Empathy: Necessary for effective pain management?

Empathy is a provider attribute that has been a topic of increased clinical interest, particularly as it relates to pain. This article examines various dimensions of the pain and empathy literature: definitions of empathy, research regarding the psychophysiology of empathy for pain, and research related to empathy in psychological and medical care. Research regarding topics broadly related to empathy is also reviewed, including communication skills and patient-centered care. Although this literature supports the clinical value of provider empathy and/or behaviors likely to reflect empathy, little research has explicitly examined empathy in the treatment of pain. Nonetheless, when considered in the broader context, the evidence is sufficient to draw some conclusions regarding approaches to pain care that are likely to reflect and/or elicit provider empathy and are central to effective pain management.     

Pulmonary rehabilitation: is it cost effective?

The purpose of the study was to evaluate number of hospitalizations, length of stay, exercise routine, and patient satisfaction following attendance at a pulmonary rehabilitative program. A retrospective chart review and survey conducted on 72 subjects with chronic obstructive pulmonary disease showed a significant decrease in number of hospitalizations and length of stay following attendance at the program. In addition, 72% of the subjects continued to carry out an exercise routine and 99% indicated that the rehabilitation program had met their expectations. This study suggests that the pulmonary rehabilitative program was cost-effective.     

Prone positioning: is it safe and effective?

Prone positioning has been used as a treatment option for patients with acute lung injury or acute respiratory distress syndrome (ARDS) since the early 1970s. Prone position and extended prone position ventilation have been shown to increase end-expiratory lung volume, alveolar recruitment, and oxygenation in patients with severe hypoxemic and acute respiratory failure. Prone positioning is not a benign procedure, and there are potential risks (complications) that can occur to both the patient and the health care worker. Notable complications that can arise include: unplanned extubation, lines pulled, tubes kinked, and back and other injuries to personnel. Prone positioning is a viable, inexpensive therapy for the treatment of severe ARDS. This maneuver consistently improves systemic oxygenation in 70% to 80% of patients with ARDS. With the utilization of a standardized protocol and a trained and dedicated critical care staff, prone positioning can be performed safely.     

Publishing outcome data: is it an effective approach?

RATIONALE, AIMS AND OBJECTIVES: The publication of health outcome data--rather than merely the measurement and collection--is being given increasing consideration. Publication reflects society's increasing emphasis on a general 'right to know', as well as being a means of informing consumer choice. In theory, publication may help to promote public trust, support patient choice, and stimulate action to improve the quality of care whilst controlling costs. METHODS: Drawing on a literature review, this paper overviews the strategies employed in the UK and US to publish outcome data. The focus is on outcomes, and certain related process measures, that measure the performance of hospitals or surgeons. RESULTS AND CONCLUSIONS: Presenting the limited evidence that exists, we review the potential beneficial and harmful effects of publishing hospital outcome data. We also consider the risks of making incorrect inferences based on these data and the potential for dysfunctional consequences. Recognizing that the public largely mistrusts currently published health outcome data, we offer some recommendations for the future direction of strategies for publication.     

Continuous control of tracheal cuff pressure: an effective measure to prevent ventilator-associated pneumonia?

In a previous issue of Critical Care, Lorente and colleagues reported the results of a prospective observational study aiming at evaluating the effect of continuous control of cuff pressure (P_cuff ) on the incidence of ventilator-associated pneumonia (VAP). The results suggest a beneficial impact of this intervention on VAP prevention, which is in line with the results of a recent randomized controlled study. However, another randomized controlled study found no significant impact of continuous control of P_cuff on VAP incidence. Several differences regarding the device used to control P_cuff, study population, and design might explain the different reported results. Future randomized multicenter studies are needed to confirm the beneficial effect of continuous control of P_cuff on VAP incidence. Furthermore, the efficiency and cost-effectiveness of different available devices should be compared. Meanwhile, given the single-center design and the limitations of the available studies, no strong recommendation can be made regarding continuous control of P_cuff as a preventive measure of VAP.     

Diabetic nephropathy: how effective is treatment in clinical practice?

BACKGROUND: Diabetic nephropathy is the most common cause of end-stage renal failure in patients starting dialysis in the developed world. In clinical trials, interventions, particularly blood pressure control, have achieved major reductions in the rate of decline in renal function. AIM: To investigate whether results from clinical trials can be achieved in routine clinical practice. DESIGN: Observational study of 170 consecutive patients referred to a combined diabetic-renal clinic over a 10 year period. METHODS: We collected demographic and laboratory data from the electronic patient record. RESULTS: Median serum creatinine at referral was 170 micromol/l and was >350 micromol/l in 26% of patients. Mean blood pressure (BP) was 159/85. The publication of guidelines by the Scottish Intercollegiate Guidelines Network in 1997, recommending more active intervention and earlier referral, had no impact on referral BP and creatinine. In the 125 patients with at least 1 year follow-up, significant improvements in BP, albuminuria, HbA(1c) and serum cholesterol were seen. In the 63 patients followed up for 3 years (median creatinine 120 micromol/l), the median rate of decline in renal function slowed from 0.52 ml/min/month (first year) to 0.27 ml/min/month (third year) (p=0.003), nearly doubling the time to end-stage renal failure. DISCUSSION: Patients referred early to a combined diabetic-renal clinic benefited by slowing in the rate of decline of renal function. A challenging but achievable standard for audit would be to reduce the rate of progression to <0.25 ml/min/month in 70% of patients with diabetic nephropathy presenting with a serum creatinine <150 micromol/l.