Moral distress among healthcare professionals working in intensive care units in Spain / Desasosiego moral entre los profesionales sanitarios que trabajan en unidades de cuidados intensivos en España

Objective To assess moral distress (MD) among Spanish critical care healthcare professionals (HCPs). Design Cross-sectional, prospective study. Setting ICUs in Spain. Participants HCPs currently working in Spanish ICUs. Interventions A 55-item questionnaire was electronically distributed. Main variables The questionnaire included work-related and socio-demographic characteristics, the Spanish version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA), and the Hospital Ethical Climate Survey (HECS). Results In total, 1065 intensive care providers completed the questionnaire. Three out of four validity hypotheses were supported. MD was significantly higher for physicians (80, IQR 40–135) than for nurses (61, IQR 35–133, p=0.026). MD was significantly higher for those clinicians considering leaving their position (78, IQR 46–163 vs. 61, IQR 32–117; p<0.001). The MMD-HP-SPA was inversely correlated with the HECS (r=−0.277, p<0.001). An exploratory factor analysis revealed a four-factor structure, evidencing the patient, team, and system levels of MD. Conclusions In the study sample, Spanish intensivists report higher MD than nurses. Strategies to improve ICU ethical climate and to correct other related factors in order to mitigate MD at a patient, team, and system level should be implemented. Both groups of HCPs manifest a relevant intention to leave their position due to MD. Further studies are needed to determine the extent to which MD influences their desire to leave the job (AU)

Objetivo Evaluar el desasosiego moral (DM) entre los profesionales sanitarios que trabajan en UCI en España. Diseño Estudio prospectivo transversal. Ámbito UCI en España. Participantes Profesionales sanitarios que actualmente trabajan en UCI españolas. Intervenciones Se distribuyó electrónicamente un cuestionario de 55 ítems. Variables principales El cuestionario incluía características sociodemográficas y laborales, la versión en español de la Medida de desasosiego moral para profesionales sanitarios (MMD-HP-SPA) y la Encuesta de clima ético hospitalario (HECS). Resultados En total 1.065 profesionales sanitarios de cuidados intensivos completaron el cuestionario. Tres de 4 hipótesis de validez fueron apoyadas. El DM fue significativamente mayor entre los médicos (80, IQR 40-135) que entre las enfermeras (61, IQR 35-133, p=0,026). El DM fue significativamente más alto para aquellos médicos que estaban considerando dejar su puesto de trabajo (78, IQR 46-163 vs. 61, IQR 32-117; p<0,001). El MMD-HP-SPA se correlacionó inversamente con el HECS (r=–0,277, p<0,001). Un análisis factorial exploratorio reveló una estructura de 4 factores, evidenciando los niveles de paciente, equipo y sistema del DM. Conclusiones En este estudio los intensivistas refirieron niveles de DM más altos que las enfermeras. Se deben implementar estrategias para mejorar el clima ético en las UCI y corregir otros factores relacionados con el fin de mitigar el DM en lo que atañe al paciente, al equipo y al sistema. Ambos grupos de profesionales manifestaron una intención relevante de abandonar su puesto de trabajo debido al DM. Se necesitan más estudios para determinar en qué medida el DM influye sobre su deseo de abandonar su puesto de trabajo (AU)

Moral distress among healthcare professionals working in intensive care units in Spain.

OBJECTIVE: To assess moral distress (MD) among Spanish critical care healthcare professionals (HCPs). DESIGN: Cross-sectional, prospective study. SETTING: ICUs in Spain. PARTICIPANTS: HCPs currently working in Spanish ICUs. INTERVENTIONS: A 55-item questionnaire was electronically distributed. MAIN VARIABLES: The questionnaire included work-related and socio-demographic characteristics, the Spanish version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA), and the Hospital Ethical Climate Survey (HECS). RESULTS: In total, 1065 intensive care providers completed the questionnaire. Three out of four validity hypotheses were supported. MD was significantly higher for physicians (80, IQR 40-135) than for nurses (61, IQR 35-133, p=0.026). MD was significantly higher for those clinicians considering leaving their position (78, IQR 46-163 vs. 61, IQR 32-117; p<0.001). The MMD-HP-SPA was inversely correlated with the HECS (r=-0.277, p<0.001). An exploratory factor analysis revealed a four-factor structure, evidencing the patient, team, and system levels of MD. CONCLUSIONS: In the study sample, Spanish intensivists report higher MD than nurses. Strategies to improve ICU ethical climate and to correct other related factors in order to mitigate MD at a patient, team, and system level should be implemented. Both groups of HCPs manifest a relevant intention to leave their position due to MD. Further studies are needed to determine the extent to which MD influences their desire to leave the job.

Moral distress among healthcare professionals working in intensive care units in Spain.

OBJECTIVE: To assess moral distress (MD) among Spanish critical care healthcare professionals (HCPs). DESIGN: Cross-sectional, prospective study. SETTING: ICUs in Spain. PARTICIPANTS: HCPs currently working in Spanish ICUs. INTERVENTIONS: A 55-item questionnaire was electronically distributed. MAIN VARIABLES: The questionnaire included work-related and socio-demographic characteristics, the Spanish version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA), and the Hospital Ethical Climate Survey (HECS). RESULTS: In total, 1065 intensive care providers completed the questionnaire. Three out of four validity hypotheses were supported. MD was significantly higher for physicians (80, IQR 40-135) than for nurses (61, IQR 35-133, p=0.026). MD was significantly higher for those clinicians considering leaving their position (78, IQR 46-163 vs. 61, IQR 32-117; p<0.001). The MMD-HP-SPA was inversely correlated with the HECS (r=-0.277, p<0.001). An exploratory factor analysis revealed a four-factor structure, evidencing the patient, team, and system levels of MD. CONCLUSIONS: In the study sample, Spanish intensivists report higher MD than nurses. Strategies to improve ICU ethical climate and to correct other related factors in order to mitigate MD at a patient, team, and system level should be implemented. Both groups of HCPs manifest a relevant intention to leave their position due to MD. Further studies are needed to determine the extent to which MD influences their desire to leave the job.

[Profile of the Family Doctor who gains access to positions with teaching tutorship of Family and Community Medicine by means of relocation examination in Galicia]. / Perfil del médico de familia que accede a plazas con tutoría docente de Medicina Familiar y Comunitaria mediante concurso de traslados en Galicia.

OBJECTIVE: To analyse the profile of Family Doctors who gain access to positions, both to the general quota, as well those reserved for teaching tutors of Family and Community Medicine, by means of a relocation competition. MATERIAL AND METHODS: A descriptive observational study was conducted in which 2 comparison groups were established: A Non-Teaching group that did not include Family Doctors who did not request or gain access to tutor positions, and a Teaching group with those that gained access to positions reserved for tutors. The information was obtained from the marks of the relocation competition carried out in Galicia in 2018. A total of 426 General Practitioners that entered the examination were included, of which 301 were female (70.7%) and 125 (29.3%) males. The variables were the obtaining of a position reserved for tutor, gender, and the merits considered in the competition: professional experience, training, scientific publications, and Galician language. The non-parametric statistics tests of Mann-Whitney and Kruskal-Wallis were used, after checking for non-normal distribution. RESULTS: Statistically significant differences were found in the distribution by gender in favour of males in the Teaching group compared to the Non-Teaching group (P<.01). The Teaching group obtained better results in training and publications. The females obtained statistically significant results in their favour in the training variable, and the males in experience. CONCLUSIONS: For the choice of teaching places in relocation interviews and examinations, publications and training had an important weighting; but, taking the gender perspective into account, a lower percentage of women had gained access to teaching positions due to having lower score in the experience category.

[Therapeutic Aggressiveness and Liquid Oncology]. / La Agresividad Terapéutica y la Oncología Líquida.

Aggressiveness criteria proposed in the scientific literature a decade ago provide a quality judgment and are a reference in the care of patients with advanced cancer, but their use is not generalized in the evaluation of Oncology Services. In this paper we analyze the therapeutic aggressiveness, according to standard criteria, in 1.001 patients with advanced cancer who died in our Institution between 2010 and 2013. The results seem to show that aggressiveness at the end of life is present more frequently than experts recommend. About 25% of patients fulfill at least one criterion of aggressiveness. This result could be explained by a liquid Oncology which does not prioritize the patient as a moral subject in the clinical appointment. Medical care is oriented to necessities and must be articulated in a model focused on dignity and communication. Its implementation through Advanced Care Planning, consideration of patient's values and preferences, and Limitation of therapeutic effort are ways to reduce aggressiveness and improve clinical practice at the end of life. We need to encourage synergic and proactive attitudes, adding the best of cancer research with the best clinical care for the benefit of human being, moral subject and main goal of Medicine.

No cash no whiplash?: Influence of the legal system on the incidence of whiplash injury.

Whiplash injury has been a continuous source of controversy due to its association with litigation. We studied the incidence of whiplash associated disorder (WAD) in two similar socioeconomic areas and carried out a retrospective study based on the hypothesis that the Spanish law 30/1995 might have an affect on the incidence and duration of cervical symptoms and the persistence of impairment. More than 10,000 patients injured in traffic accidents were studied over a period three years. Of these, only patients with an initial diagnosis of whiplash injury were included in the study. Patients with other injuries were excluded. The patients were classified into two groups: Galicia-Spain and North-Central Portugal (depending on where the accident took place and the medico-legal evaluation procedure in force). Statistical analysis was made using SPSS 13.0 and Statistix 8.0. We found a statistically significant difference between Spain and Portugal in the incidence of WAD and in the duration of symptoms. The incongruities caused by the compulsory application of Spanish law arise from the fact that evaluation on a points scale of impairment does not always reflect the functional state of the injured person.

Immunohistochemical analysis of P-Selectin as a possible marker of vitality in human cutaneous wounds.

Immunohistochemical detection of mediators of inflammation, such as P-Selectin, has been proposed to assess vitality of wounds. Forty-five incised cutaneous wounds (24 vital, 14 post-mortem, seven with induced autolysis/putrefaction) were immunostained with antibodies against P-Selectin and CD31. The percentage of stained lumina for P-Selectin out of the total of CD31 positive vessels (P-S/CD31 index) was calculated at both edges of every specimen. In vital samples, the P-S/CD31 index ranged from 10.7% to 71.4% at the wound edge, and was 12.5-58.8% for the opposite margin, with a ratio between both indices of 0.37-1.77 (mean: 0.94). In post-mortem cases, the index ranged from 22.5% to 69.2% at the wound edge, and was 28-89.5% at the opposite margin, with a ratio between both indices of 0.76-1.9 (mean: 0.96). Differences between ratios were not statistically significant and thus precluded any assessment of vitality. The analysis of P-Selectin/CD31 immunoreactivity in skin wounds was not useful for the diagnosis of vitality when evaluating both edges for each specimen. Moreover, P-Selectin has been detected in post-mortem injuries and it is not specific to vital injuries. Microscopic evaluation becomes difficult after autolysis/putrefaction.

The pathology of the heart conduction system in congenital heart block.

The incidence of congenital complete heart block is estimated in 1 of 2500-20,000 births. Many cases are isolated (found in an otherwise normal heart) and the pathology of the heart conduction system is variable. We report a 51-year-old man with the diagnosis of complete heart block, with a permanent pacemaker. No family history of rhythm disturbances was available. The patient presented and endocarditis after replacement of the pacemaker battery. The prognosis was poor and the patient died three months later. Autopsy examination showed signs of shock, of septic origin. The heart was hypertrophic (450g) and the left ventricle thickened. Histopathological examination of the heart conduction system showed that the sinus and atrioventricular nodes were normal, but the His bundle was interrupted and replaced by fibrous tissue. No inflammatory signs were present. Loss of conducting fibres and their replacement by fibrous tissue is the most common pathological process in complete heart block. In this case His bundle was mostly affected, different to Lev's disease where the process is more distal (branching atrioventricular bundle) and to Lenegre's disease, which shows a diffuse damage in the conducting system.

A high-performance liquid chromatography method for hypoxanthine determination in vitreous humour: application to estimation of post mortem interval.

We have developed a new technique to determine the concentration of hypoxanthine [Hx] in a reverse phase column using a modified high-performance liquid chromatography (HPLC) method that is faster and more reliable than those previously described. In this paper we present a formula for estimating the post mortem interval (PMI) based on this HPLC method by applying the inverse prediction method. The regression line obtained by changing the variables gives PMI = 0.183 [Hx] + 0.599 (PMI in hours, [Hx] in micromol/L, R2 = 0.531, P < 0.05).

Expression of fibronectin and tenascin as a demonstration of vital reaction in rat skin and muscle.

The efficiency of immunohistochemical techniques for the diagnosis of vitality of wounds decreases for lesions occurring fairly close to death. We analyzed the expression of fibronectin (FN) and tenascin (TN) in wounds inflicted in abdominal skin of 12 adult rats. An incised injury was made at 5, 10 or 15 min before death and another at 5 min after sacrifice, and collected after 45 min. Formalin-fixed paraffin-embedded sections from a total of 36 samples (mean 1.5 per wound) were immunostained following the streptABC technique. Microscopic examination revealed a reticular pattern staining in 18 out of 20 vital samples for FN, 16 out of 20 for TN, 2 out of 16 postmortem samples for FN and 3 out of 16 for TN. Intracellular staining of muscle fibres was observed in 7 out of 20 vital and 5 out of 16 postmortem samples. FN and TN were detected in most of the vital injuries but they are not completely specific. Postmortem staining occurred in a few cases probably related to a passive extravasation of these molecules from damaged blood vessels. Reactivity of muscle fibres occurs both in vital and postmortem lesions, and is not useful in the diagnosis of vitality.

Demonstration of apoptosis in human skin injuries as an indicator of vital reaction.

Demonstrating the vital character of an injury and estimation of the age are routine tasks in forensic pathology and although many different techniques have been applied to this problem none have been found to be completely satisfactory. Apoptosis, an active genetically controlled process, is the major mechanism by which homeostasis of a number of physiological systems in the body is regulated and changes in the rate following different kinds of stimuli have prompted us to test it as an indicator of vitality. We used an in situ end-labelling technique (Apop-Tag) in 30 human surgical skin injuries with age since injury ranging from 3 min to 8 h and found that apoptotic keratinocytes are found in over 50% of the cases with a post-infliction interval of at least 120 min. Apoptosis was not seen in injuries less than 120 min old or in normal skin, which was used as an external control. These results suggest that apoptosis could be a useful indicator for the intravital occurrence of injuries and could help to estimate the date of the skin injuries in some cases. The importance of strict technical control is stressed and the necessity of a complementary technique to confirm apoptosis is discussed.

Sudden neonatal death from congenital cystic adenomatoid malformation.

We report a case of congenital cystic adenomatoid malformation (CCAM) of the lungs resulting in sudden death immediately after birth. The case is extremely unusual because of the diffuse bilateral involvement. The extensive involvement of both lungs could explain the abrupt onset of the symptoms and the ineffectiveness of resuscitation attempts. The presence of cartilage as a part of the malformation adds interest to the case, since it is seldom found in this malformation and to the best of our knowledge has been reported only exceptionally in a type II CCAM.

Rupture of liver cell adenoma with fatal massive hemoperitoneum resulting from minor road accident.

Blunt abdominal trauma can cause rapid death resulting from serious injuries of internal organs. The liver is commonly involved and may show tearing, usually in its upper surface, resulting in hemoperitoneum eventually leading to death. Minor trauma implies serious liver damage only when previous pathologic changes causing enlargement of the organ are present. The case of a 25-year-old woman who died as a consequence of a minor road accident is reported. At autopsy, the body showed no external injuries, the only relevant finding being a massive hemoperitoneum from the rupture of an unusually large liver cell adenoma. Liver cell adenomas carry a serious risk of spontaneous rupture, which may result in the death of the patient. The occurrence of the rupture after a minor blunt abdominal trauma is highly unusual.

Detection of apoptosis in ischemic heart. Usefulness in the diagnosis of early myocardial injury.

Myocardial samples of hearts with histologic findings of acute myocardial infarction (group A), sudden coronary deaths without histologic changes (group B), and chronic ischemic heart disease (group C) were analyzed to investigate the appearance of apoptosis in acute and chronic ischemic cardiac disorders. This analysis involved the morphologic detection of DNA strand breaks in myocyte nuclei by the terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL) assay and the biochemical determination of DNA laddering in the myocardium using archival formalin-fixed, paraffin-embedded tissue sections of human myocardium. The authors demonstrated that apoptosis of myocardial cells could occur after ischemic myocardial cell injury. In all documented cases of acute myocardial infarction (group A), the infarcted area included extensive presence of both apoptosis and necrosis. In the tissue bordering on and away from the obviously infarcted areas, positive nuclei were intermingled with nonstained normal myocytes. The number of positive nuclei decreased with the distance from the infarction foci. In group B, myocardial samples showed focal or diffuse nuclear positivity of varying degrees for apoptosis, confirming the presence of myocardial ischemic cell death, whereas the histologic diagnosis remained inconclusive. This finding suggests that apoptosis could be used as a marker for acute ischemic injury. In group C, stained nuclei were dispersed with intermingled normal cardiomyocytes.

A new perspective in the estimation of postmortem interval (PMI) based on vitreous.

The relation between the potassium concentration in the vitreous humor, [K+], and the postmortem interval has been studied by several authors. Many formulae are available and they are based on a correlation test and linear regression using the PMI as the independent variable and [K+] as the dependent variable. The estimation of the confidence interval is based on this formulation. However, in forensic work, it is necessary to use [K+] as the independent variable to estimate the PMI. Although all authors have obtained the PMI by direct use of these formulae, it is, nevertheless, an inexact approach, which leads to false estimations. What is required is to change the variables, obtaining a new equation in which [K+] is considered as the independent variable and the PMI as the dependent. The regression line obtained from our data is [K+] = 5.35 + 0.22 PMI, by changing the variables we get PMI = 2.58[K+] - 9.30. When only nonhospital deaths are considered, the results are considerably improved. In this case, we get [K+] = 5.60 + 0.17 PMI and, consequently, PMI = 3.92[K+] - 19.04.

Stature estimation from radiographically determined long bone length in a Spanish population sample.

The estimation of stature from of a variety of bones is an important aspect of forensic work. In order to obtain reliable results, it is important to have comparative data obtained from the same population group as the skeletal remains. However, lack of up to date information on the population groups of Southern Europe makes the estimation of stature from bones in this area subject to possible error. In this study, the stature of 104 healthy adults from Spain was measured, and an anteroposterior teleradiograph of the right lower and the right upper limb of every subject in the study was made in order to measure the lengths of the femur, tibia, fibula, humerus, cubitus and ulna. Pearson's regression formulae were obtained for both limbs. In males, we found the femur to be the most accurate predictor of stature (R = 0.851), whereas in females best results were obtained with the tibia (R = 0.876).

Y chromosome STR haplotypes: genetic and sequencing data of the Galician population (NW Spain).

Recently described Y-STR polymorphisms can be analysed as informative haplotypes which are useful in the forensic field. In order to include these systems in our forensic routine, we have carried out a population study in Galicia (NW Spain) analysing seven Y-STR polymorphisms (DYS19, DYS389-I, DYS389-II, DYS390, DYS393 and DYS385: two loci). The results were compared with other population studies. In addition various alleles for each system (except DYS385) were sequenced and the corresponding allelic ladders constructed.