Selective decontamination of the digestive tract: effect of cessation of routine application at an ICU

BACKGROUND: Selective decontamination of the digestive tract (SDD) with non-absorbable antibiotics was extensively used at intensive care units (ICU) in Europe to prevent nosocomial infections in critically ill patients. After three recent meta-analyses in which it was demonstrated that SDD did not influence hospital stay and mortality in these patients several ICU's decided to stop the routine use of SDD. OBJECTIVE: To examine the effects of the cessation of SDD on nosocomial infections, mortality and hospital stay at an ICU in post-operative patients. DESIGN: Retro- and prospective follow-up. PATIENTS: Post-operative patients with mechanical ventilation (MV) for > or = 5 days at an ICU were included. The retrospective group (SDD group) comprised of 138 patients (mean age 66, range 10-91; 78% male) and the prospective group (non-SDD group) of 142 patients (mean age 67 range 18-85; 65% male). The SDD regime consisted of colistin, tobramycin and amphotericin B. Cessation of the SDD was accompanied by a shortening of the routine intravenous cefuroxime prophylaxis. RESULTS: There was a nonsignificant increase from an average 21 to 23 days ICU stay in the non-SDD group when compared with the SDD group (p > 0.05). Of the 280 patients 97 (35%) died on the ICU. The risk of death was lower in the non-SDD group (adjusted hazard ratio 0.7 with 95% Cl 0.5-1.1). There was a trend towards an increase in infections as a cause of death in the non-SDD group (38% of the ceased patients versus 20% in the SDD group) (p > 0.05). The incidence of respiratory tract infection (per 1000 person days) was 80 (95% Cl 48-113) in the non-SDD group versus 19 (95% Cl 8-22) in the SDD group (adjusted hazard ratio 4.5 (95% Cl 2.9-7.1)). CONCLUSION: The cessation of the routine application of SDD in post-operative patients mechanically ventilated for 5 days or more did nod adversely affect survival nor increased length of stay at the ICU. There may have been a shift to infections as a cause of death after cessation of SDD.     

Notifying patients exposed to blood products associated with Creutzfeldt-Jakob disease: theoretical risk for real people

BACKGROUND: In July 1995 the Canadian Red Cross Society recalled blood products because of the hypothetical risk of transmission of Creutzfeldt-Jakob disease (CJD) through those blood products. The authors undertook a survey to determine the views of patients and parents of patients about being notified that they or their child had received such blood products. METHODS: The study population consisted of 528 transfusion recipients, of whom 453 (85.8%) were under 16 years of age, notified by the Hospital for Sick Children, Toronto, of the CJD recalls in 1995 and 1996. Families attending an information session were asked to complete a self-administered questionnaire (85 cases). Ninety-seven families randomly selected from those who did not attend the session were interviewed by telephone. The questionnaire was adapted from a questionnaire used to evaluate families' responses to notification of transfusion and risk of HIV infection. RESULTS: More than 80% of the respondents said they wanted to be notified and would want to be notified if there were another recall. On initial receipt of the notification about two-thirds of the respondents had been anxious, fearful or angry. There was no one method of conveying the information that suited all, but a personalized letter was seen as the most acceptable method. INTERPRETATION: Most parents of children who have received blood products are in favour of being informed about the risk of CJD, despite the uncertainty of the information on risk and the anxiety that such information causes.     

Neurological intensive care admissions: identifying candidates for intermediate care and the services they receive

OBJECTIVE: The high cost and scarcity of intensive care unit (ICU) beds has resulted in a need for improved utilization. This study describes the characteristics of patients who are admitted to the ICU for neurosurgical and neurological care, identifies patients who might receive all or most of their care in an intermediate care unit, and describes the services the patients would receive in an intermediate care unit. METHODS: We describe patients who received neurological care and who were part of a prospective study of 17,440 patients admitted to 42 ICUs at 40 United States hospitals. We identified patients who received only monitoring during ICU Day 1 and then used a previously validated equation to distinguish which patients were at low risk (< 10%) for subsequent active life-supporting therapy. We also describe the services these patients received during their ICU stay. RESULTS: Among 3000 patients admitted to the ICU for neurological care, 1350 received active therapy and 1650 (55%) underwent monitoring and received concentrated nursing care on ICU Day 1. After excluding those patients who received active therapy at admission, 1288 (78%) of the 1650 patients who underwent monitoring at admission were at low risk (< 10%) for subsequent active therapy; 95.8% received no active therapy. These patients who were at low risk for subsequent active therapy were significantly (P < 0.001) more often admitted postoperatively, were younger and less severely ill, and had lower ICU and hospital mortality rates (0.9 and 3.9%, respectively) than patients who received active treatment at admission. CONCLUSIONS: Patients receiving neurological care at an ICU who receive only monitoring during their 1st ICU day and have a less than 10% predicted risk of active treatment can be safely transferred to an intermediate care unit. Some of these patients may not require ICU admission. We suggest guidelines for equipping and staffing neurological intermediate care units based on the type and amount of therapy received by these patients.     

Intensity of treatment and severity of illness in the intensive care unit (ICU)

OBJECTIVE: To investigate the relationship between Therapeutic Intervention Scoring System (TISS), length of ICU stay and severity of illness. DESIGN: Prospective study lasting 1 year. SETTING: Two 4-bed surgical-medical ICU. PATIENTS: All consecutively ICU admitted patients. METHODS: Every day TISS of each patient during the last 24 h was computed. Age, sex, type of admission, SAPS II and APACHE II, length of ICU stay and hospital outcome were recorded. Out of 446 admissions, 14 were excluded since the ICU stay was < 16 h. Severity of illness was considered in 405 of the remaining 432; total TISS of readmitted patients resulted from all ICU admissions during the same hospital stay. RESULTS: Median TISS on day 1 was 24 (range 3-58, CI 95% 0.57) and median TISS +/- CI 95% during the first 10 ICU days ranged from 20 to 26. Spearman's correlation coefficient between TISS total and length of stay in ICU was 0.962. Total TISS increased with risk of hospital death predicted by both SAPS II and APACHE II. Total TISS of non surviving patients was significantly (p < 0.001) higher than that of the surviving up to probability of death of 20%. CONCLUSIONS: Intensity of treatment is essentially steady and total TISS is well related to length of ICU stay. Total TISS increases with increasing risk of hospital death predicted by SAPS II and APACHE II, but it is high especially in non surviving patients with low probability of hospital mortality at the admission.     

Gene mutations with characteristic deletions in cord blood T lymphocytes associated with passive maternal exposure to tobacco smoke

OBJECTIVE: To determine variations among hospitals in use of intensive care units (ICUs) for patients with low severity of illness. DESIGN: Retrospective cohort study. SETTING: Twenty-eight hospitals with 44 ICUs in a large metropolitan region. PATIENTS: Consecutive eligible patients (N=104,487) admitted to medical, surgical, neurological, or mixed medical-surgical ICUs from March 1, 1991, to March 31, 1995. OUTCOME MEASURES: The predicted risk of in-hospital death for each patient was assessed using a validated method that is based on age, ICU admission source, diagnosis, severe comorbid conditions, and abnormalities in 17 physiologic variables. Admissions were classified as low severity if the patient's predicted risk of death was less than 1%. In a subset of 12,929 consecutive patients, use of 19 specific interventions typically delivered in ICUs was examined. RESULTS: Twenty thousand four hundred fifty-one admissions (19.6%) were categorized as low severity, including 23.6% of postoperative and 16.9% of nonoperative admissions. Alcohol and other drug overdoses accounted for 40.2% of nonoperative low-severity admissions; laminectomy and carotid endarterectomy accounted for 52.3% of postoperative low-severity admissions. Mortality among patients with low-severity illness was 0.3%, and only 28.6% received an ICU-specific intervention during the first ICU day. Although mean ICU length of stay was shorter (P<.001) in low-severity admissions (2.2 vs 4.7 days in nonoperative and 2.4 vs 4.2 days in postoperative admissions), low-severity admissions accounted for 11.1% of total ICU bed days. Rates of low-severity admissions varied (P<.001) across hospitals, ranging from 5% to 27% for nonoperative and 9% to 68% for postoperative admissions. CONCLUSIONS: A large proportion of patients admitted to the ICU have a low probability of death and do not receive ICU-specific interventions. Rates of low-severity admissions varied among hospitals. The development and implementation of protocols to target ICU care to patients most likely to benefit may decrease the number of low-severity ICU admissions and improve the cost-effectiveness of ICU care.     

The management of bereavement on intensive care units

OBJECTIVE: To investigate the management of the bereaved on Intensive Care Units (ICU) throughout the United Kingdom, and to identify inadequacies that may exist either in the provision of staff training in dealing with bereavement or in the facilities or support available for the bereaved. DESIGN: Questionnaires were sent to the senior nurse and senior doctor in all general ICUs with more than four beds nationwide. The questions asked about nursing and medical practice around the time of a patient's death, as well as about staff attitudes towards, and training in, dealing with bereavement and the support they received for this role. RESULTS: We obtained a 68% (293/430) response rate. Most ICUs had facilities for relatives, but little for the specific needs of the bereaved. Only 6% of doctors and 21% of nurses had training in dealing with bereavement and grieving. A staff support group was available in 23% of ICUs, and 75% of the remainder thought it would be useful to have one. Lack of staff training and poor facilities for relatives were identified as the major concerns of ICU staff. CONCLUSION: Many doctors and nurses working in Intensive Care Units feel inadequately trained to deal confidently with the bereaved. A minority of ICUs have support mechanisms available for their staff, inspite of the perceived need for them. Furthermore, many ICU staff feel the facilities they are able to offer the bereaved are inadequate. We have identified the major inadequacies and the needs of ICU staff for improved training. Meeting these needs would play a significant role not only in reducing staff stress but also minimising the morbidity in surviving relatives.     

Usefulness of gastric intramucosal pH for monitoring hemodynamic complications in critically ill children

OBJECTIVE: To assess the efficacy of gastric intramucosal pH for the evaluation of tissue perfusion and prediction of hemodynamic complications in critically ill children. DESIGN: Open prospective study without controls. SETTING: Pediatric intensive care unit (ICU) of a tertiary care university pediatric hospital. PATIENTS: Thirty critically ill children (16 boys and 14 girls), age range: 3 months-12 years. MEASUREMENTS AND RESULTS: A tonometry catheter was placed in the stomach of all patients on admission to the pediatric ICU. Simultaneous tonometry and arterial gas measurements were made on admittance and every 6-12 h throughout the study; a total of 202 measurements were made. The catheter was removed after extubation and/or when the patient was hemodynamically stable. Intramucosal pH was calculated using the Henderson-Hasselbalch equation based on the pCO2 of the tonometer and arterial bicarbonate. Intramucosal pH values between 7.30 and 7.45 were considered to be normal. The patient's condition was analyzed using the Pediatric Risk Mortality Score (PRISM). The relations between intramucosal pH and the presence of major hemodynamic complications (cardiopulmonary arrest, shock), minor hemodynamic complications (hypotension, hypovolemia or arrhythmia), death, PRISM score and the duration of the stay in the pediatric ICU were analyzed. Intramucosal pH on admission was 7.48 +/- 0.15 on average (range 7.04-7.68). Five patients (16%) had an intramucosal pH lower than 7.30 on admission; these patients did not have a higher incidence of hemodynamic complications. The 16 patients (53%) who had an intramucosal pH of less than 7.30 at some time during the course of their disease had more hemodynamic complications than the patients who did not have pH lower than 7.30 (p < 0.0001). Every case of cardiopulmonary arrest and shock was related to intramucosal pH of less than 7.30. Patients with major complications (cardiopulmonary arrest and shock) had lower intramucosal pHs than those with minor hemodynamic complications (p = 0.03); similarly, they had low intramucosal pH readings more often than those with minor complications (p = 0.0032). Intramucosal pH values less than 7.30 had a sensitivity of 90% and a specificity of 98% as a predictor of hemodynamic complications. There was no relation between intramucosal pH lower than 7.30 and either PRISM or the duration of the stay in the pediatric ICU. Patients with intramucosal pH less than 7.20 had a higher PRISM than the patients who did not have pH lower than 7.20 (p < 0.05). A patient who died during the study due to cardiopulmonary arrest had prior intramucosal pH measurements of 7.23 and 7.10, and three patients died of late complications after the end of the study. Hemodynamic complications were not detected with arterial pH. Gap pH (arterial pH-intramucosal pH) and standard pH measurements yielded the same results as gastric intramucosal pH. CONCLUSION: Intramucosal pH could provide a useful early indication of hemodynamic complications in critically ill children.     

The C-terminal region of the Escherichia coli UvrC protein, which is homologous to the C-terminal region of the human ERCC1 protein, is involved in DNA binding and 5''-incision

STUDY OBJECTIVES: To examine the incidence and consequences of atrial arrhythmias in surgical ICU patients following major noncardiac, nonthoracic surgery. DESIGN: Prospective observational study. SETTING: University hospital surgical ICU. PATIENTS: Four hundred sixty-two consecutive patients after noncardiothoracic surgery. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Patients were assigned to one of three groups: group 1-new-onset atrial arrhythmias (n=47); group 2-history of atrial arrhythmias (n=58); and group 3-no atrial arrhythmias (n=357). New arrhythmias occurred in 10.2% of patients. Most began within the first 2 postoperative days. These patients had a higher mortality rate (23.4%), longer ICU stay (8.5+/-17.4 [SD] days), and extended hospital stay (23.3+/-23.6 days) than patients without atrial arrhythmias (mortality, 4.3%; ICU stay, 2.0+/-4.5 days; hospital stay; 13.3+/-17.7 days; p<0.02). Thirteen percent of patients had a history of atrial arrhythmias. They had a higher mortality rate (8.6%) and longer ICU stays (2.9+/-4.9 days; p<0.02) than patients without arrhythmias. Most deaths in the two arrhythmia groups were not due to cardiac problems, but to sepsis or cancer. CONCLUSIONS: Patients admitted to a surgical ICU after noncardiothoracic surgery with a history of or who developed new atrial arrhythmias had greater mortality and longer ICU stays than patients without arrhythmias. The incidence of new-onset arrhythmias was lower than reported after cardiac and thoracic surgery, but higher than in the general population. Atrial arrhythmias were not the cause of death and appear to be markers of increased mortality and morbidity.     

Fine needle tissue aspiration for accurate localization of histological specimens from complex structures

There is little information available regarding quality of life following critical illness. The consequences of a stay in an intensive care unit (ICU) can result in considerable psychological and physical morbidity. At the Homerton Hospital, London, UK an intensive care follow-up outpatient clinic was established to ascertain patients' experiences after discharge from the ICU. This exploratory study examines narrative data collected from 26 patients by means of unstructured client-led interviews. Themes are derived that have implications for staff, patients and relatives. The findings suggest that patients experience a variety of psychological and physical symptoms. Patients experienced vivid dreams, flashbacks, relocation and convalescent stress as well as profound tiredness and weakness. These are consistent with previous research findings. New themes were identified which suggest that mood changes, inability to cope, the need to talk about their ICU experience and indistinct memories of the ICU made recovery at home difficult for both the patients and their families. As a result of these findings, the role of a clinical nurse specialist has developed in order to improve liaison between and within departments, the hospital and the community. Future research will aim to focus on the role of the critical care/community liaison clinical nurse specialist and in improving outcomes through the use of action research.     

Epidemiological and prognostic data from 2054 patients of an internal medicine intensive care unit

BACKGROUND: Computer-based data collection and objective gathering of degree of illness severity and risk of death with a prognostic scoring system make it possible to obtain, in addition to epidemiological and aetiological data, risk-related outcome values for patients in an intensive care unit. PATIENTS AND METHODS: All 2054 patients who during a 2-year period (1995-1996) had stayed in a medical intensive care unit (MICU) for more than 4 hours were studied prospectively. The simplified acute physiology score II (SAPS II), risk of death, duration of stay in the MICU and in the hospital, and death rates during MICU and hospital stay were determined. Mean and median values and histograms of the various parameters as well as the standardized mortality index (SMI: observed/ predicted death rate with 99% confidence limits) were calculated for each of the patients and certain defined subgroups (basic disease, age, risk). Receiver operating characteristics curves (discrimination) and calibration curves were obtained for SAPS II. RESULTS: Mean age for the cohort was 59.8 years, duration of stay in the MICU 3.1 days, in hospital 14.7 days, SAPS II was 30.3 points, death risk 0.17, death rate during ICU stay was 8.3%, during hospital stay 13.9% and the SMI 0.8% (0.74-0.88). Cardiac disease was the most common underlying condition (60%), while the small group of neurological conditions was remarkable for the high degree of severity and unfavourable prognosis. Both death rate and degree of disease severity increased with age. But the SMI was not significantly higher than 1.0 in both the elderly patients and the high-risk group of patients (on ventilator, renal replacement procedures, death risk > 0.5). CONCLUSIONS: Most patients in a MICU have underlying cardiac disease. Permanently available neurological consultation is essential. The high hospital death rate for elderly patients and those requiring respiratory support is a problem of disease severity, not of the quality of treatment. The risk of death is high on transfer to a general ward. Determination of the SMI is recommended for internal quality control in an ICU.     

A prospective study of the efficacy of the physician order form for life-sustaining treatment

OBJECTIVES: The Physician Orders for Life-Sustaining Treatment (POLST), a comprehensive, one-page order form, was developed to convey preferences for life-sustaining treatments during transfer from one care site to another. This study examined the extent to which the POLST form ensured that nursing home residents' wishes were honored for Do Not Resuscitate (DNR) and requests for transfer only if comfort measures fail. DESIGN: The study used chart record data to follow prospectively a sample of nursing home residents with the POLST. SETTING: Eight geographically diverse, long-term, adult-care facilities in Oregon in which the POLST was in use. PARTICIPANTS: Nursing home residents (n = 180), who had a POLST recording DNR designation and who indicated a desire for transfer only if comfort measures failed, were followed for 1 year. MEASUREMENTS: For all subjects: treatment and disposition after significant health status changes; orders for narcotics and for provision or limitation of aggressive interventions. For hospitalized subjects: diagnosis, medical interventions, and DNR orders. For those who died: cause and location of death, life-sustaining treatments attempted, and comfort measures provided. RESULTS: No study subject received CPR, ICU care, or ventilator support, and only 2% were hospitalized to extend life. Of the 38 subjects who died during the study year, 63% had an order for narcotics, and only two (5%) died in an acute care hospital. A total of 24 subjects (13%) were hospitalized during the year. Hospitalized subjects' mean length of stay was 4.9 days, and the mean rate of hospitalizations for all subjects was 174 per 1000 resident years. In 85% of all hospitalizations, patients were transferred because the nursing home could not control suffering. In 15% of hospitalizations (n = 4), the transfer was to extend life, overriding POLST orders. CONCLUSIONS: POLST orders regarding CPR in nursing home residents in this study were universally respected. Study subjects received remarkably high levels of comfort care and low rates of transfer for aggressive life-extending treatments.     

Analysis of deaths during the course of status asthmaticus in patients treated at the Acute Asthma Center in the Pneumonology Clinic of the Warsaw Medical School in the years 1991-1996]

In the Acute Asthma Treatment Center (OLSA) in the Department of Pneumonology of Warsaw Medical School in years 1991-1996, 582 patients with status asthmaticus were treated. The causes of status asthmaticus were bronchial asthma in 317 patients and COPD in 265 patients. Status asthmaticus was the cause of death in 21 patients treated in OLSA, which accounts for 3.6% of the total. 10 subjects were admitted with symptoms of brain death, who underwent resuscitation on their way to hospital. This study retrospectively analyzes the clinical characteristics (age, sex, PaCO2, pH, PaO2, time of mechanical ventilation and duration of treatment in ICU) of patients who died in status asthmaticus. They were divided into two groups: patients with asthma and COPD. A significant difference (p < 0.01) was detected between those two groups only in patients age. Mean duration of mechanical ventilation was 151 h in asthmatic and 104 h in COPD group. Mean duration of the OLSA stay was 19.5 days in the first and 7.4 days in the second group. The following fatal complications were observed: 2 cerebral strokes, 4 cardiac infarctions, 3 pneumothoraces, 2 atelectasis, 4 pneumonia, 1 case of gastric hemorrhage and 1 hemorrhage to mediastinum.     

Limitations in the use of gamma-glutamyl transferase estimations in alcohol-dependent subjects

OBJECTIVE: To investigate any relationship between the pathological features of amiodarone-induced pulmonary toxicity (APT) and clinical use of amiodarone in patients dying from acute respiratory distress syndrome (ARDS). DESIGN: Retrospective study. Review of clinical and pathological findings of patients dying from ARDS. SETTING: Intensive Care Unit (ICU) and Pathology Department of University hospital. SUBJECTS: Ten patients with clinical diagnosis of ARDS, who died in ICU and underwent post mortem examination. INTERVENTIONS: Case note review of clinical details; independent review of histological specimens. MEASUREMENT AND RESULTS: Over a 3-year period, ten patients underwent post mortem examination, of whom seven had received amiodarone. Three patients who received longer than 48 h of amiodarone had histological changes of widespread lipoid pneumonia, a recognised pattern of APT. CONCLUSIONS: Acute amiodarone pulmonary toxicity is a definite pathological entity in ICU patients. High oxygen concentrations may be a risk factor, while pre-existing pathology, e. g. ARDS, may mask its development. Amiodarone should be used with caution in this group of patients.     

Evaluating the FONE FIM: Part II. Concurrent validity & influencing factors

The "motor" (activities of daily living) component of the FONE FIM, the telephone version of the Functional Independence Measure (FIM) was evaluated in a cohort of 132 patients who had been discharged to home from a geriatric inpatient assessment and rehabilitation program. In the current study, Rasch person ability measures were derived from telephone assessments 5 weeks after discharge and in-home assessments 1 week later. Concordance between the modes was shown to be satisfactory for the Rasch measures based on intraclass correlation coefficients. However, the telephone mode consistently generated lower estimates than did the observational mode. This was due to the fact that the telephone mode underestimated motor function for the majority of patients who were at higher levels of cognition and motor function, but overestimated for patients who were at lower levels of cognition and motor function. At the item level, concordance, as determined by Kappa statistics, was better when the FONE FIM responses came from the patient rather than proxy respondents, and when the assessments were done by more experienced rather than less experienced raters. Based on these findings, a mixed strategy, the telephone mode for patients capable of responding to the FONE FIM and in-home assessments for those who are incapable, is recommended.     

Percutaneous intentional extraluminal (subintimal) recanalization: how to do it yourself

INTRODUCTION AND OBJECTIVES: The high demand for health care has obliged Coronary Units to hasten the discharge of patients in less serious condition and this might be an influence on their prognosis. Our objective have been: a) to analyse the characteristics and the evolution (death or readmission) during the first month of patients with myocardial infarction and very early discharge from the Coronary Unit (stay of 2 days or less), and b) to assess the profile of very low risk group patients for complications who could be discharged early from the Coronary Unit. PATIENTS AND METHODS: A study of 978 consecutive patients who had been admitted for acute myocardial, in faration were divided into two groups according to their length of stay in the Coronary Unit (A < or = 2 and B > 2 days). Their baseline characteristics, course of stay and vital status at month, were compared. A subgroup of patients at low risk was studied and complications that might have arisen from their early discharge from the Coronary Unit were assessed. RESULTS: Seventy-three patients (7.5%) died within the first two days. Of the remaining 905, the stay was 2 days or less for 336 patients (group A); and longer than 2 days for 569 (group B). Group A had a higher frequency of dyslipemia, Killip class I on admission, uncomplicated myocardial infarction in the Coronary Unit and the use of beta-blockers and had less frequency of diabetes, Q wave myocardial infarction, anterior infarction or the use of fibrinolytics. In the first month after discharge from the Coronary Unit, 10 patients from group A and 18 patients from group B died, the rate of death or readmission into the Coronary Unit within 30 days was similar between both groups (group A = 13% and group B = 13%). A multiple regression showed that Killip class on admission (p < 0.001) and an uncomplicated course (p < 0.001) were independently related with the length of stay in the coronary unit. A subset of 378 low risk patients (Killip I on admission, uncomplicated course in the ICU and age < 71 years) had no mortality at 30 days and their readmission rate in the first month was 4%. In this subgroup, those patients whose stay was equal to or less than two days were more frequently readmitted in the first week. (group A = 9/197 [5%] and group B = 1/181 ([0.5%]; p = 0.034). CONCLUSION: Selected patients with myocardial infarction can be discharged very early from the Coronary Unit with a low risk of death. A readmission rate following discharge of some 5% must be allowed for these patients.     

Computed tomography of the normal feline nasal cavity and paranasal sinuses

We studied physical, cognitive, emotional and quality-of-life changes noted by relatives in a sample of 65 severely traumatic brain injured (TBI) patients several years after injury. The purpose of the present study was to evaluate the families perception of these changes and their need for information concerning the consequences of TBI. Our results indicated that the perceived changes in behavioural and affective symptoms and in the patient's quality of life were most closely associated with the need expressed by family members for information concerning, TBI. We also found that family relationships were especially affected by problems in the behavioral and affective domain, and the decrease in patient quality of life, as reported by relatives. These findings underline the importance of providing the relatives of TBI patients with information about the consequences of the injury with particular emphasis on behavioural and emotional disturbances, in order that they might cope better with these problems.     

Duplication and distribution of repetitive elements and non-unique regions in the human genome

The natural history of patients with coronary artery disease and diastolic dysfunction who underwent coronary artery bypass grafting (CABG) is not well known. The aims of our study were to evaluate the incidence of diastolic dysfunction, its evolution after CABG and its possible correlation with adverse in-ICU prognosis. We studied 88 consecutive patients scheduled for CABG with not severely depressed left ventricular function (ejection fraction > 35%) and multivessels disease. Buckberg cardioplegia was used for myocardial protection. Diastolic function was investigated by recording mitral and venous pulmonary flow by transesophageal Doppler echocardiography (TEE). TEE examination was performed in operative room pre and post-bypass, at ICU arrival and after three months. Diastolic dysfunction was defined as mild, moderate and severe. Adverse in ICU events were defined as: use of inotropic drugs or ventricular mechanical support, an ICU stay > 24 hours, perioperative myocardial infarction and death. The study group was compared with a control group. T-Student test was used; a p < 0.05 was considered significant. A reduced diastolic function was present in 77% of patients at baseline examination. Diastolic dysfunction did not worsen significantly after hypothermic cardiac arrest and reperfusion. It persisted during ICU stay and normalized after three months from CABG in the majority of patients (85%). Diastolic failure was not associated with an adverse ICU prognosis (adverse events: 18 versus 13%; p = ns).     

Homosexual parents

Does the homosexuality of parents affect the sexual orientation or experiences of their children? Seventeen of 5,182 randomly obtained adults from six U.S. cities answered questionnaires indicating that they had a homosexual parent. Parental homosexuality may be related to findings that: (1) 5 of the 17 reported sexual relations with their parents; (2) a disproportionate fraction reported sexual relations with other caretakers and relatives; and (3) a disproportionate fraction: (a) claimed a less than exclusively heterosexual orientation (47%); (b) indicated gender dissatisfaction; and (c) reported that their first sexual experience was homosexual. Of 1,388 consecutive obituaries in a major homosexual newspaper, 87 of the gays who died had children and registered a median age of death of 47 (the 1,267 without children had a median age of death of 38); 10 lesbians did and 24 did not have children. We estimate that less than 1% of parents are bisexual or homosexual and that < 7% of gays and about a third of lesbians are parents.     

Outcome of ICU treatment in invasive aspergillosis

OBJECTIVE: To assess the outcome of intensive care treatment in invasive aspergillosis. DESIGN: Retrospective study. SETTING: University Hospital, Medical Intensive Care Unit (ICU). PATIENTS: Twenty-five patients with invasive aspergillosis who were admitted to the medical ICU in a 5 1/2 year period. Twenty-two had received high-dose chemotherapy for (mainly hematologic) malignancies, one had been treated with cyclosporine and prednisolone for systemic lupus erythematosus, one with high-dose methylprednisolone for polyarteritis nodosa and one had an ARDS after near-drowning. MEASUREMENTS AND RESULTS: The medical records were reviewed for patient and disease characteristics, outcome, reasons for admission to the ICU, supportive care and antifungal therapy as well as for the results of cultures and autopsy. Out of 25 patients, a definite ante mortem diagnosis could be established in seven. When autopsied patients were included, a total of 15 suffered from proven invasive aspergillosis. Although standard antifungal treatment and maximal available supportive care were given, 23 of 25 patients (92%) died after a mean of 15 (1-51) days in the ICU. Both patients who recovered had received high-dose chemotherapy for hematologic malignancy and showed bone marrow recovery and/or had a localized pulmonary infection. CONCLUSIONS: In patients with highly suspected or proven invasive aspergillosis, admission to an ICU and mechanical ventilation should be considered in cases of localized infection and obvious signs of hematologic recovery. In most other circumstances ICU admission for mechanical ventilation does not seem to improve survival.     

Stability of expressed emotion in relatives of those with schizophrenia and its relationship with burden of care and perception of patients' social functioning

BACKGROUND: There is evidence that high expressed emotion (EE) in relatives of patients with schizophrenia is associated with higher levels of burden of care, and with worse perception of patient's social functioning. However, it is not clear whether changes in EE levels over time are associated with changes in relatives' burden of care and their perception of patients' social functioning. METHODS: Fifty patients with a diagnosis of schizophrenia and 50 relatives were included in the study soon after patients' admission to hospital. Thirty-six relatives and 31 patients were re-assessed 9 months after patients' discharge. Both assessments included patients' symptomatology and relatives' EE levels, burden of care, and perception of patients' social functioning. RESULTS: Twenty-three relatives (64%) had the same EE level in both assessments, nine (25%) had changed from high to low EE, and four (11%) from low to high EE. Improvement in burden and perception of patients' social role performance were significantly more accentuated among relatives who changed from high to low EE than among relatives who had a stable EE level. Variables that best predicted changes in EE levels were changes in burden scores and number of hours of contact between patients and relatives at follow-up. CONCLUSIONS: Change in EE is associated with change in circumstances and burden. Findings support the idea that EE is better understood in an integrative model.