Family Economic Hardship and Progression of Poor Mental Health in Middle‐Aged Husbands and Wives

Using prospective data from 370 middle‐aged husbands and wives during a 12‐year period, we investigated the intra‐individual and dyadic influence of family economic hardship on the levels of depressive symptoms of husbands and wives over their middle years. The results suggest that family economic hardship during the early middle years contributes to a subsequent increase in depressive symptoms of husbands and wives. Consistent with stress‐process theory, economic hardship influences depressive symptoms directly and indirectly through its influence on self‐esteem. The results also provided evidence for the scar hypothesis, which suggests that depression predicts subsequent level of self‐esteem and forms a reciprocal process between depressive symptoms and self‐esteem over time. In sum, for both husbands and wives, our findings showed that depressive symptoms progress over the middle years through a self‐perpetuating reciprocal process between self‐esteem and depression initiated by early family economic hardship and through cross‐spouse influences involving self‐esteem and depressive symptoms.     

Creation of Minimum Standard Tool for Palliative Care in India and Self-evaluation of Palliative Care Programs Using It

Background:

It is important to ensure that minimum standards for palliative care based on available resources are clearly defined and achieved.

Aims:

(1) Creation of minimum National Standards for Palliative Care for India. (2) Development of a tool for self-evaluation of palliative care organizations. (3) Evaluation of the tool in India. In 2006, Pallium India assembled a working group at the national level to develop minimum standards. The standards were to be evaluated by palliative care services in the country.

Materials and Methods:

The working group prepared a “standards” document, which had two parts – the first composed of eight “essential” components and the second, 22 “desirable” components. The working group sent the document to 86 hospice and palliative care providers nationwide, requesting them to self-evaluate their palliative care services based on the standards document, on a modified Likert scale.

Results:

Forty-nine (57%) palliative care organizations responded, and their self-evaluation of services based on the standards tool was analyzed. The majority of the palliative care providers met most of the standards identified as essential by the working group. A variable percentage of organizations had satisfied the desirable components of the standards.

Conclusions:

We demonstrated that the “standards tool” could be applied effectively in practice for self-evaluation of quality of palliative care services.     

Pulmonary acute respiratory distress syndrome: positive end-expiratory pressure titration needs stress index

Background

The heterogeneity of lung injury in pulmonary acute respiratory distress syndrome (ARDS) may have contributed to the greater response of hyperinflated area with positive end-expiratory pressure (PEEP). PEEP titrated by stress index can reduce the risk of alveolar hyperinflation in patients with pulmonary ARDS. The authors sought to investigate the effects of PEEP titrated by stress index on lung recruitment and protection after recruitment maneuver (RM) in pulmonary ARDS patients.

Materials and methods

Thirty patients with pulmonary ARDS were enrolled. After RM, PEEP was randomly set according to stress index, oxygenation, static pulmonary compliance (Cst), or lower inflection point (LIP) + 2 cmH₂O strategies. Recruitment volume, gas exchange, respiratory mechanics, and hemodynamic parameters were collected.

Results

PEEP titrated by stress index (15.1 ± 1.8 cmH₂O) was similar to the levels titrated by oxygenation (14.5 ± 2.9 cmH₂O), higher than that titrated by Cst (11.3 ± 2.5 cmH₂O) and LIP (12.9 ± 1.6 cmH₂O) (P < 0.05). Compared with baseline, PaO₂/FiO₂ and recruitment volume were significantly improved after PEEP titration with the four strategies (P < 0.05). PaO₂/FiO₂ and recruitment volume were similar when using PEEP titrated by stress index and oxygenation but higher than that titrated by Cst and LIP. Compared with baseline, lung compliance increased significantly when PEEP determined by Cst, but there was no difference of Cst in these four strategies. There was no influence of PEEP titration with the four strategies on hemodynamic parameters.

Conclusions

PEEP titration by stress index might be more beneficial for pulmonary ARDS patients after RM.     

Cardiac arrest patients have an impaired immune response,which is not influenced by induced hypothermia

Introduction

Induced hypothermia is increasingly applied as a therapeutic intervention in ICUs. One of the underlying mechanisms of the beneficial effects of hypothermia is proposed to be reduction of the inflammatory response. However, a fear of reducing the inflammatory response is an increased infection risk. Therefore, we studied the effect of induced hypothermia on immune response after cardiac arrest.

Methods

A prospective observational cohort study in a mixed surgical-medical ICU. Patients admitted at the ICU after surviving cardiac arrest were included and during 24 hours body temperature was strictly regulated at 33°C or 36°C. Blood was drawn at three time points: after reaching target temperature, at the end of the target temperature protocol and after rewarming to 37°C. Plasma cytokine levels and response of blood leucocytes to stimulation with toll-like receptor (TLR) ligands lipopolysaccharide (LPS) from Gram-negative bacteria and lipoteicoic acid (LTA) from Gram-positive bacteria were measured. Also, monocyte HLA-DR expression was determined.

Results

In total, 20 patients were enrolled in the study. Compared to healthy controls, cardiac arrest patients kept at 36°C (n = 9) had increased plasma cytokines levels, which was not apparent in patients kept at 33°C (n = 11). Immune response to TLR ligands in patients after cardiac arrest was generally reduced and associated with lower HLA-DR expression. Patients kept at 33°C had preserved ability of immune cells to respond to LPS and LTA compared to patients kept at 36°C. These differences disappeared over time. HLA-DR expression did not differ between 33°C and 36°C.

Conclusions

Patients after cardiac arrest have a modest systemic inflammatory response compared to healthy controls, associated with lower HLA-DR expression and attenuated immune response to Gram-negative and Gram-positive antigens, the latter indicative of an impaired immune response to bacteria. Patients with a body temperature of 33°C did not differ from patients with a body temperature of 36°C, suggesting induced hypothermia does not affect immune response in patients with cardiac arrest.

Trial registration

ClinicalTrials.gov {"type":"clinical-trial","attrs":{"text":"NCT01020916","term_id":"NCT01020916"}}NCT01020916, registered 25 November 2009