Delirium prevalence and prevention in patients with acute brain injury: A prospective before-and-after intervention study

ObjectivesKnowledge regarding delirium prevention in patients with acute brain injury remains limited. We tested the hypothesis that an intervention bundle which targeted sedation, sleep, pain, and mobilisation would reduce delirium in patients with acute brain injury.DesignA prospective before-after intervention study: a five-month phase of standard care was followed by a six-month intervention phase.SettingThe neuro-intensive care unit, University Hospital of Copenhagen, Denmark.Main outcome measuresThe Intensive Care Delirium Screening Checklist was used to detect delirium. Primary outcome was delirium duration; secondary outcomes were delirium prevalence, ICU length of stay and one year mortality.ResultsForty-four patients were included during the standard care phase, and 50 during the intervention phase. Delirium was present in 90% of patients in the standard care group and 88% in the intervention group (p = 1.0), and time with delirium was 4 days vs 3.5 days (p = 0.26), respectively. Also, ICU length of stay (13 vs. 10.5 days (p = 0.4)) and the one year mortality (21% vs 12% (p = 0.38))) were similar between groups.ConclusionWe found a high prevalence of delirium in patients with acute brain injury. The intervention bundle did not significantly reduce prevalence or duration of delirium, ICU length of stay or one year mortality.     

EuroQol and survival prediction in terminal cancer patients: a multicenter prospective study in hospice-palliative care units

Goals of work Although the EuroQol (EQ-5D) is widely used for economic evaluation, it remains unclear whether it can be combined with medical data to predict survival in patients with terminal cancer.Patients and methods We carried out this prospective study on 142 terminal cancer patients in four hospice-palliative care units. Association was sought between survival time and a range of variables such as cancer site, performance, previous treatment, age, sex, pain, and EuroQol. The EQ-5D was transformed into the corresponding EQ-5D utility. For univariate analysis, we estimated differences in survival with the Gehan generalized Wilcoxon test. For those variables that were significant, we performed multivariate analysis using the Cox proportional hazard model.Main results Univariate analysis showed that sex, age, performance, previous use of chemotherapy, and the EQ-5D utility provided statistically significant prognostic survival information. The median survival time was 13.0 days for the group with an EQ-5D utility score lower than −0.5 and 21.0 days for the group with an EQ-5D utility score above −0.5. In multivariate analysis with the Cox proportional hazard model, an EQ-5D utility score ≤0.5 (RR 1.57, 95% confidence interval 1.06–2.33) was an independent negative predictor of survival.Conclusions The EQ-5D quality-of-life assessment tool might be useful for predicting survival time for terminal cancer patients.     

胰腺癌早期诊断及筛查中的问题及进展

胰腺癌是高死亡率的肿瘤,近年来中国胰腺癌发病率呈上升趋势,本文就胰腺癌的早期诊断文献分析发现,临床医生要高度警惕厌食、消瘦等不典型的临床症状,合理选择实验室和辅助检查以期望达到早期诊断。但至今胰腺癌的早期诊断仍然是个难题,因此积极探讨散发胰腺癌早期筛查策略是解决问题的关键;同时胰腺癌早期筛查,对于中国癌症的预防和控制的发展有重要意义。     

Lung cancer screening: promise and pitfalls

OBJECTIVES: To provide an overview of the status of lung cancer screening. DATA SOURCES: Published articles, book chapters, websites, and research studies. CONCLUSION: Screening with chest x-ray and sputum cytology has not been shown to be effective in reducing lung cancer mortality. Although screening with helical CT is currently under investigation in randomized clinical trials, observational studies have not shown evidence that it can detect lung cancer that is curable. IMPLICATIONS FOR NURSING PRACTICE: As health care educators and caregivers, nurses should be informed of the status and current controversies associated with lung cancer screening.     

上海市晚期癌症患者姑息照护质量及其影响因素的分析

目的 调查上海市晚期癌症患者的姑息照护质量及其影响因素.方法 采用一般资料调查表和姑息照护结局量表对300例晚期癌症患者进行调查.结果 晚期癌症患者姑息照护质量得分为（16.55±6.47）分;家庭人均月收入、经济压力、遵守医嘱程度、病程、患者是否知晓病情、心理护理、被照护医院等级是影响晚期癌症患者姑息照护质量的主要因素.结论 鉴别晚期癌症患者姑息照护质量的主要影响因素可帮助临床医护人员及相关政策部门制订针对性强的于预对策,以提高晚期癌症患者的照护质量水平,进而提升其生存质量.     

A prospective study of the incidence of falls in patients with advanced cancer

Context

The association between aging and falls risk, and the morbidity and mortality resulting from falls in older persons, is well documented. Results from a small number of studies of patients with cancer in inpatient settings suggest that patients with advanced cancer may be at high risk of falling. We present preliminary results pertaining to the incidence of falls in patients with advanced cancer from an ongoing study of risk factors for falls.

Objectives

To measure incidence of falls in patients with advanced cancer receiving palliative care, and to test the hypothesis that patients aged ≥65 years are at greater risk of falling than those aged <65 years.

Methods

Ambulant patients with cancer admitted to palliative care services were recruited. Demographic details were ascertained by patient interview and routine record review. Participants were followed-up by weekly telephone calls for up to six months.

Results

Follow-up has been completed for 119 patients; mean age was 66.91 (±12.86) years and 53.8% were male. Sixty-two participants (52.1%) fell during follow-up. The median time to fall for participants aged <65 and ≥65 years was 85 days (95% confidence interval [CI] 51.54-118.46) and 80 days (95% CI 44.07-115.93), respectively (χ² = 0.034, P = 0.85). The incidence density of falls was 2770 per 1000 person-years.

Conclusion

One in two patients with advanced cancer fell during follow-up of up to six months, regardless of age. There is a need to investigate the sequelae of falls in patients with cancer, to ascertain the risk factors, and in particular, the modifiable risk factors in this population.     

An exploration of the reliability and usability of two delirium screening tools in an Australian intensive care unit: A pilot study

ObjectiveTo compare the inter-rater reliability and usability of two delirium screening tools designed for use in ICU; the Confusion Assessment Method for ICU and the Intensive Care Delirium Screening Checklist.Research methodology/designA multiple methods design was used. The intra and inter rater reliability of the tools were evaluated using Kappa statistics and intra class correlation coefficients. Focus groups were conducted to explore ICU staff perceptions of the usability of the tools and feasibility of delirium screening.SettingPrivate hospital ICU, Melbourne Australia.Results66 patients were assessed for delirium; median age of 71 (IQR 62–75) years. Seventeen patients (26%) scored positive for delirium using the screening tools and 11 (17%) had delirium confirmed on the medical ICU discharge summary. Ten nurse assessors performed 99 paired assessments using the two tools sequentially, demonstrating the intra and inter-rater agreement and reliability of the tools was moderate to high.Four focus groups were conducted with 16 participants. Content analysis identified three themes: (i) current recognition of delirium, (ii) benefits of delirium screening, and (iii) future directions for delirium management. Time and medical staff indifference were identified as barriers to screening, facilitators were education and having a follow-up plan.ConclusionThis study found that the reliability and usability of the CAM-ICU and ICDSC were acceptable and that using structured delirium screening was feasible as part of a wider, multi-disciplinary delirium management plan.     

血清胃功能检测在早期胃癌筛查中的临床应用研究

目的探讨血清胃功能检测在早期胃癌筛查中的临床应用价值。方法选取该院2015年12月至2016年12月收治的42例胃癌患者、75例胃部良性疾病患者、44例健康体检者为研究对象,所有被研究对象均进行胃镜检查,同时行镜下活检术,并按要求抽血化验,检测胃功能相关指标:胃蛋白酶原Ⅰ(PGⅠ)、胃蛋白酶原Ⅱ(PGⅡ)、PGⅠ/PGⅡ、胃泌素17(G17)及幽门螺杆菌(HP)。分析4组研究对象的血清胃功能指标的情况。结果 PGⅠ,PGⅠ/PGⅡ的表达,从低到高,分别是胃癌组、萎缩性胃炎组、胃溃疡组、浅表性胃炎组和对照组,且两两相比,差异均有统计学意义(P0.05);对照组的G17低于胃溃疡组、萎缩性胃炎组、胃癌组,胃溃疡组的G17低于胃癌组,差异有统计学意义(P0.05)。对照组的HP阳性率低于浅表性胃炎组,浅表性胃炎组低于胃溃疡组,胃溃疡组低于萎缩性胃炎组,萎缩性胃炎组低于胃癌组,差异均有统计学意义(P0.05)。结论血清胃功能检测能较好地区分胃部良性病变与恶性病变,可作为早期筛查的重要指标,且易于接受、成本低,对于检测结果阳性者,应进行胃镜下检查,以提高早期诊断率。     

渭南地区先天性甲状腺功能减低症新生儿筛查和早期诊断

目的：总结与分析渭南地区先天性甲状腺功能减低症（C H ）新生儿筛查结果与早期诊断特点。方法回顾性分析2010年8月至2013年10月于渭南市新生儿疾病筛查中心进行新生儿C H筛查与诊断的资料。结果共筛查新生儿标本71084例,确诊C H患儿45例,发病率为0．633‰,患儿的临床表现以病理性黄疸为主（51．11％）,促甲状腺激素（TSH）≥32 mIU/L患儿占62．22％;经Pearson相关性分析后,四碘甲状腺原氨酸（T4）、游离甲状腺素T4（FT4）与CH患儿婴幼儿智力发育测试总分、精细运动以及适应性等均呈正相关关系（P＜0．05）。结论渭南地区新生儿先天性甲状腺功能减低症的发病率较高,开展新生儿疾病筛查工作,有利于该类患儿的早期诊断与治疗,值得推广与完善。     

New molecular diagnosis and screening methods for colorectal cancer using fecal protein,DNA and RNA

Several screening methods for reducing the mortality rate of colorectal cancer (CRC) have been reported in recent decades. Fecal occult blood tests (FOBTs) are widely used for CRC screening and immunochemical FOBTs perform better than guaiac FOBTs; however, the sensitivity and specificity of immunochemical FOBTs remain unsatisfactory. To resolve this problem, novel fecal molecular methods based on fecal protein, DNA and RNA analyses have been developed. Regarding fecal proteins, several marker proteins indicating intestinal bleeding and cancer cell-specific proteins have been investigated. Regarding fecal DNA, numerous gene mutation and gene methylation analyses have been reported. Consequently, fecal DNA analysis was recommended as a CRC screening method in 2008. In addition, gene expression analyses of CRC-specific genes and miRNAs in fecal RNA have been investigated over the last decade. This review article summarizes molecular methods using fecal samples for CRC screening, focusing on reports within the last 5 years.     

Association between self-reported sleep disturbance and other symptoms in patients with advanced cancer

ContextSleep disturbance (SD) is a significant source of distress for patients with cancer. Studies of patients with advanced cancer receiving palliative care to identify symptoms associated with the severity of SD are limited.ObjectivesIn this study, we sought to identify the symptoms measured by the Edmonton Symptom Assessment Scale (ESAS) that are associated with SD, as measured by the Pittsburgh Sleep Quality Index (PSQI). Secondary aims of the study were to determine the association between occurrences of SD with occurrences of other symptoms and screening performance of the ESAS-Sleep item against the PSQI.MethodsWe reviewed the completed ESAS and PSQI assessments of 101 patients with advanced cancer who were receiving palliative care and had been admitted to prospective clinical trials previously initiated by us. Patients with a PSQI score of ≥5 were considered to have an SD. The frequency and severity of the ESAS symptoms items, their correlation with each other, the PSQI score, and the screening performance of the ESAS-Sleep item were calculated.ResultsThe median age of patients was 60 years. Most were white non-Hispanic (73%), had lung or breast cancer (41%), and were diagnosed with SD (85%). The PSQI score was correlated with the ESAS items of pain (r = 0.27, P = 0.006), dyspnea (r = 0.25, P < 0.001), well-being (r = 0.35, P < 0.0001), and sleep (r = 0.44, P < 0.0001). Compared with patients without SD, those with SD were more likely to report pain (P = 0.0132), depression (P = 0.019), anxiety (P = 0.01), and a poorer sense of well-being (P = 0.035). An ESAS-Sleep item cutoff score of ≥3 (of 10) resulted in a sensitivity of 74% and a specificity of 73%.ConclusionSD is associated with increased frequency of pain, depression, anxiety, and a worse sense of well-being. These four symptoms should be assessed in all patients with advanced cancer with a complaint of SD. The ideal cutoff point of the ESAS-Sleep item for screening for SD is a score of ≥3. More research is needed to better characterize this frequent and distressing syndrome.     

Demographic and clinical predictors of spirituality in advanced cancer patients: a randomized control study

Aim.  To study the influence of cancer patients’ sociodemographic and clinical characteristics in their spiritual beliefs and attitudes. Background.  Patients’ sociodemographic and clinical characteristics may have an important role in their spirituality. Failure to control these factors can lead to a false estimation on patients’ spiritual beliefs. Previous studies have found that age, gender and health status associate with spiritual attitudes and beliefs. Design.  Survey. Methods.  The Spiritual Involvement and Beliefs Scale was administered to 82 cancer patients. Demographic characteristics, disease status and treatment regimen were recorded. Results.  Among the most significant correlations were those between gender and all the subscales, cancer diagnosis, existential/meditative subscale, radiotherapy treatment and external/ritual, internal/fluid and existential meditative. In the prediction of spirituality, the contribution of gender, age, years of education, performance status and radiotherapy is high. Conclusion.  Acknowledging the specific patients’ demographic and medical characteristics, such as female gender, old age, years of education, performance status and radiotherapy treatment, contributes to the prediction of patients’ spiritual beliefs and attitudes. Relevance to clinical practice.  Addressing spiritual needs in palliative care among the dying needs to be a priority and could be a crucial aspect of psychological functioning, especially when considering certain demographic and clinical characteristics.     

Mindfulness-Based stress reduction in early palliative care for people with metastatic cancer: A mixed-method study

ObjectivesTo explore the impact of a Mindfulness-Based Stress Reduction (MBSR) intervention for people with metastatic cancer integrated in Early Palliative Care (EPC). Design: Mixed-method study.Settings/LocationEPC Service integrated with Oncology Unit, Carpi General Hospital, Italy from January to October 2017. The MBSR intervention took place inside the hospital.SubjectsStudy participation was offered to 25 consecutive people referred to the EPC service. Inclusion criteria: people with metastatic cancer between 18 and 75 years old; informed consent. Exclusion criteria: Performance Status <60% according to Karnofsky scale; active psychiatric disorder. 20 patients were included in the study.InterventionThe adapted program consists of 8 meetings for 2.5 h once a week, a 4.5 h session between the 6th and 7th weeks and 0.5 h home practice daily. The following mindfulness practices were included during the training: formal sitting meditation, body scan, light yoga, walking meditation, and Aikido exercises. Participants were provided with materials for home practice. A qualified MBSR instructor conducted the program. Sessions were attended by a clinical psychologist and a physician trained in meditation, together with the palliative nurse as facilitators.Outcome MeasuresFeasibility and acceptability were assessed on 16 participants. In addition, pre-post measures of cancer pain and mood state were collected. Semi-structured, in-depth interviews were conducted on a subset of 8 participants at the end of the study and analysed using the Interpretative-Phenomenological approach.ResultsMBSR attendance to meetings and adherence to home practice were 75%. MBSR intervention helped participants to develop an accepting attitude in respect to metastatic cancer disease helping them to face anxiety and cancer pain. MBSR improves self-regulation of mood state engendering feelings of compassion MBSR program supports participants in questioning and reconnecting with their values and spiritual beliefs.ConclusionsA Mindfulness intervention integrated into EPC setting is feasible, well accepted and could help metastatic cancer patients to control cancer pain together with an opportunity of emotional and spiritual relief.     

尊严疗法在晚期癌症患者中应用的研究进展

随着医学技术的发展,癌症患者的生命终末期可能延长,但并未明显成功提高癌症的治愈率[1]。晚期癌症患者生命的延长,患者身体机能日益衰退,生存质量日益下降,对照顾者的生活依赖程度愈加强烈。同时患者的隐私不受保护,自我价值逐渐丧失,从而使患者的自尊心下降、尊严受损[2]。研究报道[3],我国晚期癌症患者的尊严丧失率53.3%~63.3%,较CHOCHINOV等[4]报道的5.3%~7.5%高。尊严作为安宁疗护的哲学基础,是患者心理健康的重要组成部分[5],但我国安宁疗护重在改善患者的躯体症状和疼痛控制,对心理支持方面相对欠缺[6]。CHOCHINOV等[7]于2005年在尊严模型为理论框架的基础上提出尊严疗法。尊严疗法作为安宁疗护中一种较新颖的心理干预方法,在改善尊严感、心理健康和整体生化质量方面显示出较好的效果[8]。国外对尊严疗法的研究已较成熟,但在我国还处于初级探索阶段,因此本研究对尊严疗法展开综述,以期为临床护理提供参考,现报道如下。     

Delirium in patients admitted to a step-down unit: Analysis of incidence and risk factors

Background

Delirium is a rather common complication among patients admitted in intensive care units (ICUs), and rather than a single entity, it can be considered a spectrum of diseases where, besides overt cases, there are also many subsyndromal forms. Although there are many data about ICU delirium, there are few data concerning this complication in patients transferred from the ICU to a step-down unit (SDU) once clinically stable.

Objectives

With the present study, we wanted to assess the incidence of and risk factors for delirium and subsyndromal forms and their impact on clinical outcome in a group of patients transferred from an ICU to an SDU.

Methods

All patients transferred from an ICU to our SDU over a 2-year period were screened for delirium and subsyndromal delirious forms using the Intensive Care Delirium Screening Checklist, a simple tool already validated in the ICU. The following data were also recorded: demographic data, severity score (SAPS II), reason for admission to the SDU, length of stay, death rate, use of sedatives, impact of delirium on weaning from mechanical ventilation (MV).

Results

Among the 234 patients, the incidence of delirium and subsyndromal forms was 7.6% and 20%, respectively. Subsyndromal forms diagnosed at admission represented a risk factor for the subsequent development of delirium (odds ratio [OR], P < .0001). A previous episode of brain failure during ICU stay and older age were risks factors for the development of subsyndromal forms, whereas not needing MV was a protective factor. Delirium significantly prolonged the stay in the SDU but did not influence survival and the process of weaning from MV. Overall, the percentage of patients with an abnormal Intensive Care Delirium Screening Checklist score at discharge (5%) was reduced compared with that recorded at admission (18%).

Conclusions

Delirium may still occur after discharge from an ICU in patients who are transferred to an SDU. The strategy of care adopted in the SDU seems to positively affect the recovery from a delirious state. Patients with subsyndromal forms should be promptly recognized and treated because of the risk of developing delirium. Weaning from MV is not hindered by delirium.