Prioritisation of citizen-centric information for disaster response.

In the aftermath of a disaster event, and in the absence of trained professionals, many responsibilities are assumed by uninjured citizens who are willing and able to help, such as care of the injured or search and rescue. These citizens are constrained by communications and logistics problems but are less equipped to deal with them as most often they are cut off from any coordinated assistance. The method proposed in this study would increase the survivability of those injured or trapped by a disaster event by providing a facility to allow citizens to coordinate and share information among themselves. This is facilitated by the proposed deployment and the autonomous management of an ad hoc infrastructure that liaises directly with survivors without central control. Furthermore, as energy concerns present critical constraints to these networks, this research proposes a system of categorising information elements within the network to ensure efficient information exchange.

Attitudes of legal guardians in the ICU - a qualitative report.

UNLABELLED: Decision-making in intensive care units (ICUs) is often made by surrogates, since patients are unconscious or incompetent. In Israel, Legal Guardians (LGs), appointed by the court, are required to make these decisions. OBJECTIVE: To qualitatively assess the attitudes of LGs required to make decisions on behalf of their relatives. RESEARCH DESIGN: Demographic and semi-structured questionnaires were used to assess the attitudes of LGs regarding difficulties, positive aspects and areas for improvement with regard to surrogate decision-making. The study sampled sixty-four LGs in two large Israeli hospitals. After reading and analysing the responses provided by the LGs, the authors categorised the pertinent topics raised using a thematic analysis. RESULTS: Themes were: bureaucratic and legal issues, unclear or unknown patient preferences and fear of outcomes. Family and medical staff support was stated as the most beneficial. Suggestions for improvement included alleviation of bureaucracy and improved communication with the medical staff. CONCLUSIONS: The importance of communication and bureaucratic difficulties, making the best decision for the patient and uncertainty regarding decision outcomes were found to be important issue for the LGs. The healthcare team should try and alleviate some of these burdens, mostly by improving communication with relatives, stressing and educating the importance of advance directives. Reporting the problems found in the decision making process of LGs to the legislators in order to revise and simplify the current legal requirements is advised.

A retrospective study of antipsychotic drug switching in a pediatric population.

BACKGROUND: Antipsychotic drugs can be used to help treat a wide variety of psychiatric disorders. However, specific antipsychotic drugs for any particular patient may need to be changed for a number of different reasons, including a lack of therapeutic efficacy and / or intolerance to medication side-effects. Drug switching may occur through a limited number of established patterns. The nature of these changes is not well characterized in youth, despite their frequent occurrence. METHODS: A retrospective analysis of antipsychotic drug switches was conducted on patients who had been admitted as inpatients to a tertiary care child and adolescent psychiatric institute. PharmaNet (a large, central administrative database) records of all medications prescribed in the 52 weeks prior to admission, and then between admission and discharge, were analyzed for switching patterns. Additional data regarding diagnoses were obtained from medical chart review. RESULTS: Patients represented a diagnostically heterogeneous population, and almost all antipsychotic drugs were administered off-label. In the one year prior to and during admission to the hospital, a total of 31 out of 139 patients switched antipsychotic drugs. The frequency of switching increased closer to the time of admission, and the proportional rate of switching was even higher during hospital stay. The most common switch was from risperidone to quetiapine. Our analysis identified three main patterns of drug switching, all occurring with similar frequency: titrated drug switches, abrupt drug switches and concurrent drug administration. CONCLUSIONS: The present study indicates that antipsychotic drug switching in youth may be relatively common, particularly in the year prior to hospitalization. No specific manner of drug switching predominates. This study also demonstrates the feasibility of using large administrative databases to characterise switching patterns in youth.

Antipsychotic and psychostimulant drug combination therapy in attention deficit/hyperactivity and disruptive behavior disorders: a systematic review of efficacy and tolerability.

This systematic review examines treatment guidelines, efficacy/effectiveness, and tolerability regarding the use of antipsychotics concurrently with psychostimulants in treating aggression and hyperactivity in children and adolescents. Articles examining the concurrent use of antipsychotics and psychostimulants to treat comorbid attention deficit/hyperactivity disorder (ADHD) and disruptive behavior disorders (DBDs) were identified and their results were summarized and critically analyzed. Antipsychotic and stimulant combination therapy is recommended by some guidelines, but only as a third-line treatment following stimulant monotherapy and stimulants combined with behavioral interventions to treat aggression in patients with ADHD. Some studies suggest efficacy/effectiveness for an antipsychotic and stimulant combination in the treatment of aggression and hyperactivity in children and adolescents. However, the data do not clearly demonstrate superiority compared to antipsychotic or psychostimulant monotherapy. Most studies were performed over short time periods, several lacked blinding, few studies used any placebo control, and no comparisons were made with behavioral interventions. There are concerns about the tolerability of combination therapy, but data do not suggest significantly worse adverse effects for combination compared to either antipsychotic or stimulant monotherapy. Conversely, and contrary to speculation, use of a stimulant does not significantly reduce metabolic effects of antipsychotics. Combination treatment with antipsychotics and psychostimulants is used frequently, and increasingly more often. Few studies have directly examined this combination for the treatment of ADHD and DBDs. Further studies are necessary to confirm the efficacy and tolerability of the concurrent use of antipsychotics and psychostimulants in children and adolescents.

Electrical methods of controlling bacterial adhesion and biofilm on device surfaces.

This review will summarize the significant body of research within the field of electrical methods of controlling the growth of microorganisms. We examine the progress from early work using current to kill bacteria in static fluids to more realistic treatment scenarios such as flow-through systems designed to imitate the human urinary tract. Additionally, the electrical enhancement of biocide and antibiotic efficacy will be examined alongside recent innovations including the biological applications of acoustic energy systems to prevent bacterial surface adherence. Particular attention will be paid to the electrical engineering aspects of previous work, such as electrode composition, quantitative electrical parameters and the conductive medium used. Scrutiny of published systems from an electrical engineering perspective will help to facilitate improved understanding of the methods, devices and mechanisms that have been effective in controlling bacteria, as well as providing insights and strategies to improve the performance of such systems and develop the next generation of antimicrobial bioelectric materials.

The legal guardians' dilemma: Decision making associated with invasive non-life-saving procedures.

BACKGROUND: ICU patients frequently undergo non-life-saving invasive procedures. When patient informed consent cannot be obtained, legal guardianship (LG), often from a close relative, may be required by law. The objective of this cohort study was to investigate the attitudes of LGs of ICU patients regarding the process of decision making for invasive non-life-saving procedures. METHODS: The study was conducted from May 2009 until June 2010 in general medical/surgical ICUs in two large Israeli medical centers. All 64 LGs who met the study criteria agreed to participate in the study. Three questionnaires were administered: a demographic data questionnaire, the Family Satisfaction with ICU 34 Questionnaire, and the Attitudes towards the LG Decision Making Process questionnaire, developed by the authors. RESULTS: The sample consisted of 64 LGs. Most participants were married (n = 56, 87.5%), male (n = 33, 51.6%), who had either a high school (n = 24, 37.5%) or college (n = 19, 29.7%) education, and were at a mean age of 49.2 (±11.22). Almost all of the procedures performed were tracheotomies (n = 63, 98.4%). About two-thirds of the LGs preferred decisions to be made by the medical staff after discussing options with them (n = 42, 65.6%) and about three-fifths stated that decisions could be made without the need for the appointment of an LG (n = 37, 57.8%). Attitudes towards ease of obtaining information and honesty of information were more positive compared to those of consistency and understanding of information. CONCLUSIONS: The legal guardianship process requires better communication and more understandable information in order to assist LGs in making decisions for others in at times vague and stressful situations.

The hemodynamic and respiratory effects of cuirass ventilation in healthy volunteers: Part 1.

OBJECTIVE: Negative-pressure ventilation (NPV) by external cuirass (RTX; Deminax Medical Instruments Limited, London, UK) in intubated patients after cardiac surgery improves hemodynamics measured by pulmonary artery catheter (PAC)-based methods, with an increased cardiac output (CO) and stroke volume (SV), without changing the heart rate (HR). The less-invasive pressure recording analytical method (PRAM) (Mostcare; Vytech Health srl, Padova, Italy) allows radial artery-based monitoring of the CO, SV, SV variation, and cardiac cycle efficiency (CCE). The authors investigated the hypothesis that NPV improves PRAM-based hemodynamics and arterial blood gas analysis in spontaneously breathing subjects. DESIGN: A clinical investigation. SETTING: A teaching hospital. PARTICIPANTS: Ten healthy volunteers. INTERVENTIONS: Subjects underwent 5 consecutive experimental ventilation modalities lasting 5 minutes: (1) baseline (no cuirass ventilation), (2) mode 1: cuirass ventilation with a continuous negative pressure of -20 cmH(2)O, (3) first rest period (no cuirass ventilation), (4) mode 2: cuirass ventilation in control mode of 12 breaths/min at -20 cmH(2)O, and (5) second rest period. MEASUREMENTS AND MAIN RESULTS: PRAM parameters were analyzed throughout the final minute of each experimental modality, which concluded with arterial blood gas sampling. Both NPV modes significantly reduced HR without changing CO or systemic vascular resistance. Mode 1 significantly increased CCE and decreased SVV. PO(2) decreased in both rest modes compared with baseline. This was prevented by NPV. In 5 smokers, PO(2) significantly increased in the control mode compared with first rest period. The control mode NPV improved oxygenation with a reduced PCO(2) and reciprocally increased pH. CONCLUSIONS: Five minutes of NPV improves hemodynamics and oxygenation in healthy subjects.

The hemodynamic and respiratory effects of continuous negative and control-mode cuirass ventilation in recently extubated cardiac surgery patients: Part 2.

OBJECTIVE: Negative-pressure ventilation (NPV) by external cuirass (RTX; Deminax Medical Instruments Limited, London, UK) in intubated patients after cardiac surgery improves hemodynamics measured by pulmonary artery catheter (PAC)-based methods with increased cardiac output (CO) and stroke volume (SV) without changing the heart rate (HR). The less-invasive pressure recording analytical method (PRAM) (MostCare; Vytech Health srl, Padova, Italy) allows radial artery monitoring of CO, SV, SV variation, and cardiac cycle efficiency (CCE). The authors investigated the hypothesis that NPV improves PRAM-based hemodynamics and arterial blood gas analysis in extubated cardiac surgery patients. DESIGN: A clinical investigation. SETTING: A teaching hospital. PARTICIPANTS: Twenty recently extubated cardiac surgery patients. INTERVENTIONS: Five consecutive experimental ventilation modalities lasted 5 minutes: (1) baseline (no cuirass ventilation), (2) mode 1 (cuirass ventilation with a continuous negative pressure of -20 cmH(2)O), (3) rest 1 (no cuirass ventilation), (4) mode 2 (cuirass ventilation in the control mode of 12 breaths/min at -20 cmH(2)O, and (5) rest 2. MEASUREMENTS AND MAIN RESULTS: PRAM parameters were analyzed throughout the final minute of each experimental modality, concluding with arterial blood gas sampling. NPV was well tolerated. HR was unchanged. Mode 2 SV was higher than baseline and rest 2. Mode 2 CO was higher than rest 2. Rest 2 systolic blood pressure was lower than rest 1 and mode 2. Increased CCE with NPV was not significant (p = 0.0696). Oxygenation and PCO(2) were unchanged although mode 2 pH increased. CONCLUSIONS: Extubated sedated cardiac surgery patients comfortably tolerated NPV with unchanged HR. SV and pH increased.

Nurse-led implementation of a safe and effective intravenous insulin protocol in a medical intensive care unit.

BACKGROUND: Recent evidence has linked tight glucose control to worsened clinical outcomes among adults in intensive care units. OBJECTIVE: To evaluate the effectiveness and safety of a nurse-led intravenous insulin protocol designed to achieve conservative blood glucose control in patients in a medical intensive care unit. METHODS: A nurse-led intravenous insulin protocol was developed, targeting blood glucose levels at 110 to 149 mg/dL. Hypoglycemia was defined as a blood glucose level less than 70 mg/dL. Patients admitted to the medical intensive care unit who required an insulin infusion were enrolled in the study. Blood glucose levels in those patients were compared with levels in 153 historical control patients admitted to the unit in the 12 months before the protocol was implemented who required an insulin infusion. RESULTS: Ninety-six patients were enrolled and treated with the protocol. The protocol and control groups had similar characteristics at baseline. More measurements in the protocol group than in the control group (46.3% vs 36.1%, P<.001) were within the target glucose range (110-149 mg/dL). Hyperglycemia (blood glucose ≥200 mg/dL) occurred less often in the protocol group than in the control group (14.8% vs 20.1%, P=.003). Hypoglycemic events (blood glucose <70 mg/dL) also occurred less often in the protocol group (0.07% vs 0.83%, P<.001). CONCLUSIONS: Implementation of a nurse-led, conservative intravenous insulin protocol in the medical intensive care unit is effective and safe and markedly reduces the rate of hypoglycemia.

Communication difficulties and psychoemotional distress in patients receiving mechanical ventilation.

BACKGROUND: Difficulties in communication in intensive care patients receiving mechanical ventilation are a source of stressful experiences and psychoemotional distress. OBJECTIVES: To examine the association between communication characteristics and psychoemotional distress among patients treated with mechanical ventilation in a medical intensive care unit and to identify factors that may be predictive of psychological outcomes. METHODS: A total of 65 critically ill patients, extubated within the preceding 72 hours, were included in this cross-sectional study. Data were collected by using a structured interview. Separate regression analysis of data on 3 psychoemotional outcomes (psychological distress, fear, and anger) were used for baseline variables, communication characteristics, and stressful experiences. RESULTS: Difficulty in communication was a positive predictor of patients' psychological distress, and length of anesthesia was a negative predictor. Fear and anger were also positively related to difficulty in communication. In addition, the number of communication methods was negatively associated with feelings of fear and anger. Finally, the stressful experiences associated with the endotracheal tube were positively related to feelings of anger. CONCLUSIONS: Patients treated with mechanical ventilation experience a moderate to extreme level of psychoemotional distress because they cannot speak and communicate their needs. Nurses should be aware of the patients' need to communicate. Decreasing stressful experiences associated with the endotracheal tube and implementing more appropriate communication methods may reduce patients' distress.

Evaluation of intradialytic hypotension using impedance cardiography.

BACKGROUND: Hypotension during hemodialysis is frequent in patients with cardiovascular disease who have a limited physiological compensatory response. Recent advances in technology allow non-invasive monitoring of cardiac output and derived hemodynamic parameters. This prospective study evaluated episodes of intradialytic hypotension using clinical data and continuous non-invasive hemodynamic monitoring by impedance cardiography. METHODS: Forty-eight chronic hemodialysis patients, with prevalence for intradialytic hypotensive episodes, underwent evaluation with non-invasive impedance cardiography (Physioflow) before, during and after a regular dialysis session. RESULTS: During continuous non-invasive cardiac monitoring, a fall of systolic arterial blood pressure of 20% or more at least once during hemodialysis was detected in 18 patients (37.5%)--thereafter identified as the "Unstable" group. In 30 patients--thereafter called the "Stable" group, the blood pressure did not change significantly. During hypotension, a decrease in cardiac output was found in 11 of the 18 unstable patients, and a significant fall in peripheral resistance in the remaining 7. End-diastolic filling ratio was significantly lower in the unstable group. The most significant predictors associated with intradialytic hypotension were the presence of ischemic heart disease (P = 0.05), and medication with beta blockers (P = 0.037) and calcium channel blockers (P = 0.018). CONCLUSIONS: Hemodynamic changes in dialysis patients with hypotensive episodes included decreased cardiac output or decreased peripheral resistance. A lower end-diastolic filling ratio may be regarded as a marker for reduced preload in these patients. Non-invasive impedance cardiography may be used to evaluate risk factors for hypotension in dialysis patients.

Contradictions in end-of-life decisions for self and other, expressed by relatives of chronically ventilated patients.

OBJECTIVES: In certain populations, social, legal, and religious factors may influence end-of-life decisions in ventilator-dependent patients. This study aims to evaluate attitudes of first-degree relatives of chronically ventilated patients in Israel, toward end-of-life decisions regarding their loved ones, themselves, and unrelated others. MATERIALS AND METHODS: The study was conducted in a chronic ventilation unit. First-degree family members of chronically ventilated patients were interviewed about their end-of-life attitudes for patients with end-stage diseases. Distinctions were made between attitudes in the case of their ventilated relatives, themselves, and unrelated others; between conscious and unconscious patients; and between a variety of interventions. RESULTS: Thirty-one family members of 25 patients were interviewed. Median length of ventilation at the time of the interview was 13.4 months. Most interviewees wanted further interventions for their ventilated relatives, yet, for themselves, only 21% and 18% supported chronic ventilation and resuscitation, respectively, and 48% would want to be disconnected from the ventilator. Interventions were more likely to be endorsed for others (vs self), for the conscious self (vs unconscious self), and for artificial feeding (vs chronic ventilation and resuscitation). Interviewees were reluctant to disconnect patients from a ventilator. CONCLUSIONS: Family members often want escalation of treatment for their ventilated relatives; however, most would not wish to be chronically ventilated or resuscitated under similar circumstances. Advance directives may reconcile people's wishes at the end of their own lives with their reticence to make decisions regarding others.

Men in menstrual product advertising--1920-1949.

Menstruation and menstrual products are commonly thought to be solely the concerns of women, yet the values that shape attitudes and representations of the period are strongly influenced by men. Magazine advertising for menstrual products reveals both subtle and overt examples of male presence in the formation of perspectives on the period. This article examines a variety of menstrual product ads from two decades in order to assess how the presence of men shapes these perspectives.

Conservative management of flail chest after cardiopulmonary resuscitation by continuous negative extrathoracic pressure.

Flail chest after blunt trauma usually requires good pain control and positive pressure support. Continuous negative extrathoracic pressure (CNEP) causes a splinting effect around the anterior chest wall and upper abdomen which increases functional residual capacity and improves lung mechanics. We report an 82-year-old woman with flail chest after cardiopulmonary resuscitation. She underwent mechanical ventilation, with two failed attempts at extubation. She was subsequently ventilated non-invasively using CNEP, allowing early successful extubation. This case illustrates the use of CNEP for weaning and ventilating patients with flail chest after blunt trauma.