Short and longterm outcomes for patients with systemic rheumatic diseases admitted to intensive care units: a prognostic study of 181 patients

OBJECTIVE: To determine short and longterm outcomes and prognostic factors for patients with systemic rheumatic diseases admitted to intensive care units in 4 teaching hospitals. METHODS: All adult intensive care unit admissions over a 12 year period for systemic rheumatic diseases were retrospectively assessed. One hundred and eighty-one patients with a mean age of 57 +/- 17 years were studied. RESULTS: The death rate in intensive care units was 33% (59/181) and in-hospital mortality was 43% (77/181). One hundred and four patients were discharged alive from hospital; 40 died during followup (mean 105 +/- 7 mo). The estimated 5 year survival rate for the discharged patients was 69%. The 4 factors significantly associated with in-hospital mortality by multivariate analysis were simplified acute physiologic score (p = 10(-4)), poor prior health status (p = 10(-4)), corticosteroid administration (p = 0.005), and the reason for admission; mortality was higher in the group admitted to intensive care for infectious complication (55 versus 34% for others; p = 0.006). In contrast, in-hospital mortality was not influenced by age or by systemic rheumatic diseases. Using Cox's model, only age over 60 years was a prognostic factor significantly associated with an increase in longterm mortality (p = 10(-4)). CONCLUSION: The short term outcome for patients with systemic rheumatic diseases in intensive care units was poor. The longterm prognosis after hospital discharge appeared fair, although the standardized mortality ratio was 5-fold that of a nonselected population. Short and longterm prognoses were similar for different systemic rheumatic disease groups.     

Prevention of heat loss with infusion warming

We compared the outcome of cementless hip arthroplasty in patients with chronic rheumatic diseases (cases) and patients with osteoarthritis (controls). Between 1985 and 1993 we implanted 26 cementless hips in 22 patients with Rheumatoid Arthritis, Psoriatic Arthritis or Ankylosing Spondylitis. From a pool of more than 600 patients with Osteoarthritis we chose 40 matched controls (41 hips). Matching variables were year of implantation, age, follow-up, height, weight, gender and type of implant. At follow-up (cases: 58 +/- 27 months; controls: 56 +/- 26 Monate) no signs of loosening or migration of the stem were found, neither in the cases nor in the controls. Loose and/or migrated cups were found in 4 patients with rheumatic diseases (after 44, 65, 65 and 107 months) and in 3 patients with osteoarthritis (after 63, 84 and 100 months). Two cups were revised within 18 months in the control group, in the case group one revision was necessary after 5 years. Loosening and revision rates did not differ significantly (p > 0.20). Clinically, those with Osteoarthritis had a better extension (p < 0.02), were more satisfied with their (artificial) hips (p < 0.05) and did better in some activities of daily living (climbing stairs, dressing, sitting/standing up). Within a mean follow-up of 5 years the results of patients with chronic rheumatic diseases seem to be comparable to those of a matched control-group of patients with Osteoarthritis. Differences between the groups concern areas, in which rheumatic patients are handicapped due to their chronic illness. Nevertheless, we need long-term-results, before we can recommend cementless implants for these patients.     

Pain analysis is vital in rheumatic diseases. Pain often causes much worry to patients

The article consists of a synthesis of a rheumatic pain symposium held at the annual meeting of the Swedish Medical Association in 1996. Various aspects of pain in rheumatic diseases were discussed, such as physiological, neurohumoral and neurogenic mechanisms, sensory stimulation treatment, differentiation of mechanical and inflammatory pain, quality enhancement by improved co-operation between primary and tertiary care facilities, pharmacological treatment with (centrally and peripherally acting) opioids, selective cyclo-oxygenase inhibitors, and NMDA (N-methyl-D-aspartate) receptor antagonists. For patients with rheumatic disorders exacerbated by pain problems, as for other patients, a pain diagnosis is of fundamental importance. This can be achieved by analysis of the social, psychological, physiological and medical factors contributing to the cause and degree of pain and to pain behaviour, and of the extent to which the pain may be nociceptive (i.e., inflammatory, mechanical, or ischaemic in origin), neurogenic or idiopathic. Pain analysis should be followed by individualised treatment focused on the patient's most crucial problems, thus enhancing the prospect of optimal treatment outcome.     

Pain analysis is vital in rheumatic diseases. The pain is often the patient's worst problem

The article consists of a synthesis of a rheumatic pain symposium held at the annual meeting of the Swedish Medical Association in 1996. Various aspects of pain in rheumatic diseases were discussed, such as physiological, neurohumoral and neurogenic mechanisms, sensory stimulation treatment, differentiation of mechanical and inflammatory pain, quality enhancement by improved cooperation between primary and tertiary care facilities, pharmacological treatment with (centrally and peripherally acting) opioids, selective cyclo-oxygenase inhibitors, and NMDA (N-methyl-D-aspartate) receptor antagonists. The aim of the symposium, with its focus on the manifest pain problem, was to improve our knowledge and skill in the understanding and treatment of this large patient category. For patients with rheumatic disorders exacerbated by pain problems, as for other patients, a pain diagnosis is of fundamental importance. This can be achieved by analysis of the social, psychological, physiological and medical factors contributing to the cause and degree of pain and to pain behaviour, and of the extent to which the pain may be nociceptive (i.e., inflammatory, mechanical, or ischaemic in origin), neurogenic or idiopathic. Pain analysis should be followed by individualised treatment focused on the patient's most crucial problems, thus enhancing the prospect of optimal treatment outcome.     

Home exercise and compliance in inflammatory rheumatic diseases--a prospective clinical trial

OBJECTIVE: To survey and to compare the one year effects of dynamic muscle training and progressive muscle relaxation as home exercise for patients with inflammatory rheumatic diseases; and to identify predictors for compliance with a longterm home exercise regimen. METHODS: Fifty-four patients (mean age 54 yrs, mean symptom duration 14 yrs) were assessed for health related quality of life, exercise motivation, joint tenderness, and physical capacities. After randomization into 2 groups, every patient was instructed on one occasion in a 30 min program of either dynamic training or muscle relaxation to carry out at home, 5 times a week during 3 months, and then 2-3 times a week for another 9 months. RESULTS: Seventeen patients in each group completed the one year exercise protocol, while 10 from each group did not. Compliance with the one year exercise regimen seemed to be predicted by high self-efficacy for exercise, regular range-of-motion exercises before the intervention, and being unmarried. After one year, minor improvements in physical effect (p < or = 0.05) and work effect (p < or = 0.05) were found in the dynamic training group, while minor improvements in pain effect (p < or = 0.05), emotional reactions (p < or = 0.05), and arm endurance (p < or = 0.01) were found in the muscle relaxation group. No differences between the groups regarding changes in health status, joint tenderness, or physical capacities during the intervention period were found. CONCLUSION: These results may improve the selection of patients for home exercise, and form a basis for improved administration of home exercise programs.     

Comparison of patient satisfaction with ambulatory visits in competing health care delivery settings in Geneva, Switzerland

OBJECTIVES: To measure satisfaction with medical visits in various health care settings and to assess the extent to which differences in satisfaction scores between health care settings can be attributed to patients' characteristics. DESIGN: This was a cross sectional survey to measure seven dimensions of patient satisfaction. SETTINGS: Ambulatory visits to 'gatekeepers' or specialists in a newly established managed care organisation, a private group practice, or a university hospital outpatient clinic in Geneva, Switzerland. PATIENTS: There were altogether 1027 adult patients (81% participation rate). RESULTS: Patients who consulted physicians in the private group practice reported higher levels of satisfaction (overall mean 83.2 on a scale between 0 and 100) than university clinic patients (79.7), patients of independent specialists within the managed plan (78.5), and patients of managed plan gatekeepers (69.8, intergroup differences p < 0.001). Differences between settings were reduced after adjustment for sex, age, country of origin, general practitioner versus specialist visit, and scheduled versus urgent visit (adjusted scores: 80.8, 78.8, 77.6, and 72.7 in the four settings, p < 0.001). Intergroup differences were largest for general satisfaction, but small and non-significant for satisfaction with explanations given by the physician and for time spent with the patient. CONCLUSIONS: Patient satisfaction varied widely between health care settings. Differences in satisfaction ratings could be ascribed only partly to disparities in patient populations. Patients of managed plan gatekeepers were least satisfied, presumably because they could not choose their physician freely. Comparison of patient satisfaction across health care settings can provide a basis for targeted quality improvement initiatives.     

Primary Clinical Evaluation of the Joint Replacement for the Treatment of the First Metatarsophalangeal Arthritis

Objective To retrospectively assess the primary clinical results of a cohort of the first metatarsophalangeal joint replacement with double-stemmed hinge silicone implant.Methods A total of 12 patients (15 feet) received the joint replacement with double-stemmed hinge silicone implant.There were 2 males and 10 females with a mean age of 61.4 (range,56-75) years old.Of them,9 cases (11 feet) were hallux valgus with osteoarthritis; 1 case (2 feet) was rheumatic arthritis; 2 cases (2 feet) were traumatic arthritis.The subjective and objective results were evaluated during follow-up.Results All of the patients were followed up regularly with an average of 24.7 months,ranging from 12 to 38 months.Ten patients were completely satisfied with the operation; 1 patient showed partial satisfaction,and 1 patient was not satisfied because of the first matatarsophalangeal joint pain due to severe hy-perosteogeny surrounding the cut bone surface 3 years after the operation.Osteolysis around the implant occurred in 2 cases without clinical symptoms,and no special treatment was given.Conclusion The joint replacement is a preferable method in alleviating pain and improving walking function with proper indication.     

The Impact of Patient-Centered Information on Patients' Treatment Satisfaction and Outcomes in Traumatic Brain Injury Rehabilitation.

Objective: To evaluate the effects on patients with traumatic brain injury (TBI) of detailed, personalized information about their injuries, acute care treatment, and rehabilitation progress. Participants: Twenty-eight former or present military personnel (mean age = 30 years) with moderate to severe TBI (mean of 29 days spent in intensive care before admission to TBI unit). Design: Two (personalized information vs. general information) × 2 (high- vs. low-patient preference for health care information) factorial design. Interpersonal behavior of patients, information providers, and health care staff were measured by the Impact Message Inventory. Outcome Measures: Rehabilitation Intensity of Therapy Scale, Functional Independence Measure, Treatment Satisfaction Questionnaire. Results: Patients given personalized information exerted greater effort in physical therapy, made greater improvement in functional independence, and were more satisfied with rehabilitation treatment. Patient preference for information and ratings of interpersonal behavior were largely unrelated to patient outcomes. Conclusion: Cognitively impaired TBI patients can benefit from interventions designed to enhance their sense of control and personal involvement in their own care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Assessing noninstitutionalized asthma and COPD patients' priorities and perceptions of quality of health care: the development of the QUOTE-CNSLD instrument

Patient judgments on the quality of health care services have become increasingly important. This research describes the development and empirical testing of an instrument that measures quality of health care services from the perspective of noninstitutionalized patients. The instrument was developed in close collaboration with noninstitutionalized patients with chronic nonspecific lung diseases (asthma and COPD), rheumatic diseases, and disabled and elderly patients. Four instruments were developed with a common generic part and four disease-specific parts. This article focuses on the psychometric properties and the practical use of outcomes for quality assurance policies of the instrument for patients with chronic nonspecific lung diseases.     

What is wrong with end-of-life care? Opinions of bereaved family members

OBJECTIVE: To describe family perceptions of care at the end of life. METHODS: In a representative sample of older people who died from chronic diseases, family members were interviewed about satisfaction with treatment intensity, decision-making, and symptom relief in the last month of life, and gave suggestions to improve care. RESULTS: Interviews were completed with 461 family members, 80% of those contacted. They reported that 9% of decedents received CPR, 11% ventilator support, and 24% intensive care during their last month of life. Family members could not recall a discussion of treatment decisions in 23% of cases. Presence or absence of a living will did not affect the likelihood of no discussion (22% vs 24%, P = .85). Family informants desired more treatment to sustain life in 8% of deaths. They or the decedent wanted treatments doctors did not recommend in 6% of deaths but refused recommended therapies in 18% of deaths. They believed more care to relieve pain or other symptoms was indicated in 18% of deaths. Asked to make positive or negative comments about any aspect of terminal care, 91% of comments on hospice were positive. Nursing home care received the smallest proportion of positive comments (51%). Family members recommendations to improve end of life care emphasized better communication (44%), greater access to physicians' time (17%), and better pain management (10%). CONCLUSION: Bereaved family members are generally satisfied with life-sustaining treatment decisions. Their primary concerns are failures in communication and pain control. Discussions that focus on specific treatment decisions may not satisfy the real needs of dying patients and their families.     

Exploratory eye movement dysfunctions in patients with schizophrenia: possibility as a discriminator for schizophrenia

Emergency oral health care, as conceived in Tanzania, is an on-demand service provided at a rural health center or dispensary by a Rural Medical Aide. The service includes: simple tooth extraction under local anesthesia, draining of abscesses, control of acute oral infection with appropriate drug therapy, first aid for maxillo-facial trauma, and recognition of oral conditions requiring patient referral for further care at the district or regional hospital dental clinic. The objective of the present study was to describe patient satisfaction with emergency oral health care services in rural Tanzania and determine the relative importance of factors influencing patient satisfaction. The study was carried out as a cross-sectional interview survey between April 1993 and May 1994 using a patient satisfaction questionnaire in rural villages in the Rungwe district of Tanzania. It included 206 patients aged 18 years or more who had received emergency oral health care between April 1993 and March 1994. Overall, 92.7% of the respondents reported that they were satisfied with the service. Patients who were married, had no formal education and lived more than 3 km from the dispensary were more likely to be satisfied with treatment. In a logistic regression model, a good working atmosphere at the dispensary, a good relationship between care provider and patients (art of care) and absence of post-treatment complications significantly influenced patient satisfaction with odds ratios of 10.3, 17.4 and 6.2, respectively.     

Perspectives of patients with terminal renal failure: quality of life and psychological adjustment before and in the first year after heart transplantation

This prospective study was designed to compare quality of life, life satisfaction, and subjective ratings of health before and at variable time intervals after heart transplantation (HTx). 175 patients were included between February 1994 and December 1997. Every six months before and 1 1/2, 3, 6, and 12 months after HTx, they received the following standardized and validated questionnaires: German SF 36, heart failure and specific transplant symptom list, global quality of life assessment, Munich life quality dimension list, expected/experienced life changes after HTx. Inclusion criteria were the acceptance of the patient on the waiting list for HTx, good command of the German language, and a minimum age of 18 years. During data evaluation, median (Me), mean (M), and standard deviation (SD) were created from individual parameters. Quality of life was rated as very poor by 84% of patients with congestive heart failure. Only 6 weeks after HTx, 74% rated their quality of life as significantly better. Before HTx 80% were very unsatisfied about their health status and 87% about physical performance. Six weeks after HTx, this parameter improved significantly and 76% were very satisfied about their health status and 50% about physical performance. While somatic changes expected before HTx corresponded well with experienced ones, psychological improvements were smaller than expected, but one year after HTx they were significant (before: M = 3.66; SD = 0.9; Range (R) = 3.78 vs 12 months postop: M = 4.61; SD = 0.6; R = 2.67; p < 0.05). Quality of life correlated before HTx best with subjectively rated health (r = 0.61, p < 0.01) and 6 months after with satisfaction about health status (r = 0.76, p < 0.01). Only in 25% were expected improvements fulfilled regarding sexual activity/satisfaction, professional situation, and recreational activities. 90% of post-transplant patients reported physical complaints, most by effects of immunsuppression, but were coping well. The study shows that already 6 weeks after successful HTx all quality of life parameters improved significantly. Despite some unfulfilled expectations and complaints, the postoperative life situation of HTx patients appeared significantly improved.     

Prediction of long-term mortality in patients with rheumatoid arthritis according to simple questionnaire and joint count measures

This study examined changes in employment status and quality of work in 109 chronic pain patients who underwent a cognitive-behavioural pain management course; 68% of patients were female, mean age was 45 years, mean pain chronicity 10.7 years, 70% had spinal pain, and mean impairment on the Sickness Impact Profile was 26%. Twenty-six per cent of patients were employed at pre-treatment; the remaining 74% had been unemployed for 4.3 years on average. Measures of work status and quality, mood, pain, self-efficacy and walking performance were taken before admission, and at 1-, 6-, and 12-month follow-ups. Among employed patients quality of work scores improved by 35% from pre- to post-treatment (p < 0.01). Thirty per cent of previously unemployed patients returned to work during the 1-year follow-up, although employment status fluctuated greatly during this period. Non-workers were generally more impaired than workers on most measures, but the same measures did not differentiate between those who successfully returned to work and those who remained unemployed.     

Myocardial infarction in critically ill patients presenting with gastrointestinal hemorrhage: retrospective analysis of risks and outcomes

OBJECTIVES: To determine the frequency of and risk factors for myocardial infarction (MI) in patients admitted to an ICU with GI hemorrhage, and the effects of MI on mortality and length of stay. METHODS: A retrospective review of the medical records of patients admitted to our ICU with GI hemorrhage was conducted. Charts were reviewed for various demographic, laboratory, and outcome parameters. Patients were categorized as having MI, not having MI, or inadequate data to allow classification. RESULTS: Two hundred thirty admissions to the ICU for GI hemorrhage were reviewed. One hundred thirteen cases had serial creatine phosphokinase (CK) measurements with isoenzymes allowing diagnosis of MI. In these 113 cases, patients' mean age was 67.4+/-1.3 years and the mean APACHE II (acute physiology and chronic health evaluation) score was 10.9+/-0.6. The in-hospital mortality rate was 13/113 (11.5%). Patients who did not survive had a higher admission APACHE II score (15.8+/-2.0 vs 10.2+/-0.5; p = 0.02), lower initial systolic BP (104.5+/-4.4 vs 121.2+/-3.2 mm Hg; p = 0.005), and a longer length of ICU stay (8.3+/-1.8 vs 4.0+/-0.4 days; p = 0.04) than those who survived. Sixteen of 113 patients met enzymatic and ECG criteria for MI. One patient complained of chest pain and nine of 16 had shortness of breath and/or dizziness. Patients with MI had significantly more cardiac risk factors (2.4+/-0.2 vs 1.6+/-0.1; p = 0.006), lower presenting hematocrit (26.0+/-1.3 vs 30.5+/-0.8; p = 0.007), and lower lowest hematocrit in the first 48 h (22.3+/-0.9 vs 25.1+/-0.6; p = 0.01), and tended to have a longer ICU stays (7.9+/-2.2 vs 4.0+/-0.4 days; p = 0.09) than those without MI. Patients who had MI were not more likely to die during hospitalization (risk ratio = 1.8; 95% confidence interval, 0.6 to 5.8). CONCLUSIONS: Myocardial infarction occurs frequently in patients admitted to intensive care with GI hemorrhage. A clinical history of and multiple risk factors for coronary artery disease may help identify patients who are at increased risk of MI, which tends to be associated with a higher acuity of illness and in-hospital mortality. Prospective studies are required to further substantiate these associations.     

Communication problems for patients hospitalized with chest pain

In many settings, primary care physicians have begun to delegate inpatient care to hospitalists, but the impact of this change on patients' hospital experience is unknown. To determine the effect on physician-patient communication of having the regular outpatient physician (continuity physician) continue involvement in hospital care, we surveyed 1,059 consecutive patients hospitalized with chest pain. Patients whose continuity physicians remained involved in their hospital care were less likely to report communication problems regarding tests (20% vs 31%, p =.03), activity after discharge (42% vs 51%, p =.02), and health habits (31% vs 38%, p =. 07). In a setting without a designated hospitalist system, communication problems were less frequent among patients whose continuity physicians were involved in their hospital care. New models of inpatient care delivery can maintain patient satisfaction but to do so must focus attention on improving physician-patient communication.     

Outcome of cardiac valve ring abscesses after medical treatment: attempt to identify criteria of favorable prognosis

OBJECTIVES: Identify factors predicting favorable outcome after medical management of valve ring abscesses in order to propose a surveillance schedule for conservative treatment. METHODS: A multicentric study conducted from July 1989 to February 1996 included 28 patients (mean age 64 +/- 16 years, range 26-83) hospitalized for active endocarditis and valve ring abscesses diagnosed at transthoracic or transesophageal echography. Conservative medical therapy was given because of a decision of the medico-surgical team (n = 9), high surgical risk (n = 12), or patient refusal of surgery (n = 7). Outcome was favourable in 18 patients (Group I) and unfavorable in 10 (Group II) due to death (n = 9) or subsequent surgery (n = 1). Univariate and multivariate analysis were used to determine differences between the groups in terms of clinical and laboratory data. RESULTS: Mean follow-up in Group I was 33 +/- 18 months and 15 +/- 10 months in Group II. Univariate analysis showed significant differences between Group I and II respectively for age (59 +/- 18 yr vs 72 +/- 10, p = 0.04), delay to apyrexia after antibiotics (4.3 +/- 2.8 vs 8.3 +/- 2.4 days, p < 0.0008), heart failure (5% vs 70%, p = 0.003), grade III or IV valvular regurgitation (5% vs 60%, p < 0.04), and mean surface area of the abscess (1.5 +/- 1.2 vs 5.4 +/- 6.4 cm2, p < 0.03). Independent factors at multivariate analysis were by decreasing order: lack of heart failure at admission, delay to apyrexia, abscess surface area, and age. Outcome was favorable (mean follow-up 33 +/- 10 months) in all patients with an abscess surface area < 1.5 cm2, no signs of heart failure, no grade III or IV valvular regurgitation, apyrexia after less than 8 days on antibiotics and no staphylococcus positive blood culture. CONCLUSION: Medical management of valve ring abscesses may be indicated in selected patients in care units with rigorous surveillance facilities. Further studies are needed to precisely identify surveillance and treatment criteria.