the total costs obtained for individual patients (median: €3443, range: €243.70-€116,355). Medicines were responsible for more than half of the cost and antibiotics accounted for the largest part of it, followed by blood products and cardiovascular drugs. Medical cause of admission, severe illness and increased length of stay, mechanical ventilation and dialysis were the factors associated with cost escalation. ICU variable cost is patient-specific, varies according to each patient's needs and is influenced by several factors. The exact estimation of variable cost is a pre-requisite in order to control ICU expenses.

Translation and validation of the Greek version of the hypertension knowledge-level scale

AIMS AND OBJECTIVES

To translate and validate a Greek version of the Hypertension Knowledge-Level Scale.

BACKGROUND

The major barrier in the management of hypertension is the lack of adherence to medications and lifestyle adjustments. Patients' knowledge of the nature of hypertension and cardiovascular risk factors is a significant factor affecting individuals' adherence. However, few instruments have been developed to assess patients' knowledge level and no one has been translated into Greek.

DESIGN

This study used a case control study design.

METHODS

Data collection for this research occurred between February 7, 2013 and March 10, 2013. The sample included both hypertensives and non-hypertensives. Participants simultaneously completed the version of the Hypertension Knowledge-Level Scale. A total of 68 individuals completed the questionnaire.

RESULTS

Coefficient alpha was 0·66 for hypertensives and 0·79 for non-hypertensives. The difference for the mean scores in the entire scale between the two samples was statistically significant. In addition, significant differences were observed in many sub-dimensions and no correlation was found between level, knowledge and age, gender and education level.

CONCLUSIONS

Findings provide support for the validity of the Greek version of the Hypertension Knowledge-Level Scale.

RELEVANCE TO CLINICAL PRACTICE

The translation and validation of an instrument evaluating the level of knowledge of hypertension contribute to assessing the provided educational intervention. Low knowledge level should lead to the development of new methods of education, therefore nurses will have the opportunity to amplify their role in patients' education and develop relationships based on honesty and respect.

Management of sudden hearing loss with hyperbaric oxygen therapy

Idiopathic sudden sensorineural hearing loss (ISSHL) is defined as the sensorineural hearing loss of a minimum of 30 dB in at least three frequencies for three days or more. This study aims to evaluate the clinical efficacy of hyperbaric oxygen therapy (HBO2) in the management of idiopathic sudden sensorineural hearing loss.

MATERIAL-METHODS

Patients with ISSHL received treatment including oral corticosteroids and HBO2. HBO2 protocol included five phases of five sessions each. ISSHL was assessed by measuring the tonal audiogram before and after each phase. Tinnitus was assessed using a questionnaire and a visual analogue scale at the beginning and the end of the study. Secondary assessment points included changes in the intensity and the improvement of tinnitus.

RESULTS

56 patients were included in the study. All patients completed Phases I and II of HBO2, 43 completed Phase III, 13 completed Phase IV, and six completed all five phases. Overall, a significant improvement was noted between the initial and final audiogram after HBO2 (p < 0.001). Tinnitus evaluation score, intensity and related problems were also significantly reduced (p < 0.001).

CONCLUSION

This study affirms previous findings that the use of HBO2 and vasodilators are efficacious in the treatment of ISSHL. Our findings also suggest benefit for the treatment of tinnitus.

The immune response after stimulation with wall components of gram-positive bacteria and fungi

Although several components of the microbial wall of gram-positive bacteria and fungi possess immunostimulatory properties, their pathogenetic role remains incompletely evaluated. The purpose of this study was to assess the basic immune status of patients susceptible to infections and their capability for cytokine production after stimulation with wall components of gram-positive bacteria and fungi. We measured serum cytokine levels as well as cytokine production after ex vivo lipoteichoic acid (LTA) and mannan stimulation of whole blood. The blood was taken from 10 healthy volunteers, 10 patients with end-stage renal disease (ESRD), 10 patients with diabetes mellitus (DM), and 10 patients on their 2nd day of stay in the Intensive Care Unit (ICU), who suffered from non septic systemic inflammatory response syndrome (SIRS) and had an APACHE II score ≥25. We used 1 μg/ml LTA and 100 μg/ml mannan for an incubation period of 8 h to stimulate 100 μl aliquots of whole blood. All patient groups had higher baseline values of TNF-α, IL-6, IL-1β, and IL-10 compared to the control group, but only for ICU patients the difference was statistically significant. The ratio IL-10/IL-6 was found 0.33, 0.22, and 0.96 in healthy persons, ESRD, and DM patients respectively, and 1.32 in ICU patients. In all examined groups, the levels of cytokines significantly increased after stimulation by LTA and mannan, although in severely ill patients this change was considerably smaller, possibly reflecting a state of monocytes' depression and relative hyporesponsiveness. No significant differences between the LTA and the mannan stimulation were observed.

A higher tidal volume may be used for athletes according to measured FVC

We investigated whether professional athletes may require higher tidal volume (Tv ) during mechanical ventilation hypothesizing that they have significantly higher "normal" lung volumes compared to what was predicted and to nonathletes. Measured and predicted spirometric values were recorded in both athletes and nonathletes using a Spirovit SP-1 spirometer (Schiller, Switzerland). Normal Tv (6 mL/kg of predicted body weight) was calculated as a percentage of measured and predicted forced vital capacity (FVC) and the difference (δ) was used to calculate the additional Tv required using the equation: New Tv(TvN) = Tv + (Tv × δ). Professional athletes had significantly higher FVC compared to what was predicted (by 9% in females and 10% in males) and to nonathletes. They may also require a Tv of 6.6 mL/kg for males and 6.5 mL/kg for females during mechanical ventilation. Nonathletes may require a T v of 5.8 ± 0.1 mL/kg and 6.3 ± 0.1 mL/kg for males and females, respectively. Our findings show that athletes may require additional Tv of 10% (0.6/6 mL/kg) for males and 8.3% (0.5/6 mL/kg) for females during general anesthesia and critical care which needs to be further investigated and tested.

Colistin pharmacokinetics in intensive care unit patients on continuous venovenous haemodiafiltration: an observational study

OBJECTIVES

Available data on colistin pharmacokinetics in patients undergoing continuous renal replacement therapy (CRRT) are limited. Our aim was to study colistin pharmacokinetics in critically ill patients treated with colistin methane sulphonate for Gram-negative sepsis and undergoing continuous venovenous haemodiafiltration for acute renal failure.

PATIENTS AND METHODS

Three patients were studied. The colistin methane sulphonate dose administered was at the discretion of the attending physician and was in all cases lower than that recommended for individuals with intact renal function. Colistin methane sulphonate was administered intravenously over 30 min, and blood samples were collected from each patient pre- and post-filter for the HPLC determination of colistin levels in serum before infusion, at 10, 60, 120, 240, 360, 480 and 600 min from the end of infusion, and immediately before the next dose. Concurrently, spot samples of effluent from the haemofilter were also collected and analysed. Both colistin total extracorporeal clearance and clearance in the effluent were calculated.

RESULTS

Extracorporeal clearance resulted in substantial removal of colistin (43%-59% of total colistin clearance). Total colistin clearance was found to be reduced (varying between 3.3 and 4.5 L/h), compared with patients with normal renal function. Colistin methane sulphonate dosage resulted in clearly suboptimal colistin steady-state concentrations.

CONCLUSIONS

In spite of substantial extracorporeal clearance, total colistin clearance was reduced, compared with patients with normal renal function. Colistin adsorption by the haemofilter contributed to its extracorporeal clearance to a large extent. Studies on other patients receiving colistin methane sulphonate and undergoing CRRT are required before more appropriate dosage regimens can be recommended.

Measurement of tumour necrosis factor receptors for immune response in colon cancer patients

Immune system is crucial to tumour's initiation, progress and establishment and is contributing to prevent upcoming damaging invasion. Tumour development and surgical resection are both immunosuppressive processes. Immune response could be evaluated by ex vivo lipopolysaccharide (LPS) test, measuring cytokines and receptors release. The aim of the study is to investigate the postoperative immune recovery of cancer patients upon discharge. Twenty-two patients with colon cancer, without pre-treatment, and 16 healthy volunteers (HV) were enrolled in the study. Ten ml of whole blood were collected from every patient on admission (PRE) and upon discharge (POD7) and every HV. Diluted whole blood samples were stimulated with 500 pg/ml LPS, at 37°C, for 4H. Cell culture supernatants (CCSP) were removed after centrifugation and stored at -70°C. Tumour necrosis factor-alpha (TNF-α), interleukin-6 and interleukin-10 (IL-6, IL-10), soluble TNF receptors (sTNFRs) were measured in serum and CCSP by enzymelinked immunosorbent assay. Serum cytokines and receptors, PRE and POD7, were significantly elevated compared to HV (P < 0.001) and significant correlations were found between POD7 IL-6 and sTNFRs (Spearman's ρ 0.47, P < 0.05). Ex vivo, TNF-α, IL-6 and TNFRI release were lower either PRE or POD7, while IL-10 and TNFRII were higher, than in HV. No significant differences (P > 0.05) were found between PRE and POD7 levels in serum or CCSP. Cancer patients are not postoperatively immune restored until discharge. The trend of anti-inflammatory TNFRs release could account for alternative marker for the control of cancer patients immune response and the schedule of their following therapeutic treatment.

The effect of physiotherapy-based breathing retraining on asthma control

BACKGROUND

The mechanism of the breathing retraining effect on asthma control is not adequately based on evidence.

OBJECTIVE

The present study was designed to evaluate the effect of physiotherapy-based breathing retraining on asthma control and on asthma physiological indices across time.

STUDY DESIGN

A 6-month controlled study was conducted. Adult patients with stable, mild to moderate asthma (n = 40), under the same specialist's care, were randomized either to be trained as one group receiving 12 individual breathing retraining sessions (n = 20), or to have usual asthma care (n = 20). The main outcome was the Asthma Control Test score, with secondary outcomes the end-tidal carbon dioxide, respiratory rate, spirometry, and the scores of Nijmegen Hyperventilation Questionnaire, Medical Research Council scale, and SF-36v2 quality-of-life questionnaire.

RESULTS

The 2 × 4 ANOVA showed significant interaction between intervention and time in asthma control (F = 9.03, p < .001, η(2) = 0.19), end-tidal carbon dioxide (p < .001), respiratory rate (p < .001), symptoms of hypocapnia (p = .001), FEV1% predicted (p = .022), and breathlessness disability (p = .023). The 2 × 4 MANOVA showed significant interaction between intervention and time, with respect to the two components of the SF-36v2 (p < .001).

CONCLUSION

Breathing retraining resulted in improvement not only in asthma control but in physiological indices across time as well. Further studies are needed to confirm the benefits of this training in order to help patients with stable asthma achieve the control of their disease.

Validity and reliability evidence of the Asthma Control Test--ACT in Greece

BACKGROUND

The dimensionality of the Asthma Control Test (ACT) was examined in two counterview studies. Up to now, the ACT has not been validated for the Greek asthma patients.

OBJECTIVE

The present study was designed to examine the validity and reliability of the ACT responses in Greek asthma outpatients under a specialist's care.

STUDY DESIGN

Following evidence for sample-specific validity, the ACT (n = 100) was examined through construct, cross-sectional, convergent, and discriminant validity as well as internal consistency and test-retest reliability [root mean squared error of approximation (RMSEA)].

RESULTS

A one-factor solution fit the data [χ(2) (chi-square) = 3.899, df (degrees of freedom) 5, ns, RMSEA <0.001]. The ACT showed a high internal consistency (Cronbach alpha = 0.72) and a high 2 months test-retest reliability (IR = 0.85) for the total sample. Significant differences were found between the five categories of asthma control patients (not controlled at all, poorly controlled, somewhat controlled, well controlled, and completely controlled), according to the specialists' rating, for the ACT (p < .001). Significant differences were found between patients with and without asthma control (p = .001), patients of different gender (p = .05), educational status (p = .05), mean year income (p = .01), body mass index (p = .05), follow-up visits (p = .01), as well as among patients of different age (p < .001) and severity (p < .001). An ACT score of 19 or less provided optimum balance of sensitivity (98.46) and specificity (88.57) for screening 'not controlled' asthma. Cross-sectional validity testing showed moderate correlation of the ACT score with FEV1% predicted (r = 0.57, p < .001) and disability (r = -0.42, p < .001) and moderately high correlation with dyspnea (r = -0.71, p < .001). Convergent validity testing showed that the ACT score was correlated with the specialists' rating (r = 0.89, p < .001).

CONCLUSION

The ACT is valid and reliable in Greek outpatients with asthma under a specialist's care.

Validity of St. George's Respiratory Questionnaire for Greek patients with chronic obstructive pulmonary disease

The purpose of the present study was to examine the validity of St. George's Respiratory Questionnaire (SGRQ), a disease-specific survey of health-related quality of life, in adult Greek patients with chronic obstructive pulmonary disease (COPD). Questionnaire scores, dyspnea scores, spirometry values, and demographic data were collected from 72 patients with a diagnosis of COPD exacerbation. Follow-up visits were performed at 1-mo. intervals for the first 3 mo. after discharge and a final visit was performed 6 mo. after discharge. 27 (37.5%) patients were readmitted during the follow-up period. Recovery after exacerbation was prolonged and questionnaire scores were sensitive to the patients' health-status changes across time. The SGRQ discriminated COPD patients according to disease stage, and the SGRQ scores during the recovery course were related to readmission. Correlations between the SGRQ and % FEV1 were not significant during exacerbation but a significant negative correlation was observed during the stable phase of the disease. The SGRQ appeared to have acceptable discriminant and concurrent validities in Greek COPD patients who differed according to their exacerbation stage.

Immune responses during and after exercise of constant and alternating intensity above the lactate threshold

AIM

Intense and prolonged exercise greatly affects circulating cytokine levels. The purpose of this study was to investigate the possible changes in tumour necrosis factor -a (TNF-a), interleukin 6 (IL-6) and cortisol concentrations during and after prolonged exercise of constant and alternating intensity of the same duration and total work performed.

METHODS

Ten male subjects underwent two main cycling exercise trials lasting one hour each. On one occasion, exercise intensity was alternated between 46.5±1.9% of maximal oxygen uptake (VO2max ) for 40 s and 120% of VO2max for 20 s, so that the mean intensity corresponded to 105% of the lactate threshold. On the other occasion, exercise intensity was constant at 105% of the lactate threshold. Levels of TNF-a, IL-6 after lipo polysaccharide (LPS) stimulation as well as cortisol were measured at rest, 30 and 60 minutes of exercise and 1 hour after.

RESULTS

No significant differences were observed in TNF-a concentrations between the two exercise protocols (P= 0.75), but there was a significant time effect (P<0.01). TNF-a was increased in both groups from a resting value of 436.1±102.5 to 649.5±187.7 pg/mL (P<0.05) at the end of exercise and was subsequently decreased 1 hour post exercise to 305.9±78.8 pg/mL (P<0.01). No significant difference in IL-6 and cortisol concentrations was observed between the two exercise protocols (P=0.13, P=0.10 accordingly).

CONCLUSION

In conclusion, prolonged constant and alternating intensity exercise of the same mean intensity and duration seemed to provoke similar changes in aspects of immune response in healthy subjects.

Monitoring plasma voriconazole levels following intravenous administration in critically ill patients: an observational study

Data relating to the pharmacokinetics of voriconazole in critically ill patients are lacking. A prospective observational study was conducted on 18 non-consecutive critically ill patients aged 24-97 years, comprising 12 patients with normal renal function (NRF) [creatinine clearance (CL(Cr)) > or = 60 mL/min] and 6 patients with moderate renal impairment (MRI) (CL(Cr) 40-55 mL/min), administered voriconazole intravenously (6 mg/kg loading dose and 3-4 mg/kg twice daily thereafter) in order to determine the suitability of these doses in this patient population. Steady-state blood levels were monitored and liver and renal function were recorded throughout treatment. Large variability in patient plasma levels was observed, ranging from 37% at < or = 1 mg/L (minimum inhibitory concentration at which, for most fungal pathogens, 90% of isolates are susceptible) to 19% at >5.5mg/L. Moreover, maintaining trough concentrations above clinical breakpoints was not consistently achieved because 16/30 (53%) were < or = 1 mg/L. In a few MRI patients, average concentrations were found to be significantly different compared with those of NRF patients administered the same dose, however this difference was not noted in pharmacokinetic parameters following dose normalisation. None of the patients experienced deterioration in renal or liver function. Recommended voriconazole doses are inadequate to achieve drug concentrations >1 microg/mL over the entire dosing interval in some critically ill patients.

Cardiopulmonary resuscitation in end-stage cancer patients

Cardiopulmonary resuscitation (CPR) in patients with end-stage cancer is an issue of significant clinical and ethical importance. In general, the overall survival to discharge in cancer patients is referred to be 6.2% (localised - 9.5% vs. metastatic disease - 5.6%) compared to 15% of unselected in-hospital arrests. However, immediate survival, as well as survival to discharge after a successful CPR is affected by multiple factors. Type and extend of tumor, degree of clinical deterioration, functional status and many other factors do correlate with outcome in different degrees. Critical illness scoring systems are commonly used in order to assess performance status of patients and predict outcome. This article will review all the above mentioned factors, as well as patients' perception about "do-not-resuscitate" orders and palliative care.

Combined nutritional support in patients with chronic obstructive pulmonary disease (COPD), under mechanical ventilation (MV)

BACKGROUND/AIMS

The importance of nutrition is clearly established in the management of the critically ill patient: malnutrition contributes to immune incompetence, poor wound healing, increased postoperative complication and prolonged hospital stay. The interaction between nutritional status, nutritional supply and respiratory function is important in the management of the Chronic Obstructive pulmonary Disease (COPD) patients under mechanical ventilation (MV). In the present study was analyzed the benefits of combined nutritional support in patients with COPD under MV.

METHODOLOGY

One hundred ninety two (192) patients with COPD were admitted to our Intensive Care Unit (ICU), due to severe respiratory failure of whom 163 (84.9%) patients were under MV. In 18 (11.04%) patients after the 10th day under MV and due to severe malnutrition (serum albumin < 2.5 gm/dl, total lymphocyte count (TLC) < 900/mm3), added in the enteral nutrition (EN) of 1800 Kcals and parenteral nutrition (PN) of 2000 Kcals, at high concentration in lipids from central venous catheter.

RESULTS

Seven (38.89%) patients on the 4th day, after combined nutrition, had a positive balance of nitrogen and normal level of the nutritional indices, 4 (22.22%) were on normal level on the 5th day, 3 (16.67%) on the 6th day, 1 (5.56%) on the 7th day after combined nutrition. We had no complications from the combination of EN and PN. Conclusively, of these 18 patients that were given both EN and PN, 15 (83.33%) were weaned from MV and continued the combined nutritional support for 3 days, while 3 (16.67%) died during the combination of EN and PN, without having achieved a normal level of the indices of nutrition and without a positive balance of nitrogen.

CONCLUSIONS

In this study was found that: 1. patients with COPD under MV rapidly developed malnutrition, 2. the combination EN and PN without complications contribute to the weaning from MV, 3. positive nitrogen balance and normal increases of nutrition are achieved after the 4th day of combined nutrition and 4. Early addition of EN and PN in patients with COPD under MV, probably accelerates the weaning from MV, reduces hospitalization, changes the outcome and reduces the cost of hospitalization of patients with COPD under MV in ICU.

Oxygenation equilibration time after alteration of inspired oxygen in critically ill patients

To determine the time required for arterial oxygen partial pressure (Pao(2)) equilibration after a change in fractional inspired oxygen (Fio(2)) in intensive care unit (ICU) patients, a prospective study in a 7-bed university ICU was performed. Forty adult patients were examined using sequential arterial blood gas measurements after a .3 alteration in Fio(2). The Pao(2) value measured at 30 minutes after a step change in Fio(2) in both periods was accepted as representative of the equilibrium value for Pao(2). The mean equilibration time was 8.26+/-5.6 minutes and 4.5+/-2.65 minutes for increases and decreases in Pao(2), respectively (P=.003). The constant k values were .44 +/- .31 minutes and .72 +/- .7 minutes for increases and decreases in Pao(2), respectively. There was no significant difference between the increase and the decrease of 90% oxygenation times in the 2 groups (P=.150 and P=.446, respectively). The study confirms that a period of less than 10 minutes is adequate for 90% of the equilibration of Pao(2) to occur after an Fio(2) change in ICU patients.

Difficult intubation provokes bacteremia

PURPOSE

To evaluate the prevalence of bacteremia after mask ventilation, laryngoscopy, and endotracheal intubation before induction of general anesthesia and to discover any correlation between traumatic manipulations and bacteremia. The specific bacteria responsible, knowledge of which may guide the prophylactic use of antibiotics, also were investigated.

METHODS

Fifty patients were enrolled. Three 10-mL blood samples were collected from a peripheral vein 10 min before induction of anesthesia, 10 min after mask ventilation, and 10 min after intubation. All samples were placed in aerobic and anaerobic bottles for culture and bacterial identification.

RESULTS

Cultures received 10 min after intubation were positive in 12% of patients. The following strains were isolated: Escherichia coli in two cases, Staphylococcus aureus in three cases, and Peptostreptococcus anaerobius in one case. A strong positive correlation was found between difficult intubation and bacteremia. No correlation between bacteremia and easy intubation or between bacteremia and face mask ventilation was identified.

CONCLUSION

Traumatic manipulations during difficult laryngoscopy and endotracheal intubation could cause bacteremia. This finding may justify and guide prophylactic use of antibiotics.

Procalcitonin in acute myocardial infarction

OBJECTIVE

Procalcitonin (PCT) is released in severe bacterial infections, sepsis and in infection independent cases such as major surgery, multiple trauma, cardiogenic shock, burns, resuscitation, and after cardiac surgery. The aim of this study was to determine the levels and the kinetics of PCT in AMI and to investigate their possible correlation with the release of IL-6 and CRP. DESIGN-PATIENTS: The study included 60 patients (47 men, 63.2+/-14.8 years) with the diagnosis of AMI at admission. In all patients, serum levels of PCT, IL-6, CK-MB, TnI and CRP were measured at admission, at 3, 6, 12, 24, 48 and 72 h and at the seventh day.

RESULTS

PCT was elevated in all patients with AMI. It was initially detected in serum approximately 2-3 h after the onset of the symptoms. The median value at admission was 1.3 ng/ml (95% CI: 0.89 to 1.80). The value of PCT showed an increase and reached a plateau after 12-24 h. The median value at 24 h was 3.57 ng/ml (95% CI: 2.89 to 4.55). PCT values fell to baseline (<0.5 ng/ml) by the seventh day. PCT was detected in serum earlier than CK-MB or TnI in 56 of the 60 patients (93.3%). The kinetics of PCT was similar to those of CK-MB and TnI. The maximal values of PCT were positively correlated with the maximal values of IL-6 (r = 0.59, P = 0.00) and of CRP (r = 0.65, P = 0.001). The maximal values of IL-6 were positively correlated with max CRP (r = 0.35, P = 0.045).

CONCLUSIONS

PCT could be considered as a novel sensitive myocardial index. Its release in AMI is probably due to the inflammatory process that occurs during AMI.

Cross-transmission of multidrug-resistant Acinetobacter baumannii clonal strains causing episodes of sepsis in a trauma intensive care unit

OBJECTIVE

To investigate the mode of transmission of imipenem-resistant Acinetobacter baumannii strains causing episodes of sepsis.

SETTING

A 7-bed trauma intensive care unit (ICU) in an orthopedic hospital in Greece.

DESIGN

During a 14-week period (from January 10 to April 16, 2006), clinical specimens, along with samples taken on a weekly basis from the ICU environment and from the hands of health care workers (HCWs), were prospectively tested for imipenem-resistant A. baumannii. Pulsed-field gel electrophoresis was used to study the genetic relatedness of the isolates recovered from these specimens and samples.

RESULTS

During the survey, imipenem-resistant A. baumannii was identified in 14 hospitalized patients, from whom 40 multidrug-resistant and imipenem-resistant A. baumanii isolates were recovered. These pathogens caused episodes of bacteremia and sepsis in all but one of the patients and contributed to the death of 3 patients. Samples for culture were obtained from the environment and from the hands of HCWs; 29 imipenem-resistant A. baumannii isolates were recovered from the environment, and 12 from HCWs. One predominant genotype and 2 less predominant genotypes were detected among the 81 imipenem-resistant A. baumannii isolates. All 3 of these genotypes were found among patients and HCWs and were recovered from environmental samples.

INTERVENTIONS

Control measures consisted of the closure of the ICU and the transfer of the patients to other units. The ICU was disinfected, and adherence to proper hand hygiene protocol was reinforced. These same clonal isolates were not recovered from clinical or environmental samples during the month after the reopening of the ICU.

CONCLUSIONS

The extensive dissemination of imipenem-resistant A. baumannii clonal strains causing episodes of bacteremia and/or sepsis resulted from modes of transmission via multiple contaminated surfaces and objects and transiently colonized HCWs' hands. Closure of the ICU and its meticulous environmental decontamination led to the successful control of the outbreak.

Approach to patients with pulmonary embolism in a surgical intensive care unit

BACKGROUND/AIMS

Pulmonary embolism (PE) is a potentially life threatening disease. Clinical signs and symptoms allow the clinician to determine the pretest probability of someone having pulmonary embolism but are insufficient to diagnose or rule out the condition. This paper aims to study the clinical presentation, identify the risk factors and evaluate the diagnostic strategies and management of patients with PE.

METHODOLOGY

The medical files of 69 patients were searched, who were diagnosed with PE and who were admitted to the Surgical Care Unit.

RESULTS

Dyspnea, pleuritic pain, haemoptysis, fever and cough were the most common presenting symptoms. Risk factors for PE were found in 90% of cases. D-dimers assay was elevated in all cases (100%) and the other diagnostic strategies used showed great accuracy in confirming the pretest probabilities of PE. It is of high importance that 75% of the patients had deep vein thrombosis as assessed by venous ultrasonography. Mortality due to PE was approximately 6.9%.

CONCLUSIONS

PE can be often overlooked with hazardous consequences. Clinical evaluation in combination with spiral CT or lung scintigraphy and vein ultrasound and D-dimer level can establish the diagnosis in the majority of patients so that effective treatment to be started as soon as possible.

Quality of life outcome of critical care survivors eighteen months after discharge from intensive care

AIM

To assess the changes in health-related quality of life in patients discharged from the intensive care unit (ICU).

METHODS

At the General University ICU, Trauma Hospital in Athens, 242 patients were enrolled prospectively over a study period of 18 months. Out of these, 116 participants (47.9%) completed all survey components at 6, 12, and 18 months. We used Quality of Life-Spanish (QOL-SP) to assess the health-related quality of life. Patients or their relatives were interviewed on ICU admission and at 6, 12, and 18 months after discharge from the ICU.

RESULTS

Mean quality of life score of the patients increased from 2.9+/-4.8 (out of maximum 25 points) on ICU admission to 7.0+/-7.2 points at 6 months after discharge, and then decreased to 5.6+/-6.9 points at 18 months (P<0.001; Friedman Test). Multilinear regression analysis showed that the variables which had the strongest association with the quality of life on admission were age (P=0.002) and male sex (P=0.001), whereas age (P<0.001), length of ICU stay (P<0.001), and male sex (P=0.002) had the strongest association 18 months after discharge from the ICU. Survival rate was 66.9% at discharge from ICU and 61.6% at hospital discharge. There were 33% deaths in the ICU, 5.3% in the hospital, and 6.2% after ICU discharge. There were 7.4% patients lost to follow-up.

CONCLUSIONS

After discharge from the ICU, patients' quality of life was poor and showed an improvement at 18 months after discharge, but was still worse than on admission. Age, ICU length of stay, and male sex were the factors that had the strongest impact on the quality of life on admission and at 18 months after discharge from the ICU.

Patient severity as an indicator of nursing workload in the intensive care unit

The importance of measuring nursing workload in the intensive care unit (ICU) has been supported by both an increasing demand for nursing personnel and the relationship of nursing workload with patient safety. According to previous studies, the correlation between clinical severity of ICU patients and nursing workload measured by Therapeutic Intervention Scoring System has been estimated to be particularly high. The aim of this study was to investigate whether clinical severity of ICU patients can be used for the prediction of nursing workload on a daily basis. All patients admitted in the ICU of the General University Hospital of Patras for a 5-month period were enrolled in the study. Projet de Recherche en Nursing (PRN) Réa and Acute Physiology and Chronic Health Evaluation (APACHE) II scores of patients were calculated, the first on a daily basis and the second on the day of admission. Simple linear regression was used for statistical analysis of data. One hundred thirty-eight patients were studied. A progressive increase in mean daily PRN Réa of patients all along the amplitude of APACHE II values was shown. APACHE II could predict 25.6% (p < 0.01) of the daily variability of PRN Réa of patients. Regarding categories of PRN Réa, respiration, communication, diagnostic methods and treatments were significantly predicted by APACHE II. APACHE II explained higher proportions of PRN Réa in medical male patients aged >60 years. Clinical severity of the ICU patients measured by APACHE II is an important early indicator of daily nursing workload, especially of care demands associated with respiration, diagnostic methods and treatments.