Patterns of care for and outcomes of Pneumocystis carinii pneumonia among persons with transfusion-acquired AIDS

BACKGROUND: The most common human immunodeficiency virus (HIV)-related cause of death in persons with transfusion-acquired (TA) AIDS has been Pneumocystis carinii pneumonia (PCP). While better treatment for PCP accounts for improved survival among HIV-infected homosexual or bisexual men, the extent to which others have benefitted from these developments is unknown. STUDY DESIGN AND METHODS: Patterns of PCP care among persons with TA-AIDS, intravenous drug users, and homosexual or bisexual men are compared. RESULTS: TA-AIDS patients were older (mean, 46 years vs. < 40 for others, p < 0.05), more severely ill (59% had an alveolar-arterial oxygen gradient > 48.5 torr vs. 41% of others, p < 0.05), and less likely to have received PCP prophylaxis (16% of TA-AIDS patients versus 24–41% of others, p < 0.05). PCP care and outcomes also differed: TA-AIDS patients were less than half as likely to have early use of PCP medications (relative odds ratio = 0.45; 95% CI, 70% vs. > 80% for others, p < 0.05), more likely to be intubated (22% vs. 9–13% of others, p < 0.05), and more likely to die in-hospital (26% vs. 13- 22% of others, p < 0.05). After controlling for differences in severity of illness, insurance, age, and hospital characteristics, TA-AIDS patients were 45 percent as likely to have early PCP therapy (95% CI, 22%, 91%) as were persons in high-risk groups. CONCLUSION: For persons whose only risk factor was transfusion, recognition of the HIV infection and its complications appears to be problematic, which may help explain poorer outcomes in persons with HIV-related PCP.     

老年肺炎住院患者流行病学特征、基础疾病与诊治情况

目的 调查老年社区获得性肺炎(CAP)住院患者基础疾病、病原学特征与治疗措施,分析影响住院时间的因素.方法 选取在我院住院治疗的CAP患者400例,按照年龄分为老年组(≥65岁、274例)与非老年组(<65岁、126例),比较两组基础疾病、病原学特征与治疗措施,采用Logistic回归分析老年组住院时间的影响因素.结果...     

Characteristics and clinical outcomes for mental health patients admitted to a behavioural assessment unit: Implications for model of care and practice

Behavioural assessment units (BAU) have been established in emergency departments (EDs) to provide short‐term observation, treatment, and care to people experiencing acute behavioural disturbance. A prospective observational study was conducted in a cohort of adult patients admitted to one BAU located within an ED (July–December 2017) to compare clinical characteristics, treatment outcomes, and use of restrictive interventions for those who received a specialist mental health (MH) assessment with those who did not. Of the 457 patients, 61.5% received a specialist MH assessment. This group had a lower acuity (Australasian Triage Score 10.4%; CI 0.2–2.0% vs 13.6%; CI 9.3–19.5%); more arrived with police (28.8%; CI 23.8–34.3 vs 5.1%; CI 2.7–9.4%); and were subjected to restrictive interventions while in the BAU. Security responses for unarmed threat (code grey) were higher (10.9%; CI 7.8–15.0% vs 4.4%; CI 2.3–8.5%), as was the use of chemical restraint (4.2%; CI 2.4–7.2 vs 0.0% CI 0.0 – 2.1%). Those requiring specialist MH assessment had a longer length of stay (12.7 vs 5.2 hours). Further development of the BAU model of care must include targeted, evidence‐based strategies to minimize the use of restrictive interventions and ensure timely access to acute mental health services.     

A comparison of seriously ill patients with or without AIDS requiring prolonged mechanical ventilation

Purpose

The aim of this study was to compare differences in underlying diagnoses, weaning outcomes, discharge disposition, and survival in prolonged mechanical ventilator (PMV)–dependent patients with and without AIDS.

Methods

Ninety consecutive AIDS patients requiring PMV were retrospectively matched with 90 clinically similar non-AIDS patients to form matched cohorts to determine differences in their outcomes.

Results

AIDS patients had more acute diagnoses requiring PMV, whereas non-AIDS patients had more chronic diagnoses (P < .001). Weaning outcomes were alike with 31 (35%) AIDS and 37 (41%) non-AIDS patients successfully weaned. More AIDS patients went home, and fewer, to nursing facilities (P = .04). In each cohort, successfully weaned patients had significantly longer survival than their unweaned counterparts (all P < .001). Successful weaning reduced the risk of death in AIDS and non-AIDS patients (hazard ratios, 0.29 and 0.20; 95% confidence intervals, 0.17-0.50 and 0.11-0.36, respectively; all P < .001).

Conclusions

AIDS had little effect on weaning success or survival. Successful weaning increased survival regardless of a diagnosis of AIDS. The AIDS patients had more home discharges and fewer to nursing facilities, which likely resulted from the AIDS patients having more acute illnesses leading to PMV than the non-AIDS patients.     

住院艾滋病患者生存质量的调查

目的 了解艾滋病住院患者的生存质量并分析其影响因素,为临床制定相应护理措施提供依据.方法 将量性与质性研究相结合,采用整群抽样法,以一般资料问卷以及世界卫生组织生存质量测定量表（WHOQOL）对40例住院艾滋病患者进行生存质量测定,选择其中10例患者进行深入访谈.将结果进行统计学分析.结果 40例住院艾滋病患者的生存质量各领域得分均低于正常人群,差异均有统计学意义（P＜0.01）.患者在生理、心理、社会关系等领域均存在不同程度的问题.结论 住院艾滋病患者的生存质量与患者的生理、心理、社会关系以及相关知识了解程度有关,护士在工作中应采取相应的护理措施提高住院艾滋病患者的生存质量.     

Oregon Trauma System: Change in Initial Admission Site and Post-admission Transfer of Injured Patients

Objective: Associate statewide trauma system development with a change in the percentage of injured patients initially hospitalized at Levels I and II categorized trauma hospitals and a change in the length of stay (LOS) prior to arrival at a Level I or II hospital (PRE-LOS) and total LOS (T-LOS) for post-admission transfer patients. Methods: A retrospective analysis was performed using a hospital discharge database of 235,395 discharges with codes for acute injury managed at 74 acute care hospitals in Oregon State from 1983 to 1991. Primary outcome measures were admission site and transfer patient PRE-LOS and T-LOS. Predictor variables included category of initial hospital admission site, injury severity scale (ISS) score, head injury, age, and status of trauma system (pre-system, 1983 to 1987; transitional, 1988 to 1989; and post-system, 1991 to 1992). Results: There was a significant increase in the percentage of initial admissions to hospitals with Level I or II categorization (17.6%, 26.2%, and 27.6% for the three periods of development, respectively; p < 0.00001). The percentage of patients with ISS scores greater than 15 admitted initially to Level I or II hospitals increased from 33.4% to 52.6% and 57.3%; p < 0.00001). Only 1,059 (0.57%) of 185,321 patients initially admitted to Level III, Level IV, or noncategorized hospitals were transferred to a Level I or II hospital. Mean PRE-LOS for the 1,059 transferred patients showed a significant decrease with system development (2.3, 1.9, and 1.8 days, respectively; p < 0.02). When adjusted for age, ISS score, and head injury effects, mean T-LOS was significantly reduced for the transitional and post-system periods (p < 0.05). Conclusions: In Oregon, development of a statewide trauma system was associated with increased initial admissions to Level I and II trauma hospitals. For those patients transferred to higher levels of care post-admission, hospital LOSs were decreased with trauma system development.     

Nebulized pentamidine for the prevention of Pneumocystis carinii pneumonia in AIDS patients: experience of 173 patients and a review of the literature

Nebulized pentamidine is increasingly used for the prevention of Pneumocystis carinii pneumonia in HIV antibody-positive patients. We report our experience of the efficacy and tolerance of a high dose regimen (300 mg every second week) in 173 HIV-positive patients over a 2 1/2-year period. Only seven episodes of P. carinii pneumonia occurred but 48 patients (28 per cent) died of other AIDS-related illnesses. Patients who had never had an episode of P. carinii infection were less likely to accept long-term prophylaxis (17 of 81), compared to those who had previously been treated for the condition (five of 92). Nebulized pentamidine is an effective form of prophylaxis against P. carinii pneumonia, but long-term mortality is still high in AIDS patients. Side-effects with this regimen were almost always local and confined to the period of nebulization.     

Association between pre-intensive care unit (ICU) hospital length of stay and ICU outcomes in a resource-limited setting

Background Previous studies demonstrated higher mortality for patients with a longer pre-intensive care unit (ICU) hospital length of stay (LOS), in well-resourced settings. Objectives The study aimed to determine the association between pre-ICU hospital LOS and ICU outcomes in a resource-limited setting. We hypothesised that longer pre-ICU hospital LOS would be associated with higher ICU mortality. Methods This was a retrospective cohort study measuring the association between pre-ICU hospital LOS and ICU outcomes using data extracted from a regional hospital ICU in KwaZulu-Natal, South Africa. Consecutive ICU admissions of all patients (medical and surgical) older than 18 years were included during the study period September 2014 to August 2018. A corrected sample size of 2 040 patients was identified. Multivariable logistic regression was used to assess the primary outcome of ICU mortality, and multivariable Cox proportional hazard regression was used for the secondary outcome of ICU LOS. Results The median pre-ICU hospital LOS was 1 day (interquartile range (IQR) 0 - 2 days). The median length of ICU stay was 2.4 days (IQR 1.1 - 4.8 days) and the observed ICU mortality was 16% (n=327/2 040). Pre-ICU hospital LOS was not associated with ICU mortality in the unadjusted (odds ratio (OR) 1.00; 95% confidence interval (CI) 0.98 - 1.02; p=0.68; n=2 040) and fully adjusted logistic regression models (OR 1.00; 95% CI 0.98 - 1.03; p=0.90; n=1 981) using a complete case analysis for missing patient-level covariates. In Cox proportional hazard models, there was no association between pre-ICU hospital LOS and ICU LOS (hazard ratio 1.00; 95% CI 0.98 - 1.03; p=0.72; n=1 967), including when stratified by admission source. Conclusion Pre-ICU hospital LOS was not associated with either ICU mortality or ICU LOS in a resource-limited setting. Future studies should aim to include multicentre data and evaluate long-term outcomes. Contributions of the study The study was conducted in a resource-limited setting and found no association between prolonged LOS pre-ICU and patient outcomes. Several potential explanations for this observation have been explored. This important subject is pertinent to the appropriate use of limited resources and encourages future studies to evaluate this association and to consider longer-term outcomes (e.g. 30-day mortality) in future findings.     

APACHE Ⅱ、SAPS Ⅱ及LODS 3种评分系统在单一重症监护室的应用比较

目的比较和评价急性生理学与慢性健康状况评分系统Ⅱ（APAcHEⅡ）、简明急性生理功能评分系统Ⅱ（SAPSⅡ）及Logistic器官功能障碍系统（LODS）3种评分系统对危重病患者院内病死率的预测能力。方法应用3种评分系统计算出病死概率并与实际病死率比较。通过受试者工作特征曲线（ROC）下的面积及分类表，判定3种评分系统的拟合优度；而各评分系统对分层精确度的预测则用校准曲线及Lemeshow—Hosmer妒统计来评估。结果APACHEⅡ评分系统的预测病死率与实际病死率基本相符，而其他两种评分系统的预测病死率偏低。APACHEⅡ、SAPSⅡ及LODS各评分系统的ROC曲线下面积分别为0．881、0．904和0．875；95％可信区间分别为0．858～0．904，0．884～0．924和0．851～0．898；而在诊断界点为50％时，APACHEⅡ、SAPSⅡ及LODS各评分系统的整体正确分类率分别为81．60％、82．Og％和79．26％。APACHEⅡ（X^2=9．69）及SAPSⅡ（X^2=13．50）评分系统对分层精确度的预测较好，LODS评分系统则较差（X^2=87．22）。结论3种评分系统预测危重病患者预后的鉴别能力均较好且接近一致，APACHEⅡ及SAPSⅡ评分系统的分层预测精确度明显好于LODS。     

住院艾滋病患者生存质量与护理需求的相关性分析

目的 评估住院艾滋病患者生存质量及护理需求,并分析二者关系,为临床护理人员帮助患者提高生存质量提供依据.方法 采用整群抽样法,以一般资料问卷、住院患者护理需求评估问卷以及世界卫生组织生存质量测定量表(WHOQOL)对36例住院艾滋病患者进行访谈研究.结果 36例艾滋病患者的护理需求处于中高水平,生活质量各领域均低于正常人群,生存质量与护理需求存在负相关.结论 护理人员在工作中应主动了解和评估患者的护理需求并采取相应的护理措施以提高住院艾滋病患者的生存质量.     

Examining the role of vocational rehabilitation on access to care and public health outcomes for people living with HIV/AIDS

Abstract

Purpose: The purpose of this study is to examine the role of vocational rehabilitation services in contributing to the goals of the National HIV/AIDS strategy. Three key research questions are addressed: (a) What is the relationship among factors associated with the use of vocational rehabilitation services for people living with HIV/AIDS? (b) Are the factors associated with use of vocational rehabilitation also associated with access to health care, supplemental employment services and reduced risk of HIV transmission? and (c) What unique role does use of vocational rehabilitation services play in access to health care and HIV prevention? Method: Survey research methods were used to collect data from a broad sample of volunteer respondents who represented diverse racial (37% Black, 37% White, 18% Latino, 7% other), gender (65% male, 34% female, 1% transgender) and sexual orientation (48% heterosexual, 44% gay, 8% bisexual) backgrounds. Results: The fit of the final structural equation model was good (root mean square error of approximation?=?0.055), with 90% upper bound of 0.058, Comparative Fit Index?=?0.953, TLI?=?0.945). Standardized effects with bootstrap confidence intervals are reported. Conclusions: Overall, the findings support the hypothesis that vocational rehabilitation services can play an important role in health and prevention strategies outlined in the National HIV/AIDS strategy.

• Implications for Rehabilitation

• Vocational rehabilitation services can play a unique role in contributing to the goals of the National HIV/AIDS strategy by increasing access to care, increasing use of job support services and reducing health-risk behaviors.

• Increased job confidence and more positive health perception reduced HIV stigma, which is a key mediator to use of vocational rehabilitation services.

• The Behavioral Model of Vulnerable Populations is a useful framework to evaluate the impact of vocational rehabilitation services on access to health care and health-risk behaviors.

     

A comparison of the health locus of control and perceived social support between cancer and AIDS patients

This study compared the health locus of control (HLOC) and perceived social support levels of 219 cancer patients and 122 acquired immunodeficiency syndrome (AIDS) patients. Further, the relationship between HLOC and social support was explored. Chinese versions of the Multidimensional Health Locus of Control Scale (MHLC) (Form B) and the Personal Resources Questionnaire (PRQ) (Part 2) were used. Results showed that AIDS patients have a higher internal HLOC than cancer patients. The perceived social support of cancer patients was higher than that of AIDS patients. Social support was positively associated with internal HLOC and negatively associated with chance HLOC in both the samples. Implications of these results for nursing practice and future research are discussed.     

A framework for the study of coping, illness behaviour and outcomes

This paper presents a theoretical framework for the study of coping, illness attribution, health behaviour and outcomes. It is based upon models developed within health psychology and aims to provide a theoretical basis for nurse researchers to utilize psychosocial variables. It is an interactionist model which views outcomes as dependent upon both situation and person variables. The situation is viewed as the health threat or illness symptoms as well as the psychosocial context within which the person is operating. This context includes socio-economic factors, social support, social norms, and external factors such as the mass media. The experience of health threat is dependent upon individual appraisal, and the framework incorporates Folkman and Lazarus' transactional model of stress, as well as Leventhal's illness representation model. Behaviour and the perception of threat are also dependent upon outcome expectancies and the appraisal of one's own coping resources, and so the concepts of locus of control and self-efficacy are also incorporated. This framework allows one to identify determinants of behaviour and outcome, and will aid nurses in identifying areas for psycho-social intervention.     

层级化管理对ICU重症肺炎患者早期活动效果的影响

目的探讨层级化管理对重症监护病房(ICU)重症肺炎患者早期活动效果的影响。方法选取2017年6月至2018年5月广东省农垦中心医院收治的100例ICU重症肺炎患者,根据患者住院病床单双号分为观察组和对照组,各50例。对照组采用常规方法每日主观判断患者活动能力并进行常规活动;观察组根据影响ICU重症肺炎患者早期活动的因素对ICU患者的活动能力进行A、B、C、D层级划分,并制定相应层级的活动方案,通过每日评估患者所属的层级,进而采取相应的活动方案进行活动。应用巴氏指数评分表(Barthel指数)进行评分,以判断日常生活的活动能力,并比较两组差异。同时,比较两组患者呼吸机使用时间、出科时的血氧饱和度、ICU平均住院时间、患者对护理工作的满意度。结果两组患者入科时Barthel指数得分比较差异无统计学意义(P>0.05);两组患者出科时的Barthel指数得分与入科时比较,差异有统计学意义(P<0.05);观察组患者呼吸机使用时间和ICU平均住院时间明显短于对照组,出科时血氧饱和度明显优于对照组,护理工作满意度明显高于对照组,差异均有统计学意义(P<0.05)。结论实施层级化管理进一步提升ICU重症肺炎患者的日常生活能力,加快患者的康复进程,提高患者的治疗效果和护理满意度。     

A new prediction model for assessing the clinical outcomes of ICU patients with community-acquired pneumonia: a decision tree analysis

Purpose: We aimed to develop a new scoring index based on decision-tree analysis to predict clinical outcomes of patients with community-acquired pneumonia (CAP) admitted to the intensive care unit (ICU).

Methods: Data of 3519 ICU patients with CAP were obtained from the Medical Information Mart for Intensive Care III (MIMIC III) 2001–2012 database and analysed between 30-d survivors and non-survivors. Accuracy, sensitivity, and specificity of the new decision tree model were compared with those of CURB-65 and SOAR.

Results: The newly developed classification and regression tree (CART) model identified coexisting illnesses as the most important single discriminating factor between survivors and non-survivors. The CART model area under the curve (AUC) 0.661 was superior to that of CURB-65 (0.609) and SOAR (0.589). CART sensitivity was 73.4%, and specificity 49.0%. CURB-65 and SOAR sensitivity for predicting 30-d mortality were 74.5 and 80.7%, and specificity was 42.3 and 33.9%, respectively. After smoothing, the CART model had higher sensitivity and specificity than both CURB-65 and SOAR.

Conclusions: The new CART prediction model has higher specificity and better receiver operating characteristics (ROC) curves than CURB-65 and SOAR score indices although its accuracy and sensitivity are only moderately better than the other systems.

• Key messages

• The new CART prediction model has higher specificity and better ROC curves than CURB-65 and SOAR score indices.

• However, accuracy and sensitivity of the new CART prediction model are only moderately better than the other systems in predicting 30-day mortality in CAP patients.