The value of uncertainty in critical illness? An ethnographic study of patterns and conflicts in care and decision-making trajectories.

BACKGROUND: With increasingly intensive treatments and population ageing, more people face complex treatment and care decisions. We explored patterns of the decision-making processes during critical care, and sources of conflict and resolution. METHODS: Ethnographic study in two Intensive Care Units (ICUs) in an inner city hospital comprising: non-participant observation of general care and decisions, followed by case studies where treatment limitation decisions, comfort care and/or end of life discussions were occurring. These involved: semi-structured interviews with consenting families, where possible, patients; direct observations of care; and review of medical records. RESULTS: Initial non-participant observation included daytime, evenings, nights and weekends. The cases were 16 patients with varied diagnoses, aged 19-87 years; 19 family members were interviewed, aged 30-73 years. Cases were observed for <1 to 156 days (median 22), depending on length of ICU admission. Decisions were made serially over the whole trajectory, usually several days or weeks. We identified four trajectories with distinct patterns: curative care from admission; oscillating curative and comfort care; shift to comfort care; comfort care from admission. Some families considered decision-making a negative concept and preferred uncertainty. Conflict occurred most commonly in the trajectories with oscillating curative and comfort care. Conflict also occurred inside clinical teams. Families were most often involved in decision-making regarding care outcomes and seemed to find it easier when patients switched definitively from curative to comfort care. We found eight categories of decision-making; three related to the care outcomes (aim, place, response to needs) and five to the care processes (resuscitation, decision support, medications/fluids, monitoring/interventions, other specialty involvement). CONCLUSIONS: Decision-making in critical illness involves a web of discussions regarding the potential outcomes and processes of care, across the whole disease trajectory. When measures oscillate between curative and comfort there is greatest conflict. This suggests a need to support early communication, especially around values and preferred care outcomes, from which other decisions follow, including DNAR. Offering further support, possibly with expert palliative care, communication, and discussion of 'trial of treatment' may be beneficial at this time, rather than waiting until the 'end of life'.

Measuring symptom load in Idiopathic Parkinson's disease.

This study evaluated the symptom burden experienced by patients with Idiopathic Parkinson's Disease (IPD) by using a standard palliative care assessment tool (PACA) and comparing it with the Unified Parkinson's Disease Rating Scale (UPDRS). These tools together with the Mini-Mental State Examination, Beck Depression Inventory and the Schedule for the Evaluation of Individual Quality of Life were used in 123 IPD patients. The PACA demonstrated broad coverage of both motor and non motor symptoms (mean=14.3 symptoms per patient) whereas the UPDRS predominantly assessed motor symptoms. Implications for symptom assessment and palliative care provision in IPD are discussed.

Topical benzydamine cream and the relief of pressure pain.

OBJECTIVE: To determine whether topical benzydamine hydrochloride 3% cream is more effective than placebo in reducing pain related to pressure areas in palliative care patients. DESIGN: Randomized double-blind, placebo-controlled trial. SETTING: Three specialist palliative care units in the north of England, with local ethical committee approval for all sites. SUBJECTS: Hospice in-patients with pain related to pressure areas. INTERVENTIONS: A single application of either benzydamine hydrochloride 3% cream or placebo cream to the painful pressure area. MAIN OUTCOME MEASURES: Pain assessed using 100 mm VAS, an 11-point numerical pain score and a five-point pain relief score. RESULTS: There was no statistically significant difference between topical benzydamine hydrochloride 3% cream and placebo cream in reducing pain related to pressure areas in palliative care patients. CONCLUSIONS: This study does not demonstrate a statistically significant difference between the two treatments. However the study does provide reliable information with respect to the use of different pain measurement tools in late-stage palliative patients. It also provides information regarding the baseline characteristics of this group of patients which may be useful in the planning of any future similar studies.

Comparison of ball-and-racquet impact force between two tennis backhand stroke techniqes.

STUDY DESIGN: A mixed design for kinetic comparison of 2 types of one-handed backhand strokes and 2 skill levels in tennis. OBJECTIVES: To develop and evaluate a model to estimate the impact force on the racquet during tennis stroke, and to compare the peak impact force between one-handed backhand stroke with a long backswing and one-handed backhand stroke with a short backswing and between the beginning and advanced players. BACKGROUND: A one-handed backhand stroke is commonly used in tennis and may be associated with many upper extremity over-use injuries. An understanding of kinetics of the backhand stroke is essential for understanding injury mechanisms and prevention. METHODS AND MEASURES: Five male advanced tennis players and 4 male and 1 female beginning tennis players participated. Mean age was 32.2 +/- 7.0 years. Each subject was instructed to use the 2 types of one-handed backhand strokes to hit balls from a tennis ball machine. Three-dimensional coordinates of critical body and racquet landmarks were obtained. A mathematical model was developed to estimate the contact duration and the peak impact force during a stroke. RESULTS: The estimated peak impact forces were reproducible and comparable to those reported in the literature from direct measurements. A one-handed backhand stroke with a short backswing had a significantly shorter contact duration (0.008 +/- 0.003 seconds) and a greater peak resultant impact force (330.0 +/- 140.7) than that with a long backswing (0.016 +/- 0.004 seconds and 180.8 +/- 49.1 N). Skill level did not significantly affect the peak resultant impact force. CONCLUSION: A long backswing in a one-handed backhand stroke may reduce the load on the upper extremity and may assist in reducing the risks of tennis-related upper extremity over-use injuries.

A comparison of sideline versus clinical cognitive test performance in collegiate athletes.

OBJECTIVE: To test whether performance on 5 cognitive tests administered in a controlled clinical environment differed compared with administration in an uncontrolled sideline environment. Additionally, we investigated the effect of testing environment order on the learning effect for each cognitive test. DESIGN AND SETTING: Athletes were assessed on 2 test occasions (8 +/- 2 days apart), once in a sports medicine research laboratory and once on a lacrosse practice field site. SUBJECTS: A total of 59 Division I collegiate student-athletes participated in this study. MEASUREMENTS: Normative data were collected on 5 cognitive tests (Stroop Test, Trail-Making Test part A, Trail-Making Test part B, Wechsler Digit-Span Forward Test, and Digit-Span Backward Test). RESULTS: An independent-samples t test for environment difference on test day 1 revealed no significant differences between tests performed in the controlled environment and those performed in the uncontrolled environment. A repeated- measures analysis of variance test revealed a significant learning effect for all 5 tests, as subjects tended to improve approximately 11 points on the Stroop Test, 3 seconds on the Trail-Making A Test, 7 seconds on the Trail-Making B Test, and 1 point each on the Wechsler Digit Span Forward and Backward Tests. A paired-samples t test using delta scores (first test minus second test), sorted by order of testing environment, revealed a significant difference for the Stroop Test, but not for the remaining cognitive tests. CONCLUSIONS: There appears to be no difference in cognitive testing performance completed in a controlled clinical environment versus that performed in an uncontrolled sideline environment. This finding suggests that clinicians can administer cognitive tests to athletes with mild head injuries in uncontrolled sideline environments and expect valid results. Thus, clinicians can more thoroughly evaluate mildly head-injured athletes during the most crucial period after injury so that a safe return-to-play decision can be based on quantifiable, objective data.

Collegiate coaches' knowledge of eating disorders.

OBJECTIVE: To assess, through exploratory research, 1) collegiate coaches' knowledge of eating disorders, 2) the confidence of collegiate coaches in their response correctness to questions about eating disorders among athletes, and 3) demographic data related to prior education about eating disorders and the role of the athletic department in providing such educational experiences. DESIGN AND SETTING: We distributed a 2-part questionnaire to 258 NCAA Division I-A coaches from 5 universities selected by sampling convenience. SUBJECTS: One hundred thirty-eight collegiate coaches responded to the questionnaire for a response rate of 53.5%. MEASUREMENTS: Our survey consisted of 30 true-false questions that tested knowledge of eating disorders overall and in 5 domains. These domains included etiology, identifying signs and symptoms, management and treatment, risk factors, and education and prevention of eating disorders. Coaches indicated their level of certainty in their responses by rating their confidence level on a 4-item Likert-type scale. Demographic data focused on educational programs attended by coaches and teams. Descriptive statistics were used to analyze all data. RESULTS: Our results suggest a need for coaches to achieve a greater knowledge of eating disorders in all domains. Evidence showed that educational programs about eating disorders were not often sponsored by the athletic department for coaches or athletes. There seemed to be poor communication between athletic departments and coaches regarding the availability of eating disorder educational resources. CONCLUSIONS: Data suggested coaches could benefit from comprehensive education in all domains of eating disorders; however, further study is needed to validate these findings, to determine the actual effectiveness of education in the prevention of eating disorders, and to differentiate coaches' knowledge specific to sport coached and to coach and team sex.

Proprioception and neuromuscular control of the shoulder after muscle fatigue.

OBJECTIVE: To examine the effects of fatigue on proprioception and neuromuscular control of the shoulder. DESIGN AND SETTING: Subjects were randomly assigned to either an experimental group or control group. Subjects were tested using either the active angle-reproduction or the single- arm dynamic stability test. The subjects were then fatigued using a dynamometer performing continuous, concentric rotation exercises of the shoulder. Once fatigued, the subjects were posttested using the same test. One week later, the subjects returned and were pretested, fatigued, and posttested using the other test. SUBJECTS: Thirty-two college-age (18 to 25 years) subjects (16 males, 16 females) with no history of glenohumeral instability or upper extremity injury volunteered for this study. MEASUREMENTS: Absolute angular error was measured using an electrogoniometer present within the isokinetic dynamometer, while sway velocity was measured using a force-plate system. RESULTS: Repeated-measures analysis of variance revealed a significant difference between the pretest and posttest values for absolute angular error in the experimental group, whereas no significant difference was revealed between pretest and posttest sway velocity for either the control or experimental group. CONCLUSIONS: Fatigue of the internal and external rotators of the shoulder decreased proprioception of the shoulder, while having no significant effect on neuromuscular control.

Establishment of normative data on cognitive tests for comparison with athletes sustaining mild head injury.

OBJECTIVE: To provide normal data for comparison with objective measures of an athlete's cognitive ability after mild head injury (MHI). SUBJECTS: Seventy-two Division I college athletes. DESIGN AND SETTING: Athletes were assessed on three test dates (two days apart) in a sports medicine research laboratory. MEASUREMENTS: Normative data were collected on four cognitive tests (Hopkins Verbal Learning Test, Stroop Test, Reitan Trail-Making Tests, and Wechsler Digit Span Tests). RESULTS: A repeated-measures analysis of variance revealed significant learning effects on all tests except the Hopkins Verbal Learning Test. A high correlation was noted between the Stroop and the Trail-Making Tests. CONCLUSIONS: These normative data can be used as comparisions to provide an objective measure of an athlete's cognitive ability following MHI. By adding this test battery to the athlete's other physical and neurologic tests, the decision to return an athlete to competition after MHI can be made with greater confidence and with less risk of reinjury.

Methicillin-resistant Staphylococcus aureus infection in palliative care.

Our objective was to assess the impact of methicillin-resistant Staphylococcus aureus (MRSA) infection in palliative care. The study was conducted at three hospices in south London, totalling 118 beds, and the following two methods were used. Firstly, a retrospective review of the notes of patients who were known to be MRSA positive at admission or were subsequently found to be MRSA positive was taken. Secondly, a prospective study of factors influencing bed occupancy in one hospice was conducted. The proportion of admissions who were MRSA positive ranged from 4% to 8% in the three hospices. Seven of the 43 patients who had MRSA suffered clinically significant infections. Risk factors for colonization and bacteraemia were similar to the general population. Sites of infection were variable and multiple and treatment regimes for eradication were variable, with varying outcomes. MRSA infection appeared to delay admission because of the need for single rooms, of which there are few Time spent cleaning rooms after discharge or death also reduced the number of available beds. It was concluded that MRSA infection is associated with significant morbidity in a small number of palliative care patients. Beds unavailable because of MRSA should be considered in bed occupancy figures, otherwise bed occupancy may appear artificially low. The psychological and financial impact of the infection in palliative care patients needs further evaluation.

A multipurpose MRI phantom based on a reverse micelle solution.

Many chemical solutions for use in magnetic resonance imaging phantoms have been reported in the literature. Each of these solutions has its application-specific advantages and disadvantages. We propose a single reverse micelle phantom solution, which, although not a universal phantom solution, may find applications in testing of the radio frequency transmit and receive fields of an imaging coil, the homogeneity of the static magnetic field, and the suppression in a fat or water saturation imaging sequence. The solution is thermodynamically stable and biologically inert, it possesses a smaller standing wave artifact than water, and its overall spin lattice relaxation times may be adjusted.

Passy-Muir tracheostomy speaking valve on ventilator-dependent patients.

Communication for handicapped ventilator-dependent patients is a problem, not only for the patient but also for the healthcare personnel. The inability of these patients to vocalize is a paramount problem in their care. This study evaluates the efficacy of a one-way speaking valve on ventilator-dependent patients and evaluates the resulting effectiveness of their speech. Fifteen ventilator-dependent patients were fitted with the one-way Passy-Muir Tracheostomy Speaking Valve and their communicative skills and ease of vocalization were evaluated. This clinical evaluation was done by the patient, a speech pathologist, two nurses in charge of the patient, and the patient's private physician. No complications were observed in any of the patients. All 15 patients showed marked improvement, not only in speech intelligibility but in speech flow, the elimination of speech hesitancy, and speech time. This ability to communicate enhanced the care given by the healthcare personnel. In conclusion, use of the Passy-Muir Tracheostomy Speaking Valve restored verbal communicative skills of ventilator-dependent patients, facilitated care, and greatly enhanced the mental outlook of these patients without observed complications.

The effects of intermittent compression on edema in postacute ankle sprains.

The purpose of this study was to compare the effects of three treatment protocols on pitting edema in patients with first- and second-degree sprained ankles. Thirty subjects with postacute (greater than 24 hours postinjury) ankle sprains and pitting edema but not requiring cast immobilization were randomly assigned to an elastic wrap group (N = 10), an intermittent compression group (N = 10), or an elevated control group (N = 10). Pretreatment and posttreatment volumetric measurements of the subjects' ankles were obtained by the water displacement method. After the pretreatment measurement, the groups were treated for 30 minutes. All subjects' ankles were elevated by raising the foot section of an adjustable table to a 45 degrees angle during treatment. For the first treatment group, the intermittent compression device was set at 40-50 mm Hg, with a 60-second on time and a 15-second off time. For the second treatment group, an elastic wrap was applied from the heads of the metatarsals to 12.7 centimeters above the malleoli. Control group subjects received only the elevated position as their treatment. A three by two repeated measures ANOVA with a follow-up post hoc test revealed that the elevated control group subjects had the least amount of edema (p < .0006). The two compression protocols produced increased edema in the subjects' sprained ankles following treatment. In conclusion, elevation is the most appropriate of the three treatment protocols if the major therapeutic objective is to minimize edema in the postacute phase of rehabilitation. J Orthop Sports Phys Ther 1991;14(2):65-69.

Decline in respiratory function and experience with long-term assisted ventilation in advanced Duchenne's muscular dystrophy.

We present 17 patients with advanced DMD who required long-term assisted ventilation. Eleven patients used part-time assisted ventilation. Five of the patients received BV and/or M-IPPV or N-IPPV between two and nine years before requiring full-time T-IPPV, while six others initially used part-time T-IPPV. One patient used all three modes before requiring full-time T-IPPV. Mean (+/- SD) FVC and rebreathe PCO2 at the outset of assisted ventilation were 0.62 +/- 0.20 L and 47.4 +/- 7.5 mm Hg, respectively. Clinical features were divided between symptoms suggesting respiratory muscle fatigue and sleep-related disordered breathing. We found that, while useful in early respiratory insufficiency, BV is associated with recurrent aspiration. In our experience, N-IPPV offers the safest and most convenient form of noninvasive ventilation. When the VC has decreased to about 300 ml, most patients will require full-time ventilation; T-IPPV is advised to provide airway access to suction secretions.

Patient and family participation in the management of respiratory failure in Duchenne's muscular dystrophy.

Mechanical ventilation is now considered a therapeutic option for respiratory failure associated with Duchenne's muscular dystrophy (DMD). Through the monitoring of forced vital capacity and PCO2, prediction of impending respiratory failure is possible. This knowledge allows the patient to choose institution of mechanical ventilation before acute respiratory failure or no intervention and preparation for a natural death. To assist patients and families in this decision making, a special clinic was established. Thirty adolescent boys with DMD were followed up. Eighteen boys reached the end stage of their disease. Three died of cardiac failure. Prediction of respiratory failure was possible in 14 of the remaining 15; 11 of the 15 were able to make educated choices regarding respirator assistance or a natural death. The clinic has shown that in the majority of cases, when properly educated, patients and families can be active participants in life-and-death decisions.

Gated radionuclide ventriculography in the evaluation of cardiac function in Duchenne's muscular dystrophy.

Left ventricular ejection fractions were determined in 38 patients with Duchenne's muscular dystrophy. No significant correlation between the severity of respiratory dysfunction or age and cardiac function was seen. We suggest that the cardiac status of each patient should be evaluated separately from his respiratory status, particularly when long-term assisted ventilation is being considered.

Comparison of three treatment procedures for minimizing ankle sprain swelling.

The purpose of this study was to compare the effects of cold, heat, and contrast bath treatments on the amount of edema in first- and second-degree sprained ankles during the postacute phase of rehabilitation. Thirty subjects with postacute sprained ankles were assigned to a cold (n = 10), heat (n = 10), or contrast bath (n = 10) treatment group. A specially constructed tank was used to take pretreatment and posttreatment volumetric measurements of subjects' sprained ankles. Descriptive statistics, a 3 x 3 two-way analysis of variance for repeated measures, and Tukey's Honestly Significant Difference post hoc test revealed that cold therapy produced the least edema in subjects with sprained ankles (p less than .05). All three treatments (cold, heat, and contrast bath) produced an increase in the amount of edema in the postacute sprained ankles of the subjects. Heat and contrast bath therapy produced almost identical increases in the amount of ankle edema on each of the three days of the study. We concluded that cold therapy is the most appropriate of the three treatments if the therapeutic objective is to minimize edema before rehabilitative exercise during the third, fourth, and fifth days postinjury for first- and second-degree ankle sprains.