Communication in healthcare: a narrative review of the literature and practical recommendations.

OBJECTIVES: Effective and efficient communication is crucial in healthcare. Written communication remains the most prevalent form of communication between specialised and primary care. We aimed at reviewing the literature on the quality of written communication, the impact of communication inefficiencies and recommendations to improve written communication in healthcare. DESIGN: Narrative literature review. METHODS: A search was carried out on the databases PubMed, Web of Science and The Cochrane Library by means of the (MeSH)terms 'communication', 'primary health care', 'correspondence', 'patient safety', 'patient handoff' and 'continuity of patient care'. Reviewers screened 4609 records and 462 full texts were checked according following inclusion criteria: (1) publication between January 1985 and March 2014, (2) availability as full text in English, (3) categorisation as original research, reviews, meta-analyses or letters to the editor. RESULTS: A total of 69 articles were included in this review. It was found that poor communication can lead to various negative outcomes: discontinuity of care, compromise of patient safety, patient dissatisfaction and inefficient use of valuable resources, both in unnecessary investigations and physician worktime as well as economic consequences. CONCLUSION: There is room for improvement of both content and timeliness of written communication. The delineation of ownership of the communication process should be clear. Peer review, process indicators and follow-up tools are required to measure the impact of quality improvement initiatives. Communication between caregivers should feature more prominently in graduate and postgraduate training, to become engraved as an essential skill and quality characteristic of each caregiver.

Recombinant interleukin 4 suppresses the production of interferon gamma by human mononuclear cells.

rIL-4 inhibits the production of IFN-gamma by PBMC stimulated with mitogens or allogeneic cells. The suppression is observed at the protein and at the mRNA level; it is dose and time dependent, and it is abolished by a neutralizing mAb to IL-4. It is suggested that the balance between the production of IL-4 and IFN-gamma may be significantly influenced by the chronological order of activation of their respective gene.

Communication satisfaction and job satisfaction among critical care nurses and their impact on burnout and intention to leave: A questionnaire study.

OBJECTIVES: To investigate the relationship between communication and job satisfaction and their association with intention to leave and burnout among intensive care unit nurses. RESEARCH METHODOLOGY/DESIGN: A multicentre questionnaire study. SETTING/PARTICIPANTS: Intensive care nurses (n = 303) from three Flemish hospitals. MAIN OUTCOME MEASURES: Communication satisfaction assessed by the Communication Satisfaction Questionnaire, intention to leave through the Turnover Intention Scale (from the Questionnaire for the Perception and Assessment of Labour) and burnout by the Maslach Burnout Inventory. Job satisfaction was measured by a visual analogue scale. RESULTS: Average job satisfaction was 7.66 ±â€¯1.34/10. Nurses were most satisfied about 'Communication with supervisor' (68.46%), and most dissatisfied about 'Organisational perspectives' (34.12%). Turnover intention was low among 49.5% (150/290) and high among 6.6% (20/290). Three percent (9/299) of intensive care nurses were at risk for burnout. All dimensions of communication satisfaction were moderately associated with job satisfaction, intention to leave and burnout. CONCLUSION: This study demonstrated high levels of communication and job satisfaction in a sample of nurses in Flanders. Intention to leave and burnout prevalence were low. To a certain extent, communication satisfaction might be associated with job satisfaction, intention to leave and burnout.

Glucocorticoids increase the synthesis of immunoglobulin E by interleukin 4-stimulated human lymphocytes.

This study indicates that hydrocortisone (HC) markedly increases the synthesis of immunoglobulin E (IgE) by interleukin 4 (IL-4)-stimulated human lymphocytes. The effect is glucocorticoid specific and is obtained with low concentrations of HC (0.1-10 microM). In both the early and the late phase of the IL-4-induced response HC exerts its effects which are respectively IL-4 dependent and IL-4 independent. The IgE potentiation cannot be explained by the inhibition of interferon-gamma (IFN-gamma) production since it is observed in the absence of endogenous secretion of IFN-gamma. HC inhibits the production of IgE-binding factors (soluble CD23) and the expression of the low-affinity receptor for IgE, also known as the (Fc epsilon RII) CD23 antigen; however, the residual expression of Fc epsilon RII by IL-4- and HC-treated peripheral blood mononuclear cells (PBMCs) is important since the IgE response of these cells is markedly inhibited by anti-CD23 monoclonal antibody. HC acts mainly by amplifying the cellular interactions between monocytes and lymphocytes; indeed, HC has no effect on monocyte-depleted PBMCs, and moreover, monocytes cannot be replaced by soluble factors. Most importantly, T cells are not required for the induction of IgE synthesis by costimulation with IL-4 and HC. However, the IgE response of rigorously T cell-depleted PBMCs may be further increased by the addition of T cells. Further analysis of the permissive effect of HC on the synthesis of IgE by T cell-depleted PBMCs suggests that HC acts in synergy with IL-4 to trigger the activation and the differentiation of B cells into IgE-producing cells.

Mutual perception of communication between general practitioners and hospital-based specialists.

BACKGROUND: Communication between general practitioners (GPs) and specialists is an important aspect of qualitative care. Efficient communication exchange is essential and key in guaranteeing continuity of care. Inefficient communication is related to several negative outcomes, including patient harm. This study aimed to investigate the perception of GPs and hospital-based specialists in Belgium of the quality of their mutual communication. METHODS: A cross-sectional study was conducted among GPs and specialists. Participants were asked to complete a validated questionnaire on several aspects of their mutual communication. RESULTS: Response rates of 17.9% (343/1.912) for GPs and 17.3% (392/2.263) for specialists were obtained. Both specialists and GPs qualify their mutual telephone accessibility as suboptimal. Specialists think poorly of the GP referral letter, in contrast to GP perception. Eighty per cent of the GPs feel that specialists address their questions appropriately; specialists have a similar perception of their own performance. According to 16.7% of the specialists, GPs not always follow their recommendations. Contrarily, GPs rate their compliance much higher (90.7%). Less than half of the GPs feel that the specialists' letter arrives on time, whereas specialists have a different and a more positive perception. CONCLUSIONS: GPs and specialists disagree on several aspects of their mutual communication. These include the perception of accessibility, in both directions, and of the timeliness of written communication. Feedback is positively appreciated, again in both directions. Nevertheless, specialists feel that uptake of their recommendations is insufficient. Hence, there may remain significant room for improvement, which could contribute significantly to continuity of care and patient safety.

Prospectives on the treatment of chronic hepatitis B and chronic hepatitis C with thymic peptides and antiviral agents.

At the present time, interferon is considered the only effective therapeutic approach in the treatment of both chronic hepatitis B and chronic hepatitis C. It is clear that the disappointing response rates in both chronic hepatitis B and C place added emphasis on efforts to identify alternative forms of therapy. In addition to the development of other antiviral agents including the nucleoside analogs which might prove more effective and have fewer associated side-effects, other agents currently under investigation include thymic peptides such as thymosin alpha 1. In the future, the therapeutic approach to the treatment of chronic hepatitis B and C may consist of combination therapy using perhaps an immune modulator and an antiviral agent or, several antiviral drugs. Alternatively, there is indication that cellular targeting systems with delivery of the toxic material to the specific cell containing the virus may be more effective, while minimizing side-effects. Finally, there are agents such as ursodeoxycholic acid which perhaps, makes bile less toxic and can be used as adjunctive therapy with improvement in liver chemistry values. The treatment of chronic hepatitis B and chronic hepatitis C has shifted in emphasis form the concept of treating liver disease towards that of treating viral infections which happen to effect primarily the liver.

Effect of Theophylline on Endotoxin and Tumor Necrosis Factor Induced Airway Changes in an in vivo Animal Model.

We have previously reported that exposure to aerosolized endotoxin causes bronchial hyperresponsiveness in rats. This is at least partly due to secondary release of tumor necrosis factor (TNF). In this study, we evaluated the effect of pretreatment with aminophylline on these lipopolysaccharide-induced airway changes. Compared to placebo-pretreated animals aminophylline (20 mg/kg i.p.) significantly inhibited the lipopolysaccharide-induced increase in responsiveness without influencing neutrophil counts or TNF levels in bronchoalveolar lavage fluid. In a second part of the study, aminophylline- or placebo-pretreated rats were exposed to aerosolized recombinant human TNF. Compared to saline-exposed animals, TNF caused a significant increase in 5-hydroxytryptamine responsiveness which was inhibited by pretreatment with aminophylline. We conclude that the attenuating effect of aminophylline on lipopolysaccharide-induced airway hyperresponsiveness is not due to inhibition of TNF release, but could be explained by its inhibitory effect on TNF-induced hyperresponsiveness.

Ultrasound and CT changes of liver parenchyma in acute schistosomiasis.

Acute schistosomiasis in travellers to endemic regions often remains unrecognized. Early diagnosis is important to avoid progression to chronic disease. Diagnosis is based on clinical, epidemiological and laboratory data. The role of imaging techniques as diagnostic tools remains to be established in acute clinical schistosomiasis. We describe hypodense nodules in the liver on ultrasound and CT scanning in a patient with acute schistosomiasis (Katayama syndrome). To our knowledge this is the first description of nodular hepatic lesions in acute schistosomiasis.

Indigenous malaria in a suburb of Ghent, Belgium.

We report here details of a patient with Plasmodium falciparum malaria which was acquired in the vicinity of Ghent (Evergem) in July 1997. Indigenous malaria disappeared from Belgium in 1938. Due to an increase in international travel, the influx of migrant labor and the changing environmental conditions, there has been an upsurge of imported malaria. Airport- and port-malaria is acquired through the bite of a tropical anophelline mosquito by people whose geographical history excludes exposure to this vector in its natural habitat. As far as we know, only two cases of port-malaria have been reported: in Marseille. We describe here another possible case of port-malaria due to infection with P. falciparum in a 42-year-old woman with an underlying non-Hodgkin lymphoma.

The need for a center-tailored treatment protocol for peritonitis.

OBJECTIVE: Despite many improvements in connectology, peritonitis continues to be a major burden in peritoneal dialysis. Because of the high variety in causative organisms and of the differences in their sensitivity patterns, surveillance of the epidemiology of peritonitis and the appropriate adaptation of the therapy are necessary. This study was performed to evaluate the influence of the nature of causative bacteria on the effectiveness of empirical treatment protocols. Based on this information, a new empiric treatment protocol was proposed. SETTING: Peritoneal dialysis program of a university hospital. DESIGN: All episodes of peritonitis at the University Hospital Gent between 1 January 1994 and 31 December 1996 were analyzed retrospectively. Results of microbiological cultures, microscopic evaluation of dialysate, and clinical course were noted. RESULTS: During 1240 patient-months at risk, 50 episodes of peritonitis with identifiable responsible bacteria were observed. Gram-positive organisms were cultured in 34 episodes, and gram-negative organisms were found in 16 episodes. No responsible organism could be identified in 25 additional cases. Resistance to methicillin was registered in 33% of the cultures with staphylococci. There was no resistance to vancomycin. A new empirical treatment protocol was proposed, using a single dose of vancomycin and gentamicin intraperitoneally the first day, followed by oral treatment with ciprofloxacin. With this protocol, a 96% coverage rate is obtained, as opposed to a 78% coverage by using the Ad Hoc Advisory Committee protocol (p < 0.01). CONCLUSION: Individual centers should continue to monitor the epidemiology of peritoneal dialysis-related peritonitis and the epidemiology of the causative organisms and their sensitivity patterns in order to adapt general guidelines into a center-tailored empirical treatment protocol.

Transmission of nosocomial infection by intravenous catheters: preventive strategies.

Intravascular catheter-related bacteraemia puts a major burden on health care due to its associated morbidity and mortality. Because of difficulties in the diagnosis and the consequences of catheter infections, prevention of infection is of the utmost importance. Depending on the setting, the intrinsic and extrinsic risk factors and the patient's personal characteristics, different strategies can be used, but they all focus on catheter care during placement and maintenance of the lines. In this review of the literature, recent data on the aetiology, diagnosis and prevention of catheter-related infections will be discussed.

Isolation rooms for highly infectious diseases: an inventory of capabilities in European countries.

Isolation of patients with highly infectious diseases (HIDs) in hospital rooms with adequate technical facilities is essential to reduce the risk of spreading disease. The European Network for Infectious Diseases (EUNID), a project co-funded by European Commission and involving 16 European Union member states, performed an inventory of high level isolation rooms (HIRs, hospital rooms with negative pressure and anteroom). In participating countries, HIRs are available in at least 211 hospitals, with at least 1789 hospital beds. The adequacy of this number is not known and will depend on prevailing circumstances. Sporadic HID cases can be managed in the available HIRs. HIRs could also have a role in the initial phases of an influenza pandemic. However, large outbreaks due to natural or to bioterrorist events will need management strategies involving healthcare facilities other than HIRs.

Mycobacterium avium complex with a distinct clinical and iconographic presentation: the Lady Windermere syndrome.

Clinically significant pulmonary disease caused by non-tuberculous mycobacteria such as Mycobacterium avium Complex (MAC) usually occurs upon pre-existing lung diseases or immune-deficiency. In 1992, a particular presentation of pulmonary MAC, occuring in otherwise healthy middle-aged women, was described with pulmonary consolidations localized in lingula and middle lobe. For this specific, rare condition, the term Lady Windermere syndrome was introduced. We report a particular case of this syndrome, in which an otherwise healthy individual developed clinically significant disease upon MAC (subtype: Mycobacterium avium) infection of the right middle lobe and lingula of the lung. The patient did not have the classical risk factors for developing this syndrome (e.g. habitual cough suppression, long and narrow bronchi) indicating their modest contribution in the pathogenesis. In our case, guideline based therapy was found to be inadequate because of multi-drug resistance, so an alternative treatment regime was given with good clinical result.

Effect of fluconazole consumption on long-term trends in candidal ecology.

BACKGROUND: Fluconazole is an antifungal agent that is widely used for the treatment of Candida infection. Because of its favourable safety profile it is extensively used for prophylaxis in patient populations with a substantial risk for Candida infection. At the individual patient level, exposure to fluconazole selects for Candida non-albicans strains such as Candida glabrata and Candida krusei, with reduced susceptibility or intrinsic resistance to fluconazole. The effect of the volume of consumption of fluconazole on candidal ecology, however, is poorly investigated. OBJECTIVES: The long-term effect of fluconazole consumption on distribution of species causing candidaemia was investigated in a university hospital during an 11 year period (1994-2004). METHODS: In a historical cohort the incidence of nosocomial candidaemia (expressed per 100,000 patient days) was linked with volume consumption of fluconazole [expressed as defined daily doses (DDDs) per 100,000 patient days] and evaluated over time. RESULTS: During the study period 308 episodes of candidaemia occurred (63.3% caused by Candida albicans). The incidence of candidaemia varied from 6.0 to 13.8 per 100,000 patient days. The percentage candidaemia caused by Candida non-albicans spp. varied between 21% and 50%. No trends in the number of candidaemias or in the proportion of C. albicans versus Candida non-albicans spp. were observed. Fluconazole consumption was high but stable ranging from 5013 to 6807 DDDs per 100,000 patient days. No relationship could be demonstrated between volume of fluconazole consumption and Candida spp. distribution (Pearson's correlation coefficient: -0.083; P=0.808). CONCLUSIONS: Despite long-term exposure to fluconazole, no change in candidal ecology was observed.

Recommendations for the use of the 23-valent polysaccharide pneumococcal vaccine in adults: a Belgian consensus report.

A multidisciplinary expert panel, appointed by the High Council for Public Health, evaluated the scientific evidence on which the recommendations for the appropriate use of the pneumococcal vaccine was based and reviewed the studies that became available since previous reports. The conclusions of the working group, presented in this manuscript, resulted in an update of the Belgian recommendations for pneumococcal vaccination.

In vitro synthesis of human IgE by neonatal lymphocytes: enhancing effect of interferon-gamma.

The present study demonstrates that neonatal human lymphocytes that are incapable of producing IgG and IgA antibodies may differentiate into IgE-secreting cells under the influence of IL4. Indeed, the addition of recombinant IL4 to cultures of unfractionated umbilical cord blood mononuclear cells (CBMC) induces a dose-dependent synthesis of IgE but not of the other classes of Ig. Moreover, IgE-secreting B lymphoblastoid cell lines can be derived from neonatal lymphocytes costimulated with EBV and IL4. Comparison of the mechanisms regulating the in vitro IgE synthesis by adult and neonatal lymphocytes indicates that in most cases IFN-gamma markedly potentiates the IgE synthesis in CBMC cultures whereas it has a reverse effect on adult lymphocytes. These reciprocal effects of IFN-gamma are specifically blocked by a neutralizing mAb to IFN-gamma; they are dose-dependent and they are observed when IFN-gamma is added at the initiation of the culture or shortly thereafter. Moreover, in a small number of cases IFN-gamma may also potentiate IgE synthesis by adult lymphocytes. The potentiation or the suppression of IgE synthesis by IFN-gamma is not explained by a differential effect of IFN-gamma on the production of soluble CD23 (sCD23); indeed in both cases IFN-gamma slightly increases the IL4-induced production of sCD23. Moreover, the spontaneous and the IL4-induced production of sCD23 by CBMC is comparable to that of adult lymphocytes. The IgE response is dependent upon the expression of Fc epsilon RII (CD23) inasmuch as it is specifically blocked by anti-CD23 mAb.

Influence of recombinant IL-4, IFN-alpha, and IFN-gamma on the production of human IgE-binding factor (soluble CD23).

This study documents the influence of rIL-4, IFN-gamma, and IFN-alpha on the production of IgE-BF and the expression of lymphocyte receptor for IgE or CD23 Ag (Fc epsilon R II) by human mononuclear cells. IL-4 increases the secretion of IgE-binding factor (BF) by highly purified B lymphocytes, adherent cells, and U937 monoblastic cells. The effect of IL-4 on purified B cells is augmented by costimulating the cells with F(ab')2 anti-IgM. IFN-gamma, IL-2, IL-1-alpha, or IL-1 beta and the low m.w. B cell growth factor have no effect on IgE-BF production by purified B cells even when they are used in combination with anti-IgM. Stimulation of purified T cells with IL-4 or IL-4 plus PMA leads to the production of very small amounts of IgE-BF that might well be derived from the contaminating non-T cells. IFN-gamma increases IgE-BF synthesis by unfractionated PBMC, T cell-depleted PBMC, adherent cells, and U937 cells suggesting that it induces monocytes to release IgE-BF, IFN-gamma suppresses the IL-4-induced Fc epsilon R II expression and IgE-BF production by highly purified B cells but not by PBMC or their T cell-depleted fractions. IFN-alpha inhibits IgE-BF production by IFN-gamma-stimulated PBMC and by IL-4-stimulated cells suggesting that it exerts its effect on B cells and on monocytes. Moreover IFN-alpha suppresses the IL-4-induced expression of Fc epsilon R II on B cells. Both IFN-alpha and IFN-gamma suppress the synthesis of IgE by PBMC in response to IL-4. Taken collectively the results indicate that: 1) IL-4 induces IgE-BF production by both B cells and monocytes, 2) IFN-gamma stimulates IgE-BF synthesis by monocytes but suppresses its production by IL-4-stimulated B cells, and finally 3) IFN-alpha inhibits IgE-BF synthesis in response to either IFN-gamma or IL-4.

Combined nitrofurantoin toxicity to liver and lung.

Nitrofurantoin is an antibiotic commonly used for prophylaxis and treatment of urinary tract infections. Pulmonary and hepatic toxicity are rare side effects of this agent. The simultaneous occurrence of pulmonary fibrosis and chronic active hepatitis in a patient undergoing long-term nitrofurantoin therapy is reported. The presence of pulmonary toxicity was evidenced by infiltrates on chest radiographs and impaired diffusion capacity during pulmonary function tests. Prolonged elevation of liver enzyme concentrations together with the presence of increased antibody titers (anti-smooth muscle antibody, antinuclear antibody) was suggestive of chronic hepatitis, a diagnosis corroborated by liver biopsy findings. After discontinuation of nitrofurantoin therapy, the patient had a full recovery. The infiltrates initially found on chest radiographs disappeared, and laboratory parameters normalized without the need for corticosteroid therapy.

Methods of examining induced sputum: do differences matter?

Analysis of induced sputum has been proposed as a direct, relatively noninvasive method for the evaluation of airway inflammation in diseases such as asthma or chronic obstructive pulmonary disease (COPD). An important question in the validation of this technique concerns the potential influence of differences in the methods of examining sputum. Up to the present time, two basic techniques for processing sputum have been described. The first approach consists of selecting all viscid portions from the expectorated sample, whereas the second approach processes the whole expectorate, containing sputum plus saliva. Both processing techniques have been shown to provide valid and reliable data on the composition of the cellular and soluble fraction of induced sputum. From the data currently available, it would therefore appear that the usefulness of induced sputum as a method for assessing airway inflammation is not influenced by differences in the methods currently used for examining sputum.