What drives change in neonatal intensive care units? A qualitative study with physicians and nurses in six European countries.

BACKGROUND: Innovation is important to improve patient care, but few studies have explored the factors that initiate change in healthcare organizations. METHODS: As part of the European project EPICE on evidence-based perinatal care, we carried out semi-structured interviews (N = 44) with medical and nursing staff from 11 randomly selected neonatal intensive care units in 6 countries. The interviews focused on the most recent clinical or organizational change in the unit relevant to the care of very preterm infants. Thematic analysis was performed using verbatim transcripts of recorded interviews. RESULTS: Reported changes concerned ventilation, feeding and nutrition, neonatal sepsis, infant care, pain management and care of parents. Six categories of drivers to change were identified: availability of new knowledge or technology; guidelines or regulations from outside the unit; need to standardize practices; participation in research; occurrence of adverse events; and wish to improve care. Innovations originating within the unit, linked to the availability of new technology and seen to provide clear benefit for patients were more likely to achieve consensus and rapid implementation. CONCLUSIONS: Innovation can be initiated by several drivers that can impact on the success and sustainability of change.

Complementary and alternative medicine in the scientific literature.

OBJECTIVE: To analyze the frequency and typology of scientific papers on complementary and alternative medicine (CAM) published in the period 1997-2002. METHODS: We performed a systematic literature search of MEDLINE in order to identify all articles dealing with CAM, in the human setting, published from January 1, 1997 to December 31, 2002. Our attention was focused on randomized controlled trials conducted on CAM and on the impact factor (IF) of the journals in which CAM articles were published. RESULTS: During the period 1997-2002, a total of 20,209 articles about CAM were published, representing the 0.7% of the total number of MEDLINE-listed articles. Approximately 50% of CAM articles published in 1996-2002 appeared on journals with no IF. The proportion of randomized clinical trials was 7.6% of total CAM articles. CONCLUSIONS: There is an upward trend in the number of CAM articles but the number of experimental studies is low and over half of articles are published in journals without an IF. We believe there is an urgent need to conduct rigorous research in the field of CAM in order to support, for the need of the public, an evidence-based approach to these therapies.

Approaches to supporting lactation and breastfeeding for very preterm infants in the NICU: a qualitative study in three European regions.

OBJECTIVES: To explore differences in approaches to supporting lactation and breastfeeding for very preterm infants in neonatal intensive care units (NICU) in 3 European regions. DESIGN: Qualitative cross-sectional study carried out by means of face-to-face semistructured interviews. Verbatim transcripts were coded using a theoretical framework derived from the literature and supplemented by data-driven concepts and codes. SETTING: 4 purposively selected NICUs in each of 3 European regions in 2010 (Ile-de-France in France, Lazio in Italy, and the former Trent region in the UK). PARTICIPANTS: NICU staff members (n=22). RESULTS: Policies and practices for managing mother's own milk for very preterm babies differed between regions, and were much more complex in Ile-de-France than in the Trent or Lazio regions. Staff approaches to mothers to initiate lactation differed by region, with an emphasis on the nutritional and immunological value of human milk in the Trent region and on the 'normalising' effect of breastfeeding on the mother-child relationship in Lazio. French and English staff expressed conflicting opinions about the use of bottles, which was routine in Italy. Italian informants stressed the importance of early maternal milk expression and feeding, but also mentioned discharging infants home before feeding at the breast was established. In Ile-de-France and Trent, successful feeding from the breast was achieved before discharge, although this was seen as a factor that could prolong hospitalisation and discourage continued breastfeeding for some women. CONCLUSIONS: Targeted health promotion policies in the NICU are necessary to increase the number of infants receiving their mother's milk and to support mothers with transfer of the infant to the breast. Integrating knowledge about the different approaches to lactation and breastfeeding in European NICUs could improve the relevance of recommendations in multiple cultural settings.

[Characteristics of unconventional medicine users and their households in Italy]. / Caratteristiche individuali e familiari degli utilizzatori di terapie non convenzionali in Italia.

The results presented in this paper are part of the largest survey on unconventional medicine conducted so far (more than 140 000 people). Families with high socio-economical levels had the highest probability of choosing unconventional medicine. The use is strongly related to geographic area probably due to different availability of structures able to provide these therapies. At individual level the choice to use unconventional medicine seems a "cultural" trend associated with healthy life styles, and with positive attitudes towards prevention. It is interesting also to underline that the use of unconventional medicine is more frequent among women. Almost all users of unconventional medicine (80%) declare to be in good health, and this can indicate that unconventional therapies are mostly used for not serious and self limited conditions. Furthermore, use of unconventional medicine is often associated with a greater use of conventional drugs and with a greater frequency of check-up. This suggests a "complementary", more than "alternative" use of this kind of therapies.

Vitamin K acupuncture pint injection for severe primary dysmenorrhea: an international pilot study.

CONTEXT: Vitamin K acupuncture point injection, a menstrual pain treatment derived from traditional Chinese medicine, has been a standard treatment in some hospitals in China since the 1980s. OBJECTIVES: To investigate the effects of vitamin K acupuncture point injection on menstrual pain in young women aged 14 to 25 from different countries and cultural backgrounds who have had unmitigated severe primary dysmenorrhea for 6 months or more. DESIGN: Prospective, observational, clinical pilot study SETTINGS: One site in China (a hospital outpatient clinic in Shanghai) and 2 sites in Italy (a hospital clinic in Milan and a private gynecology practice in Verona). INTERVENTIONS: All subjects were treated with bilateral acupuncture point injection of vitamin K on the first or second day of menstrual pain. Vitamin K3 was used in China and vitamin K4 in Italy. MAIN OUTCOME MEASURES: Pain intensity, total duration, and average intensity of menstrual distress, hours in bed, normal daily activity restrictions, and numbers of analgesic tablets taken to relieve pain were recorded before the treatment and for 4 subsequent menstrual cycles. RESULTS: Noticeable pain relief was observed 2 minutes after treatment, and subsequent pain reduction occurred at 30 minutes (P < .001). Subjects reported significantly fewer daily life restrictions, fewer hours in bed, less consumption of analgesic tablets, and lower scores of menstrual pain duration and intensity (P < .001). There were no adverse events. Some women experienced mild, self-limited pain at the injection site. CONCLUSION: Acupuncture point injection with vitamin K alleviated acute menstrual pain, and relief extended through the nontreatment follow-up cycles in this uncontrolled pilot study conducted in 2 countries. Further investigation employing controlled experimental designs is warranted.

Living with phenylketonuria from the point of view of children, adolescents, and young adults: a qualitative study.

OBJECTIVE: To explore the experiences of patients affected by phenylketonuria, a genetic metabolic disease currently screened during the neonatal period, in whom treatment was begun shortly after birth. Dietary treatment of the metabolic abnormality can prevent effects on the central nervous system through infancy, adolescence, and adulthood, but the associated challenges for personal and social life, such as everyday problems of adherence to a strict regimen, have been inadequately studied. METHOD: A qualitative study was performed using semistructured interviews involving 20 patients aged between 8 and 23 years and referred to a pediatric hospital for phenylketonuria. A thematic framework was formulated in advance which identified the main issues to be investigated, and a list of questions was devised. The interviews were audiotaped and were all transcribed and analyzed by 3 investigators with the support of NVivo software. RESULTS: Patients showed a fair knowledge of their condition but did not feel that they were truly ill. However, they adhered to their treatment regimen although they perceived no direct, immediate, adverse effects of their disease. A long-standing habit of following a demanding diet from infancy emerged from the interviews. A major problem for these patients is the difference perceived when comparing themselves with their peers, and the fear of stigmatization can prevent patients from participating in social occasions during which food is shared. One coping strategy patients may use is to disclose their condition to peers to overcome isolation. CONCLUSIONS: The impact of long-standing, demanding health behaviors on the social life of patients affected by a chronic metabolic disease must be recognized, taking into particular consideration both social functioning and adherence to dietary treatment.

Use of unconventional medicine in Italy: a nation-wide survey.

OBJECTIVE: To investigate the prevalence of use of unconventional therapies in Italy, the main health problems associated with and the motivations for use of these therapies. METHODS: Questions about the use of unconventional therapies were inserted in a nation-wide survey conducted by face-to-face interviews with all members of sampled families by the National Institute of Statistics during four quarters of the years 1999-2000. Data presented here are based on the results of the first two quarters of the survey (September and December 1999) during which a representative sample of 30,000 Italian families (70,898 individuals) was interviewed. RESULTS: Almost 9 million people (15.6% of the Italian population) used at least one unconventional therapy during the period 1997-1999. Homeopathy was the most frequently used (8.2% of the population), followed by manual treatments (7%), herbal medicine (4.8%) and acupuncture (2.9%). Homeopathy was also quite commonly used by children (7.7% of Italian children). The main reason for use was concern about potential toxicity of "conventional medicine". The health problem most frequently treated with all kinds of unconventional therapies was pain. CONCLUSIONS: Use of unconventional therapies has almost doubled since 1991. However, with 15.6% of the Italian population (9 million people) using at least one therapy, Italy ranks among the "light" users compared with other European countries. Homeopathy is the most frequently used therapy. The typical user is, as in other western countries, a highly educated woman aged 35-44 years and resident in the richest part of the country (north-eastern Italy).