What can be learned from crude intensive care unit mortality? Methodological implications

PurposeDemonstrate the practical range of information that can be obtained about ICU mortality/survival from limited administrative data.Materials and MethodsProspectively collected administrative data (length-of stay, survival/mortality, referring service) from a university medical center’s General ICU was subjected to retrospective analysis to demonstrate ways of presenting and analyzing mortality/survival information.Results16,022 patients (87,624 patient-days) admitted over 23 years were included. 28% of all deaths occurred on ICU day 1. When considering all admissions, mortality on ICU day 1 was 2%, while the overall crude mortality rate revealed that the chances of dying during an ICU stay was 8.6%. Mortality rates in the overall population steadily increased over ICU days 1–5, plateaued during days 6 to 50, decreasing after day 50. The general surgery subgroup had a similar pattern. This contrasted with the internal medicine subgroup where mortality steadily increased over the initial 14 ICU days then plateauing at rates of 40–50%.InterpretationSimple calculations using the few variables found in administrative database enhanced information provided by the crude mortality rate and demonstrated that temporal patterns of mortality change as stay lengthens. These results highlight the limitations of just using overall crude mortality rates.     

What can be learned from Cochrane systematic reviews of massage that can guide future research?

Massage is an increasingly popular complementary and alternative medicine modality used for a variety of conditions. Cochrane massage reviews are a gold mine of observations regarding the methodologic issues inherent in massage trials and have raised important questions, which can be used to guide future research. Among the research issues raised in Cochrane reviews are questions about combination trials, practitioner qualifications, adequate doses, and appropriate control groups. This article summarizes these key research issues.     

Establishing mild, moderate, and severe scores for cancer-related symptoms: how consistent and clinically meaningful are interference-based severity cut-points?

Methods are presented to separate 16 frequently occurring cancer symptoms measured on 10-point symptom severity rating scales into mild, moderate, and severe categories that are clinically interpretable and significant for use in oncology practice settings. At their initial intervention contact, 588 solid tumor cancer patients undergoing chemotherapy reported severity on a standard 11-point rating scale for 16 symptoms. All reporting a one or higher were asked to rate on an 11-point scale how much the symptom interfered with enjoyment of life, relationship with others, general daily activities, and emotions. Factor analysis revealed that these items tapped into the same dimension, and the items were summed to form an interference scale. Cut-points for mild, moderate, and severe categories of symptom severity were defined by comparing the differences in interference scores corresponding to each successive increases in severity for each symptom. The cut-points differed among symptoms. Pain, fatigue, weakness, cough, difficulty remembering, and depression had lower cut-points for each category compared to other symptoms. Cut-points for each symptom were not related to site or stage of cancer, age, or gender but were associated with a global depression measure. Cut-points were related to limitations in physical function, suggesting differences in the quality of patients' lives. The resulting cut-points summarize severity ratings into clinically significant and useful categories that clinicians can use to assess symptoms in their practices.     

Child-to-Child Unintentional Injury and Death from Firearms in the United States: What can be Done?

Children are unintentionally killing and injuring other children at an alarming rate in the United States owing to the accessibility of firearms. Firearms are found in 33-40% of American households with children. Many of those firearms are stored in an unsafe manner, loaded and unlocked, leaving children vulnerable to injury. Health care professionals dedicated to the well-being of the pediatric population must take an active role in protecting our nation's children from unnecessary injury and death owing to the unsafe storage of firearms.     

What is empathy, and can empathy be taught?

Empathy is a commonly used, but poorly understood, concept. It is often confused with related concepts such as sympathy, pity, identification, and self-transposal. The purposes of this article are to clearly distinguish empathy from related terms and to suggest that the act of empathizing cannot be taught. According to Edith Stein, a German phenomenologist, empathy can be facilitated. It also can be interrupted and blocked, but it cannot be forced to occur. What makes empathy unique, according to Stein, is that it happens to us; it is indirectly given to us, "nonprimordially." When empathy occurs, we find ourselves experiencing it, rather than directly causing it to happen. This is the characteristic that makes the act of empathy unteachable. Instead, promoting attitudes and behaviors such as self-awareness, nonjudgmental positive regard for others, good listening skills, and self-confidence are suggested as important in the development of clinicians who will demonstrate an empathic willingness.     

Can classical acupuncture points and trigger points be compared in the treatment of pain disorders? Birch's analysis revisited

BACKGROUND: A 1977 study by Melzack et al. reported 100% anatomic and 71% clinical pain correspondences of myofascial trigger points and classical acupuncture points in the treatment of pain disorders. A reanalysis of this study's data using different acupuncture resources by Birch a quarter century later concluded that correlating trigger points to classical acupuncture points was not conceptually possible and that the only class of acupuncture points that could were the a shi points. Moreover, Birch concluded that no more than 40% of the acupuncture points examined by Melzack et al. correlated clinically for the treatment of pain (correlation was more like 18%-19%). OBJECTIVE: To examine Birch's claims that myofascial trigger points cannot conceptually be compared to classical acupuncture points and that most (at least 60%) of the classical acupuncture points examined by the study of Melzack et al. are not recommended for treating pain conditions, negating their findings of a 71% clinical pain correspondence of trigger points and acupuncture points. METHODS: Acupuncture references and literature were reviewed to examine the validity of the Birch study findings. RESULTS: Acupuncture references support the conceptual comparison of trigger points to classical acupuncture points in the treatment of pain disorders, and their clinical correspondence in this regard is likely 95% or higher. CONCLUSIONS: Although separated by 2000 years temporally, the acupuncture and myofascial pain traditions have fundamental clinical similarities in the treatment of pain disorders. Myofascial pain data and research may help elucidate the mechanisms of acupuncture's effects.     

The Canadian Transfusion Surveillance System: What is it and how can the data be used?

Hemovigilance systems are important programs for: monitoring trends of known risks; evaluating effectiveness of steps taken to reduce risks; providing data to support recommendations for change and guideline development; and contributing overall to the safety of transfusion. The Transfusion Transmitted Injury Surveillance System is the hemovigilance system implemented in Canada. It evolved in 1999 as a pilot program and expanded across Canada in 2005. Each province reports their adverse reactions to the transfusion of blood products and plasma proteins to the Public Health Agency of Canada (PHAC) at predetermined intervals. PHAC reconciles, summarizes the data and publishes a report approximately 2 years after the data are collected. This is considered a passive reporting system but in spite of the delays, the program provides useful information to address a variety of questions. Examples include: assessing the impact of a provincial patient transfusion history registry in Québec on reporting of hemolytic transfusion reactions; identifying trends of bacterial contamination of blood products and assessing the impact of interventions on these events; and the impact of male-only plasma on the incidence of Transfusion Related Acute Lung Injury. Although hemovigilance data has been successfully used to improve blood safety, we must continue to explore ways to utilize such data to improve and implement safe transfusion practices.     

The effects and treatment of community violence in children and adolescents: what should be done?

The amount of community violence that children and adolescents are exposed to is unsettling. Intensifying the issue, the amount of community violence that is wit-nessed or experienced directly by children and adolescents is increasing with time. It has been documented that children and adolescents who are exposed to community violence display a wide array of psychological symptoms, ranging from depression and anxiety to antisocial and suicidal behaviors. Many variables have been studied in an attempt to determine correlates, moderators, and mediators of exposure to community violence. Furthermore, many intervention strategies have been developed from the discovery of relationships among these variables. Despite these efforts, many children continue to suffer from the negative effects of exposure to community violence. The purpose of this article is to encourage mental health professionals to mobilize their efforts to help children, adolescents, and their families cope with the effects of community violence.     

Making pain assessment more accessible to children and parents: can greater involvement improve the quality of care?

OBJECTIVES: To determine whether nursing and parental pain assessment documentation and analgesia administration increased with the use of a temporary tattoo of a pain intensity scale (TTPS) compared with a paper version of the pain scale (PPS). To document any adverse skin reactions from the use of the TTPS and to assess the feasibility and acceptability of the PPS and TTPS for use as postoperative pain assessment tools in the home and clinical setting. METHODS: Two pilot randomized controlled trials were conducted to test the TTPS intervention and the PPS control condition in children aged 6 to 12 years, after surgery. Trial 1 involved children admitted to hospital for planned inpatient surgery (n=86). Trial 2 involved children discharged home following day case surgery (n=25). RESULTS: The TTPS was well accepted and there were no adverse effects. Our hypothesis that the TTPS would increase documentation of pain assessment or analgesic administration was not supported. However, a number of confounding factors may explain the findings. Children in both trials indicated greater overall satisfaction with the TTPS and responses from both parents and children suggested some aspects of the quality of the pain management experience were enhanced with use of the TTPS in both trials. DISCUSSION: The TTPS is a new method to engage children in pain assessment, which may have positive effects on the quality of postoperative pain assessment and management in hospital and home settings. Larger trials are needed to determine the effectiveness of the TTPS across all pediatric settings and for children with nonsurgical and also surgical pain. The findings from these pilot trials provide useful information for design and power estimation for further research in inpatient and home settings.