Moral distress among healthcare professionals working in intensive care units in Spain / Desasosiego moral entre los profesionales sanitarios que trabajan en unidades de cuidados intensivos en España

Objective To assess moral distress (MD) among Spanish critical care healthcare professionals (HCPs). Design Cross-sectional, prospective study. Setting ICUs in Spain. Participants HCPs currently working in Spanish ICUs. Interventions A 55-item questionnaire was electronically distributed. Main variables The questionnaire included work-related and socio-demographic characteristics, the Spanish version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA), and the Hospital Ethical Climate Survey (HECS). Results In total, 1065 intensive care providers completed the questionnaire. Three out of four validity hypotheses were supported. MD was significantly higher for physicians (80, IQR 40–135) than for nurses (61, IQR 35–133, p=0.026). MD was significantly higher for those clinicians considering leaving their position (78, IQR 46–163 vs. 61, IQR 32–117; p<0.001). The MMD-HP-SPA was inversely correlated with the HECS (r=−0.277, p<0.001). An exploratory factor analysis revealed a four-factor structure, evidencing the patient, team, and system levels of MD. Conclusions In the study sample, Spanish intensivists report higher MD than nurses. Strategies to improve ICU ethical climate and to correct other related factors in order to mitigate MD at a patient, team, and system level should be implemented. Both groups of HCPs manifest a relevant intention to leave their position due to MD. Further studies are needed to determine the extent to which MD influences their desire to leave the job (AU)

Objetivo Evaluar el desasosiego moral (DM) entre los profesionales sanitarios que trabajan en UCI en España. Diseño Estudio prospectivo transversal. Ámbito UCI en España. Participantes Profesionales sanitarios que actualmente trabajan en UCI españolas. Intervenciones Se distribuyó electrónicamente un cuestionario de 55 ítems. Variables principales El cuestionario incluía características sociodemográficas y laborales, la versión en español de la Medida de desasosiego moral para profesionales sanitarios (MMD-HP-SPA) y la Encuesta de clima ético hospitalario (HECS). Resultados En total 1.065 profesionales sanitarios de cuidados intensivos completaron el cuestionario. Tres de 4 hipótesis de validez fueron apoyadas. El DM fue significativamente mayor entre los médicos (80, IQR 40-135) que entre las enfermeras (61, IQR 35-133, p=0,026). El DM fue significativamente más alto para aquellos médicos que estaban considerando dejar su puesto de trabajo (78, IQR 46-163 vs. 61, IQR 32-117; p<0,001). El MMD-HP-SPA se correlacionó inversamente con el HECS (r=–0,277, p<0,001). Un análisis factorial exploratorio reveló una estructura de 4 factores, evidenciando los niveles de paciente, equipo y sistema del DM. Conclusiones En este estudio los intensivistas refirieron niveles de DM más altos que las enfermeras. Se deben implementar estrategias para mejorar el clima ético en las UCI y corregir otros factores relacionados con el fin de mitigar el DM en lo que atañe al paciente, al equipo y al sistema. Ambos grupos de profesionales manifestaron una intención relevante de abandonar su puesto de trabajo debido al DM. Se necesitan más estudios para determinar en qué medida el DM influye sobre su deseo de abandonar su puesto de trabajo (AU)

Moral distress among healthcare professionals working in intensive care units in Spain.

OBJECTIVE: To assess moral distress (MD) among Spanish critical care healthcare professionals (HCPs). DESIGN: Cross-sectional, prospective study. SETTING: ICUs in Spain. PARTICIPANTS: HCPs currently working in Spanish ICUs. INTERVENTIONS: A 55-item questionnaire was electronically distributed. MAIN VARIABLES: The questionnaire included work-related and socio-demographic characteristics, the Spanish version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA), and the Hospital Ethical Climate Survey (HECS). RESULTS: In total, 1065 intensive care providers completed the questionnaire. Three out of four validity hypotheses were supported. MD was significantly higher for physicians (80, IQR 40-135) than for nurses (61, IQR 35-133, p=0.026). MD was significantly higher for those clinicians considering leaving their position (78, IQR 46-163 vs. 61, IQR 32-117; p<0.001). The MMD-HP-SPA was inversely correlated with the HECS (r=-0.277, p<0.001). An exploratory factor analysis revealed a four-factor structure, evidencing the patient, team, and system levels of MD. CONCLUSIONS: In the study sample, Spanish intensivists report higher MD than nurses. Strategies to improve ICU ethical climate and to correct other related factors in order to mitigate MD at a patient, team, and system level should be implemented. Both groups of HCPs manifest a relevant intention to leave their position due to MD. Further studies are needed to determine the extent to which MD influences their desire to leave the job.

Moral distress among healthcare professionals working in intensive care units in Spain.

OBJECTIVE: To assess moral distress (MD) among Spanish critical care healthcare professionals (HCPs). DESIGN: Cross-sectional, prospective study. SETTING: ICUs in Spain. PARTICIPANTS: HCPs currently working in Spanish ICUs. INTERVENTIONS: A 55-item questionnaire was electronically distributed. MAIN VARIABLES: The questionnaire included work-related and socio-demographic characteristics, the Spanish version of the Measure of Moral Distress for Health Care Professionals (MMD-HP-SPA), and the Hospital Ethical Climate Survey (HECS). RESULTS: In total, 1065 intensive care providers completed the questionnaire. Three out of four validity hypotheses were supported. MD was significantly higher for physicians (80, IQR 40-135) than for nurses (61, IQR 35-133, p=0.026). MD was significantly higher for those clinicians considering leaving their position (78, IQR 46-163 vs. 61, IQR 32-117; p<0.001). The MMD-HP-SPA was inversely correlated with the HECS (r=-0.277, p<0.001). An exploratory factor analysis revealed a four-factor structure, evidencing the patient, team, and system levels of MD. CONCLUSIONS: In the study sample, Spanish intensivists report higher MD than nurses. Strategies to improve ICU ethical climate and to correct other related factors in order to mitigate MD at a patient, team, and system level should be implemented. Both groups of HCPs manifest a relevant intention to leave their position due to MD. Further studies are needed to determine the extent to which MD influences their desire to leave the job.

[Profile of the Family Doctor who gains access to positions with teaching tutorship of Family and Community Medicine by means of relocation examination in Galicia]. / Perfil del médico de familia que accede a plazas con tutoría docente de Medicina Familiar y Comunitaria mediante concurso de traslados en Galicia.

OBJECTIVE: To analyse the profile of Family Doctors who gain access to positions, both to the general quota, as well those reserved for teaching tutors of Family and Community Medicine, by means of a relocation competition. MATERIAL AND METHODS: A descriptive observational study was conducted in which 2 comparison groups were established: A Non-Teaching group that did not include Family Doctors who did not request or gain access to tutor positions, and a Teaching group with those that gained access to positions reserved for tutors. The information was obtained from the marks of the relocation competition carried out in Galicia in 2018. A total of 426 General Practitioners that entered the examination were included, of which 301 were female (70.7%) and 125 (29.3%) males. The variables were the obtaining of a position reserved for tutor, gender, and the merits considered in the competition: professional experience, training, scientific publications, and Galician language. The non-parametric statistics tests of Mann-Whitney and Kruskal-Wallis were used, after checking for non-normal distribution. RESULTS: Statistically significant differences were found in the distribution by gender in favour of males in the Teaching group compared to the Non-Teaching group (P<.01). The Teaching group obtained better results in training and publications. The females obtained statistically significant results in their favour in the training variable, and the males in experience. CONCLUSIONS: For the choice of teaching places in relocation interviews and examinations, publications and training had an important weighting; but, taking the gender perspective into account, a lower percentage of women had gained access to teaching positions due to having lower score in the experience category.

[Therapeutic Aggressiveness and Liquid Oncology]. / La Agresividad Terapéutica y la Oncología Líquida.

Aggressiveness criteria proposed in the scientific literature a decade ago provide a quality judgment and are a reference in the care of patients with advanced cancer, but their use is not generalized in the evaluation of Oncology Services. In this paper we analyze the therapeutic aggressiveness, according to standard criteria, in 1.001 patients with advanced cancer who died in our Institution between 2010 and 2013. The results seem to show that aggressiveness at the end of life is present more frequently than experts recommend. About 25% of patients fulfill at least one criterion of aggressiveness. This result could be explained by a liquid Oncology which does not prioritize the patient as a moral subject in the clinical appointment. Medical care is oriented to necessities and must be articulated in a model focused on dignity and communication. Its implementation through Advanced Care Planning, consideration of patient's values and preferences, and Limitation of therapeutic effort are ways to reduce aggressiveness and improve clinical practice at the end of life. We need to encourage synergic and proactive attitudes, adding the best of cancer research with the best clinical care for the benefit of human being, moral subject and main goal of Medicine.

Bioavailability of vitamin D2 from enriched mushrooms in prediabetic adults: a randomized controlled trial.

BACKGROUND/OBJECTIVES: Based on the growing evidence of risk reduction from fresh fruit and vegetable consumption and an inverse relationship between serum 25-hydroxyvitamin D (25OHD) and the risk of type 2 diabetes (T2D), we determined the benefits of regularly consuming vitamin D-enriched mushrooms in a prediabetic cohort. Exposing edible mushrooms to ultraviolet B (UVB) light increases vitamin D2 (D2) and raises serum 25OHD2 in healthy young adults; however, their benefit to deficient prediabetics and glucose metabolism remains untested. SUBJECTS/METHODS: Forty-three prediabetic, D-deficient adults (25OHD≤20 ng/ml), BMI>25 were randomized to four groups consuming daily entrées containing 100 g fresh sliced cooked mushrooms prepared by a chef for 16 weeks. Two groups were fed UVB-treated mushrooms initially containing: 600 IU D2 or 4000 IU D2; each one also received one capsule of placebo daily. Two control groups were fed untreated mushrooms and D3 dietary supplements at two label doses: 600 IU D3 and 4000 IU D3. D2 and D3 content were analyzed in mushrooms, before and after cooking and in over-the-counter supplements. RESULTS: After 16 weeks, both D2-UVB-mushroom entrée doses, which were significantly lower after cooking, produced modest or no increases in 25OHD2 or total 25OHD relative to the positive control subjects who actually consumed about 1242 and 7320 IU per day of D3 (higher than stated on the label). CONCLUSIONS: Unanticipated D2 cooking loss from fresh UVB mushrooms and probable low absorption and/or hydroxylation may explain the smaller increase in 25OHD2 in our prediabetic overweight/obese cohort compared with past findings in younger, healthy subjects. Moreover, no dose or vitamin D source was associated with modifying T2D risk factors.

Growth promoting technologies reduce greenhouse gas, alcohol, and ammonia emissions from feedlot cattle.

Increased animal productivity has the potential to reduce the environmental impact per unit of consumable product and is believed to be the most promising and sustainable mitigation technique to meet increasing demand for high quality protein. The feedlot industry uses ionophores, antibiotics, growth implants, and ß2-adrenergic agonists to improve health and growth performance of cattle. These technologies not only increase productivity but also alter microbes in the rumen and increase nitrogen retention in the animal, which may lead to changes in greenhouse gas (GHG), volatile organic compound (VOC), and ammonia (NH3) emissions from feedlot cattle. The present study investigated GHG, VOC, and NH3 emissions from 160 Angus crossbred steers. Steers were blocked by weight in a randomized block design and assigned to 16 pens of 10 animals each. Treatments applied were 1) control (CON; no technology application), 2) monensin and tylosin phosphate (MON), 3) monensin, tylosin phosphate, and growth implant (IMP), and 4) monensin, tylosin phosphate, growth implant, and zilpaterol hydrochloride (fed during the last 20 d of the feeding period; BAA). Cattle were on feed for an average of 107 d. Performance variables (DMI, BW, ADG, and G:F) and carcass traits (HCW, dressing percent, KPH, LM area, fat thickness, marbling score, yield grade, and quality grade) were measured. Gaseous emissions were measured during the last 10 d of the feeding period when animals were housed in 4 totally enclosed identical cattle pen enclosures. To quantify gaseous emissions a 4×4 Latin square design (n=4) was used. Gaseous emissions were analyzed using Proc Mixed in SAS and reported in grams per kilogram HCW per day and grams per kilogram per animal per hour. Treatment with IMP and BAA increased (P<0.05) ADG, final BW, and HCW. Cattle on BAA had greater HCW and LM area (P<0.05) and had lower (P<0.05) CH4, methanol, and NH3 emissions per kilogram HCW than cattle on the remaining treatments. Methane emissions were similar for CON and IMP treated cattle. Nitrous oxide emissions were similar across CON, MON, and IMP treated cattle and were higher in BAA treated cattle (P<0.05). The present study provides a better understanding of how application of growth promoting technologies to feedlot steers affects GHG, VOC, and NH3 emissions per kilogram of product.

High production of poly(3-hydroxybutyrate) from a wild Bacillus megaterium Bolivian strain.

AIM: Taking into account that a novel strain of Bacillus megaterium was isolated from Uyuni salt lake (Bolivia) in a previous work, the objectives of this new study were to determine the maximal Poly-3-hydroxybutyrate production potential of B. megaterium strain uyuni S29 in an industrial conventional media, the possibility that the strain accumulates different types of polyhydroxyalkanoates, the cellular morphology during the biosynthesis process and the characterization of the produced biopolymers. METHODS AND RESULTS: The micro-organism was first tested in a 3-L bioreactor obtaining a high specific growth rate of 1·64 h(-1). A second fed-batch experiment was carried out in shaking flasks, reaching up to 70% PHB of cell dry mass. The biosynthesized polymers were extracted by two different extraction procedures and characterized. The results showed that all of them were PHB with thermal properties different to the conventional PHB. The micrographs taken by TEM show the different cell morphology during the fermentation process. CONCLUSIONS: In this previous study, the strain not only grew properly in the industrial conditions proposed without spore formation, but also produced and accumulated a large content of PHB, never reached before for its genus. Therefore, if the culture conditions can be optimized, the biopolymer production could be increased. SIGNIFICANCE AND IMPACT OF THE STUDY: The impact of the study has related to the area of the biomaterials and their production. The study provides new data related to the high production of PHB from the wild novel strain B. megaterium uyuni S29, the highest polymer accumulation for the genus Bacillus without spores formation.

Vitamin D2 from light-exposed edible mushrooms is safe, bioavailable and effectively supports bone growth in rats.

UNLABELLED: Widespread poor vitamin D status, a health risk for bone disease, increases the need for new food sources of vitamin D. Light-exposed edible mushrooms synthesize vitamin D(2). Bioavailability, safety, and efficacy of high levels of vitamin D(2) from mushrooms to support bone health was established in chronically fed growing rats. INTRODUCTION: Poor vitamin D status from reduced sun exposure is made worse by limited access to vitamin D-containing foods. Exposing white button mushrooms to ultraviolet B (UVB) light markedly increases their vitamin D(2) content, creating a new food source of vitamin D. We used a growing rat model to determine safety, bioavailability, and efficacy in support of bone growth by vitamin D(2) from UVB-exposed mushrooms. METHODS: We fed 150 weanling female rats one of five diets for 10 weeks, all formulated on AIN-93 G. Control diets contained no mushrooms either with or without vitamin D(3). Other diets contained 2.5% and 5.0% of UVB-exposed or -unexposed mushrooms. Safety of the high levels of vitamin D(2) from mushrooms was assessed by animal growth and by Von Kossa staining for soft tissue calcification. Bioavailability was determined from changes in circulating levels of 25-hydroxyvitamin D [25(OH)D] and parathyroid hormone (PTH). Efficacy in support of bone growth was determined from measures of femur bending properties, size, mineralization, and microarchitecture. RESULTS: Diets containing 2.5% and 5.0% light-exposed mushrooms significantly raised 25(OH)D and suppressed PTH levels compared to control-fed rats or rats fed 5.0% mushroom unexposed to light. Microarchitecture and trabecular mineralization were only modestly higher in the light-treated mushroom-fed rats compared to the controls. Von Kossa staining revealed no soft tissue calcification despite very high plasma 25(OH)D. CONCLUSIONS: Vitamin D(2) from UVB-exposed mushrooms is bioavailable, safe, and functional in supporting bone growth and mineralization in a growing rat model without evidence of toxicity.

Acidification of calf bedding reduces fly development and bacterial abundance.

Environmental stressors, such as high fly density, can affect calf well-being. Sodium bisulfate (SBS) is an acidifier that reduces the pH of flooring and bedding, creating a medium that neither bacteria nor immature flies (also known as larvae or maggots) can thrive in. Two experiments were conducted to investigate the application of SBS to a mixture of rice hull calf bedding and calf slurry (BED) to reduce house fly (Musca domestica L.) larval density and the abundance of bacteria. In experiment 1, dish pans containing 1L of BED and 3,000 house fly eggs were treated with SBS at concentrations of 0, 8.9, 17.7, and 26.5g of SBS/0.05m(2) of BED (CON, LOW, MED, and HIGH, respectively), with each SBS concentration applied to 4 individual pans (16 pans total). Reapplication of the same SBS concentrations in each pan occurred 3 times/wk throughout the 23-d trial. Larval house fly survival was significantly reduced in all pans with SBS relative to CON pans, with lowest survival rates in the MED and HIGH pans (99% and 100% reduction, respectively). The mean pH for each treatment was inversely related to the SBS concentration. In experiment 2, pans containing 1L of BED and 3,000 house fly eggs were treated with either 0g of SBS (CON), 8.9g of SBS/0.05m(2) of BED with reapplication of the acidifier 3 times/wk (SB3x), or 8.9g of SBS/0.05m(2) of BED applied only once at 48h before the end of the 8 d-trial (SB48). Larval house fly survival and bacterial concentrations were reduced (90% larval reduction and 68% bacterial reduction) in the SB3x treatment relative to the CON. Mean pH was also reduced in SB3x pans relative to CON or SB48 pans. Overall, acidification of calf BED using the acidifier SBS resulted in a reduction of bacteria and house fly larval survival. This form of fly control might be expected to reduce adult fly production and, therefore, fly-related stress in calves.

No cash no whiplash?: Influence of the legal system on the incidence of whiplash injury.

Whiplash injury has been a continuous source of controversy due to its association with litigation. We studied the incidence of whiplash associated disorder (WAD) in two similar socioeconomic areas and carried out a retrospective study based on the hypothesis that the Spanish law 30/1995 might have an affect on the incidence and duration of cervical symptoms and the persistence of impairment. More than 10,000 patients injured in traffic accidents were studied over a period three years. Of these, only patients with an initial diagnosis of whiplash injury were included in the study. Patients with other injuries were excluded. The patients were classified into two groups: Galicia-Spain and North-Central Portugal (depending on where the accident took place and the medico-legal evaluation procedure in force). Statistical analysis was made using SPSS 13.0 and Statistix 8.0. We found a statistically significant difference between Spain and Portugal in the incidence of WAD and in the duration of symptoms. The incongruities caused by the compulsory application of Spanish law arise from the fact that evaluation on a points scale of impairment does not always reflect the functional state of the injured person.

Immunohistochemical analysis of P-Selectin as a possible marker of vitality in human cutaneous wounds.

Immunohistochemical detection of mediators of inflammation, such as P-Selectin, has been proposed to assess vitality of wounds. Forty-five incised cutaneous wounds (24 vital, 14 post-mortem, seven with induced autolysis/putrefaction) were immunostained with antibodies against P-Selectin and CD31. The percentage of stained lumina for P-Selectin out of the total of CD31 positive vessels (P-S/CD31 index) was calculated at both edges of every specimen. In vital samples, the P-S/CD31 index ranged from 10.7% to 71.4% at the wound edge, and was 12.5-58.8% for the opposite margin, with a ratio between both indices of 0.37-1.77 (mean: 0.94). In post-mortem cases, the index ranged from 22.5% to 69.2% at the wound edge, and was 28-89.5% at the opposite margin, with a ratio between both indices of 0.76-1.9 (mean: 0.96). Differences between ratios were not statistically significant and thus precluded any assessment of vitality. The analysis of P-Selectin/CD31 immunoreactivity in skin wounds was not useful for the diagnosis of vitality when evaluating both edges for each specimen. Moreover, P-Selectin has been detected in post-mortem injuries and it is not specific to vital injuries. Microscopic evaluation becomes difficult after autolysis/putrefaction.

Worker health and safety in concentrated animal feeding operations.

A trend in consolidating livestock and poultry operations into concentrated animal feeding operations (CAFOs) potentially increases farm worker exposure to the hazards associated with high animal density conditions. The two main contributors of documented injury (fatal and non-fatal) are related to accidents with machinery and animals. Tractor rollovers are the leading accident in the area of farming machinery issues; kicks, bites, and workers being pinned between animals and fixed objects are non-machinery issues typically caused by inadequate precautions taken in the vicinity of livestock. These types of accidents are well documented; however, recommended safety strategies continue to be studied to reduce the risks and numbers of injuries associated with both machines and animals. Unlike accidents involving machinery and animals, air emission exposure and potential health effects from CAFOs are not well documented. CAFOs have the potential to show higher gaseous and particulate matter emissions compared to smaller farms. Pollutants like hydrogen sulfide, ammonia, volatile organic compounds, particulate matter, and endotoxin are emitted on CAFOs and can potentially affect worker health. These specific air emissions, their sources, and some of their harmful capabilities have been identified, and regulations have been implemented to create improved work environments on CAFOs. Despite such precautions, farm workers continue to report respiratory health symptoms related to their work environment. Air pollutant exposure and its health effects on farm workers require focused research to arrive at improved safety strategies that include mitigation techniques and protective gear to minimize adverse effects of working in CAFOs.

The pathology of the heart conduction system in congenital heart block.

The incidence of congenital complete heart block is estimated in 1 of 2500-20,000 births. Many cases are isolated (found in an otherwise normal heart) and the pathology of the heart conduction system is variable. We report a 51-year-old man with the diagnosis of complete heart block, with a permanent pacemaker. No family history of rhythm disturbances was available. The patient presented and endocarditis after replacement of the pacemaker battery. The prognosis was poor and the patient died three months later. Autopsy examination showed signs of shock, of septic origin. The heart was hypertrophic (450g) and the left ventricle thickened. Histopathological examination of the heart conduction system showed that the sinus and atrioventricular nodes were normal, but the His bundle was interrupted and replaced by fibrous tissue. No inflammatory signs were present. Loss of conducting fibres and their replacement by fibrous tissue is the most common pathological process in complete heart block. In this case His bundle was mostly affected, different to Lev's disease where the process is more distal (branching atrioventricular bundle) and to Lenegre's disease, which shows a diffuse damage in the conducting system.

A high-performance liquid chromatography method for hypoxanthine determination in vitreous humour: application to estimation of post mortem interval.

We have developed a new technique to determine the concentration of hypoxanthine [Hx] in a reverse phase column using a modified high-performance liquid chromatography (HPLC) method that is faster and more reliable than those previously described. In this paper we present a formula for estimating the post mortem interval (PMI) based on this HPLC method by applying the inverse prediction method. The regression line obtained by changing the variables gives PMI = 0.183 [Hx] + 0.599 (PMI in hours, [Hx] in micromol/L, R2 = 0.531, P < 0.05).

Paciente con VIH, fiebre y lesiones cutáneas / HIV patient, fever and skin lesions

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