The nutritional epidemic: How do we eat? How do we shop? What do we purchase?

The aim of this article is to provide some simple, clear norms which can help us to adopt and to "help to adopt" some healthy feeding habits, habits which we should transmit to our future generations.     

How should we make the admission decision in community-acquired pneumonia?

The spectrum of pneumonia patients ranges from only slightly compromised patients to patients who require life-sustaining measures. Admission decision support algorithms usually are not required for patients at either end of the spectrum. For patients presenting with intermediate severity of illness, decision support algorithms have shown that they can support clinicians in the admission decision and complement the clinicians' experience and clinical judgment with an objective tool. Clinical information systems may help overcome the existing obstacles to successful implementation. Successful guideline implementation in a clinical setting includes strategies that target not only the disease, but also include other forces that significantly influence the admission decision. Shared decision making and better managing of patients' expectations about treatment and prognosis need to be incorporated in the overall admission decision. The availability of improved outpatient management, such as outpatient intravenous antibiotic treatment and home health care, and a change in physicians' perspectives and patients' expectations may help to increase the proportion of outpatient management without compromising the quality of care. Decision support tools for pneumonia are available and show promising results. Further studies are needed, however, that show the successful dissemination and clinical implementation during routine patient care. Studies are needed that assess the impact of guidelines and prediction rules on patient outcomes. As the example of the PSI shows, the development, implementation, and dissemination of admission decision support systems is not a revolutionary, but a stepwise, evolutionary process that requires many years of research.     

How do homeopaths make decisions? An exploratory study of inter-rater reliability and intuition in the decision making process

The validity of clinical decision making in homeopathy is largely unexplored and little is understood about the process or its reliability. This exploratory study investigated, in the context of a questionnaire based re-proving of Belladonna 30c, the extent to which decisions are based on clinical facts or intuition and how reliable decisions are. Three experienced, independent homeopathic clinicians/proving researchers rated the symptom diaries of the 206 subjects taking part. They reported their proving decision (ie positive proving response, no proving response or undecided) based on the total symptom profiles and rated (on a scale of 0-10) their use of clinical facts or intuition. Keynote symptoms and overall confidence scores were also reported. The level of agreement between raters was generally poor (weighted kappa 0.349-0.064). All raters used both facts and intuition. The rater's reliance on the facts was significantly associated with classifying those subjects who had no proving response [rater 1, P<0.001; rater 2, P<0.001]. Raters used significantly higher intuition scores when classifying a prover [rater 2, P= 0.001; rater 3, P= 0.012]. Issues regarding the education and practice of homeopathy are discussed.     

Does medical futility matter in ‘do not attempt CPR’ decision‐making?

The current demographical trend towards an increasingly elderly population combined with advances in end of life care calls for a deeper understanding and common terminology about the concept of futility and additional influences on the resuscitation decision‐making process. Such improved understanding of medical futility and other contributing factors when making DNACPR orders would help to ensure that clinicians make appropriate and thoughtful decisions on whether to recommend resuscitation in a patient. When estimating medical futility a physician should consider the chance of survival over different time periods and balance this against the chance of adverse outcomes. This information can then be offered to the patient (or the relatives) so that the patient's views about what is acceptable for the survival chance, length and type of survival can be factored into the eventual decision. Given the lack of evidence in this area and the poor level of patient knowledge and the emotive nature of the topic, it is not surprising that clinicians find such discussions hard.     

How do we collect better granulocyte?

We studied retrospectively the factors affecting the product quality in 459 donor granulocyte apheresis procedures from 420 donors for 71 neutropenic patients from 2004 to 2010 in a single center. The counts of the granulocyte and platelet collected were measured to evaluate the product quality. The data was analyzed to determine a possible relationship between product quality and several parameters including gender, preleukapheresis neutrophil count, type of anticoagulation and separator type and mode of the apheresis system. We found that collection of better granulocyte is possible from a donor in a single procedure by changing anticoagulation type and separator mode during apheresis.     

How do intensive care nurses assess patients’ pain?

Identification and evaluation of pain in critical care patients may be difficult because of communication problems. Moreover, at present there are very few nursing studies that examine the attitudes of critical care nurses towards the assessment of patients' pain. This study was designed to determine the approach of critical care nurses towards assessing patients' pain levels, and to evaluate the problems in nursing diagnosis of those having difficulty in articulating their pain symptoms. We used a questionnaire to assess nurses attitudes to patients' pain. The study sample consisted of 91 critical care nurses who were recruited between January and February 2002. The results suggest that patient pain was considered undesirable by 44% of nurses. About 70-3% of the nurses reported resorting to administering analgesics to relieve their patients' pain. Some 57.1 % of nurses stated that they would have investigated whether the patients had really been experiencing pain, prior to administering the prescribed analgesics to patients. Some 85.7% of the sample indicated that the patients themselves would make the most accurate evaluation of their pain. The data suggested that 39.6% of nurses did not know how to evaluate pain symptoms in critical care patients suffering from complicated problems, and that 37.4% evaluated pain by monitoring the patients' behaviours. The study demonstrated that most of the critical care nurses did not know how to evaluate pain in patients having communication problems. The paper concludes by suggesting that there is a clear need to address nursing education and training with regard to evaluation and management of patients' pain whilst in critical care environment.     

How do we treat life‐threatening anemia in a Jehovah's Witness patient?

The refusal of allogeneic human blood and blood products by Jehovah's Witness (JW) patients complicates the treatment of life‐threatening anemia. For JW patients, when hemoglobin (Hb) levels decrease beyond traditional transfusion thresholds (<7 g/dL), alternative methods to allogeneic blood transfusion can be utilized to augment erythropoiesis and restore endogenous Hb levels. The use of erythropoietin‐stimulating agents and intravenous iron has been shown to restore red blood cell and Hb levels in JW patients, although these effects may be significantly delayed. When JW patients have evidence of life‐threatening anemia (Hb <5 g/dL), oxygen‐carrying capacity can be supplemented with the administration of Hb‐based oxygen carriers (HBOCs). Although HBOCs are not Food and Drug Administration (FDA) approved, they may be obtained and administered with FDA, institutional review board, and patient approval. We describe a protocol‐based algorithm to the management of life‐threatening anemia in JW patients and review time to anemia reversal and patient outcomes using this approach.     

Why did she do that? Issues of moral conflict in battered women's decision making

This qualitative research study was undertaken, in part, in an effort to develop an understanding of decisions experienced as moral conflicts by women who have experienced abuse by an intimate partner. Eighteen rural women who had been or were currently in an abusive relationship with a male partner participated in the study. An adaptation of the Real-Life Moral Conflict and Choice Interview (L. M. Brown, 1988) was used to gather and interpret the data. This method required each participant to describe a real life dilemma and her response to that dilemma. In this article the author discusses the types of decisions described by the women. The decisions are organized into 3 categories that emerged from the interview narratives: the decision to leave the abusive relationship, decisions that threaten sense of self, and decisions of resistance. The findings of this study make explicit some of the dimensions of moral conflict inherent in decisions battered women make. Explication of these moral conflict issues and the ways in which women seek to resolve them provide another avenue through which to understand a battered woman's life, a perspective not found in other studies.