Impact of the introduction of an enhanced recovery pathway in esophageal cancer surgery: a cohort study and propensity score matching analysis.

Enhanced recovery pathways (ERP) have the potential to improve clinical outcomes. Aim of this study was to determine the impact of ERP on perioperative results as compared with traditional care (TC) after esophagectomy. In this study, two cohorts were compared. Cohort 1 represented 296 patients to whom TC was provided. Cohort 2 consisted of 200 unselected ERP patients. Primary endpoints were postoperative complications. Secondary endpoints were the length of stay and 30-day readmission rates. To confirm the possible impact of ERP, a propensity matched analysis (1:1) was conducted. A significant decrease in complications was found in ERP patients, especially for pneumonia and respiratory failure requiring reintubation (39% in TC and 14% in ERP; P<0.0001 and 17% vs. 12%; P<0.0001, respectively) and postoperative blood transfusion (26.7%-11%; P<0.0001). Furthermore, median length of stay was also significantly shorter: 13 days (interquartile range [IQR] 10-23) in TC compared with 10 days (IQR 8-14) in ERP patients (P<0.0001). The 30-day readmission rate (5.4% in TC and 9% in ERP; P=0.121) and in-hospital mortality rate (4.4% in TC and 2.5% in ERP; P=0.270) were not significantly affected. A propensity score matching confirmed a significant impact on pneumonia (P=0.0001), anastomotic leak (P=0.047), several infectious complications (P=0.01-0.034), blood transfusion (P=0.001), Comprehensive Complications Index (P=0.01), and length of stay (P=0.0001). We conclude that ERP for esophagectomy is associated with significantly fewer postoperative complications and blood transfusions, which results in a significant decrease of length of stay without affecting readmission and mortality rates.

Self-Management Education for Bipolar Disorders: A Hermeneutic-Phenomenological Study on the Tacit Knowledge of Mental Health Nurses.

Background: Self-management of bipolar disorder (BD) education is a complex nursing intervention in which patients and informal caregivers are taught to be actively involved in self-monitoring and self-regulating activities. Some studies question if nurses are sufficiently equipped to deliver these educational tasks. Other studies suggest that nurses have gathered their knowledge implicitly by experience, but to date, this tacit knowledge is not described from the experiences of mental health nurses (MHNs) in ambulant BD care. Objective: To detect the tacit knowledge used by MHNs by interpreting their experiences in delivering self-management education to people with BD and their informal caregivers. Methods: A phenomenological-hermeneutical study amongst MHNs (N = 9) from three ambulant BD care clinics in the Netherlands. Face-to-face, open, in-depth interviews guided by a topic list, were conducted and transcribed verbatim prior to the hermeneutical analysis. Findings: We found five categories resembling the complex character of self-management interventions provided by MHNs: Building a trustful collaboration, Starting a dialogue about needs and responsibilities, Explaining BD, Utilizing mood monitoring instruments, and Conceptualizing self-management of BD. Conclusion: Eventually MHNs use tacit knowledge to cope with situations that demand an outside-the-box approach. Self-management education is partially trained and partially mastered through experience. Practice implications: In order to facilitate long-term self-management of BD, the collaboration of a supporting network is essential.

The intervention process in the European Fans in Training (EuroFIT) trial: a mixed method protocol for evaluation.

BACKGROUND: EuroFIT is a gender-sensitised, health and lifestyle program targeting physical activity, sedentary time and dietary behaviours in men. The delivery of the program in football clubs, led by the clubs' community coaches, is designed to both attract and engage men in lifestyle change through an interest in football or loyalty to the club they support. The EuroFIT program will be evaluated in a multicentre pragmatic randomised controlled trial (RCT), for which ~1000 overweight men, aged 30-65 years, will be recruited in 15 top professional football clubs in the Netherlands, Norway, Portugal and the UK. The process evaluation is designed to investigate how implementation within the RCT is achieved in the various football clubs and countries and the processes through which EuroFIT affects outcomes. METHODS: This mixed methods evaluation is guided by the Medical Research Council (MRC) guidance for conducting process evaluations of complex interventions. Data will be collected in the intervention arm of the EuroFIT trial through: participant questionnaires (n = 500); attendance sheets and coach logs (n = 360); observations of sessions (n = 30); coach questionnaires (n = 30); usage logs from a novel device for self-monitoring physical activity and non-sedentary behaviour (SitFIT); an app-based game to promote social support for physical activity outside program sessions (MatchFIT); interviews with coaches (n = 15); football club representatives (n = 15); and focus groups with participants (n = 30). Written standard operating procedures are used to ensure quality and consistency in data collection and analysis across the participating countries. Data will be analysed thematically within datasets and overall synthesis of findings will address the processes through which the program is implemented in various countries and clubs and through which it affects outcomes, with careful attention to the context of the football club. DISCUSSION: The process evaluation will provide a comprehensive account of what was necessary to implement the EuroFIT program in professional football clubs within a trial setting and how outcomes were affected by the program. This will allow us to re-appraise the program's conceptual base, optimise the program for post-trial implementation and roll out, and offer suggestions for the development and implementation of future initiatives to promote health and wellbeing through professional sports clubs. TRIAL REGISTRATION: ISRCTN81935608 . Registered on 16 June 2015.

The support needs of parents having a child with a chronic kidney disease: a focus group study.

BACKGROUND: Parents of children with a chronic kidney disease (CKD) have a crucial role in the management of their child's disease. The burden on parents is high: they are often exhausted, depressed and experience high levels of stress and a low quality of life, which could have a negative impact on their child's health outcomes. Support aiming at preventing and reducing parental stress is essential. Therefore, it is necessary to have insight in the problems and support needs among these parents. OBJECTIVE: Our aim is to describe parents' support needs regarding the problems they experience in having a child with CKD. METHODS: Five focus group interviews were conducted with parents of children: (i) with hereditary kidney disease, (ii) with nephrotic syndrome, (iii) with chronic kidney failure, (iv) using dialysis and (v) after renal transplantation. The children were treated at a paediatric nephrology unit in one university hospital in the Netherlands. The data were thematically analysed. RESULTS: Twenty-one parents participated in the focus groups. Parents need more information about their child's CKD and treatment options, and managing their own hobbies and work. Furthermore, parents need emotional support from their partner, family, friends, peers and healthcare professionals to help them cope with the disease of their child. Additionally, parents need practical support to hand over their care and support in transport, financial management and regarding their child at school. CONCLUSION: Needs regarding balancing their personal life are seldom prioritized by parents as the child's needs are considered more important. Therefore, it is important that healthcare professionals should not only attend to the abilities of parents concerning their child's disease management, but also focus on the parents' abilities in balancing their responsibilities as a caregiver with their own personal life.

Dealing with chemotherapy-related symptoms at home: a qualitative study in adult patients with cancer.

Given that chemotherapy treatments are done mostly in an outpatient setting, patients with cancer must deal with treatment-related symptoms mainly at home. Evidence suggests that they often feel left alone or unprepared to do so. This qualitative study explores how patients deal with chemotherapy-related symptoms in their home, which factors and ideas influence their self-management and what role professional caregivers play. One-off, semi-structured interviews were held with 28 adult patients with cancer being treated with chemotherapy. Using a Grounded Theory approach, we cyclically collected and analysed data to come to a thorough understanding of the major conceptual themes and their interconnections. Dealing with chemotherapy-related symptoms involves a process of experiencing and learning how side effects unfold over time and how to deal with them. Patients express very personal symptom experiences and symptom-management styles, which are shaped by personal factors (e.g. coping with cancer and cancer treatment, perceived level of control) and environmental factors (e.g. professionals' attitude, information resources). Improving symptom self-management support requires active exploration of the personal symptom experience and symptom-management style. Professional care should be tailored to the patient's perspective and should address personal and environmental determinants of their behaviour.

Identifying and describing patients' learning experiences towards self-management of bipolar disorders: a phenomenological study.

ACCESSIBLE SUMMARY: Existing evidence suggest that patient education in promoting self-management strategies of bipolar disorder (BD) is effective. However, results across the full range of service users with BD vary. Learning experiences of service users look to be a crucial factor to take into account when designing, delivering, and evaluating effective interventions that promote self-management in chronic illness. What learning activities service users actually undertake themselves when self-managing BD that might explain varying success rates, and guide future self-management educational programmes has not been examined. Unlike previous studies that suggest that outcomes in self-management depend on individual learning activities, the current study found that learning to self-manage BD takes place in a social network that functions as a learning environment in which it is saved for service users to make mistakes and to learn from these mistakes. Especially, coping with the dormant fear of a recurrent episode and acknowledging the limitations of an individual approach are important factors that facilitate this learning process. Practitioners who provide patient education in order to promote self-management of BD should tailor future interventions that facilitate learning by reflecting on the own experiences of service users. Community psychiatric nurses should keep an open discussion with service users and caregivers, facilitate the use of a network, and re-label problems into learning situations where both play an active role in building mutual trust, thereby enhancing self-management of BD. ABSTRACT: Existing evidence suggest that self-management education of bipolar disorder (BD) is effective. However, why outcomes differ across the full range of service users has not been examined. This study describes learning experiences of service users in self-managing BD that provide a possible explanation for this varying effectiveness. We have conducted a phenomenological study via face-to-face, in-depth interviews, guided by a topic list, along service users with BD I or II (n = 16) in three specialised community care clinics across the Netherlands. Interviews were digitally recorded and transcribed verbatim prior to analysis in Atlas.ti 7. Unlike existing studies, which suggest that individual abilities of service users determine outcomes in self-management of BD, the current study found that self-management of BD is a learning process that takes place in a collaborative network. We identified five categories: acknowledgment of having BD, processing the information load, illness management, reflecting on living with BD, and self-management of BD. The success of self-management depends on the acknowledgment of individual limitations in learning to cope with BD and willingness to use a social network as a back-up instead. Especially, the dormant fear of a recurrent episode is a hampering factor in this learning process.

What do we know about rheumatoid arthritis patients' support needs for self-management? A scoping review.

BACKGROUND: Self-management support is essential to perform self-management behavior. To provide this support in an effective way, insight in the needs for self-management support is necessary. OBJECTIVE: To give an overview of self-management support needs from the perspective of rheumatoid arthritis patients to help nurses to improve self-management. DESIGN: We conducted a scoping review for the period of January 2002 to May 2013 using the following inclusion criteria: (1) studies on adult patients aged 18 years and older, (2) studies from the perspective of rheumatoid arthritis patients, (3) studies reporting results on support needs, and (4) empirical studies using any design. DATA SOURCES: We searched in PubMed, CINAHL, and PsycINFO. REVIEW METHODS: Following the steps of a scoping review, we (1) identified the research question, (2) identified relevant studies, (3) selected studies, (4) charted the data, and (5) collated, summarized, and reported results. We incorporated the optional sixth step of consultation of a multidisciplinary panel of professionals and patients to validate our findings. RESULTS: Seventeen articles were included. Our review shows that rheumatoid arthritis patients have informational, emotional, social and practical support needs. We found an information need for various topics, e.g. exercises and medication. Patients express a need for emotional support in daily life, given through other RA patients, colleagues and supervisors and nurses. For information needs, emotional and social support it is important that it is tailored to the individual needs of the patient. CONCLUSION: The most important support needs for self-management mentioned by rheumatoid arthritis patients are more informational, social and practical support and emotional support. Considering patients' perspective as a starting point for delivering support for self-management can lead to the development of nursing interventions tailored to the needs of rheumatoid arthritis patients.

Multinational development and validation of an early prediction model for delirium in ICU patients.

RATIONALE: Delirium incidence in intensive care unit (ICU) patients is high and associated with poor outcome. Identification of high-risk patients may facilitate its prevention. PURPOSE: To develop and validate a model based on data available at ICU admission to predict delirium development during a patient's complete ICU stay and to determine the predictive value of this model in relation to the time of delirium development. METHODS: Prospective cohort study in 13 ICUs from seven countries. Multiple logistic regression analysis was used to develop the early prediction (E-PRE-DELIRIC) model on data of the first two-thirds and validated on data of the last one-third of the patients from every participating ICU. RESULTS: In total, 2914 patients were included. Delirium incidence was 23.6%. The E-PRE-DELIRIC model consists of nine predictors assessed at ICU admission: age, history of cognitive impairment, history of alcohol abuse, blood urea nitrogen, admission category, urgent admission, mean arterial blood pressure, use of corticosteroids, and respiratory failure. The area under the receiver operating characteristic curve (AUROC) was 0.76 [95% confidence interval (CI) 0.73-0.77] in the development dataset and 0.75 (95% CI 0.71-0.79) in the validation dataset. The model was well calibrated. AUROC increased from 0.70 (95% CI 0.67-0.74), for delirium that developed <2 days, to 0.81 (95% CI 0.78-0.84), for delirium that developed >6 days. CONCLUSION: Patients' delirium risk for the complete ICU length of stay can be predicted at admission using the E-PRE-DELIRIC model, allowing early preventive interventions aimed to reduce incidence and severity of ICU delirium.

Measuring the nursing work environment: translation and psychometric evaluation of the Essentials of Magnetism.

AIM: Translate the Essentials of Magnetism II© (EOMII; Dutch Nurses' Association, Utrecht, The Netherlands) and assess its psychometric properties in a culture different from its origin. BACKGROUND: The EOMII, developed in the USA, measures the extent to which organizations/units provide healthy, productive and satisfying work environments. As many healthcare organizations are facing difficulties in attracting and retaining staff nurses, the EOMII provides the opportunity to assess the health and effectiveness of work environments. METHODS: A three-phased (respectively N = 13, N = 74 and N = 2542) combined descriptive and correlational design was undertaken for translation and evaluation validity and psychometric qualities of the EOMII for Dutch hospitals (December 2009-January 2010). We performed forward-backward translation, face and content validation via cross-sectional survey research, and semi-structured interviews on relevance, clarity, and recognizability of instruments' items. Psychometric testing included principal component analysis using varimax rotation, item-total statistics, and reliability in terms of internal consistency (Cronbach's α) for the total scale and its subscales. RESULTS: Face validity was confirmed. Items were recognizable, relevant and clear. Confirmatory factor analysis indicated that five of eight subscales formed clear factors. Three original subscales contained two factors. Item-total correlations ranged from 0.43 to 0.83. One item correlated weakly (0.24) with its subscale. Cronbach's α for the entire scale was 0.92 and ranged from 0.58 to 0.92 for eight subscales. CONCLUSIONS: Dutch-translated EOMII (D-EOMII) demonstrated acceptable reliability and validity for assessing hospital staff nurses' work environment. IMPLICATIONS FOR NURSING AND HEALTH POLICY: The D-EOMII can be useful and effective in identifying areas in which change is needed for a hospital to pursue an excellent work environment that attracts and retains well-qualified nurses.

The relationship between challenging behaviour and anxiety in adults with intellectual disabilities: a literature review.

BACKGROUND: Anxiety and challenging behaviour (CB) often occur simultaneously in people with intellectual disabilities (ID). Understanding the associations between anxiety and CB may contribute to more accurate diagnoses and management of both anxiety and CB in this population. AIMS: To examine the relationship between anxiety and CB. METHODS: A literature review covering the period from January 2000 to January 2012. RESULTS: Seven studies about the relationship between psychiatric disorders, including anxiety, and CB were identified. These studies confirm the relationship between anxiety and CB in people with ID, although the precise nature of this relationship remains unclear. CONCLUSIONS: The study points toward the existence of a moderate association between anxiety and CB. Further research is needed to clarify the complex nature of the association between anxiety and CB.

Nursing interventions in inpatient psychiatry.

The successful application of the Nursing Interventions Classification (NIC) in inpatient psychiatry depends on whether the classification adequately describes nursing care in this setting. The present study aimed to identify nursing interventions mentioned in journal articles on psychiatric inpatient nursing care and to compare these with the labels, definitions and activities described in the NIC to elucidate how well the classification covers these interventions. The MedLine, PsychInfo, Cochrane and CINAHL databases were searched for journal articles about nursing care in the adult inpatient setting. A qualitative content analysis approach was used to indentify nursing interventions in the articles. About 84% of the statements (terms and definitions) are encompassed by the interventions listed by the NIC. Very few interventions need to be added to the NIC classification or necessitate a reorganization of the taxonomy. Nevertheless, the further development of the NIC will promote its use in the daily work of psychiatric nurses and enhance the quality of nursing care in the inpatient setting.

Oral health care in older people in long term care facilities: a systematic review of implementation strategies.

OBJECTIVES: Oral hygiene is necessary to maintain oral health and quality of life. However, the oral hygiene and the oral health care of older people in long term care facilities are poor. This indicates that care is not in compliance with the available guidelines and protocols, and stresses the importance of a clear evidence-based implementation strategy to improve oral health care. The aim of this study is to review implementation strategies used to promote or improve oral health care for older people in long term care facilities from the perspective of behaviour change, to code strategy content at the level of determinants, and to explore their effectiveness. DESIGN: Systematic review of literature. DATA SOURCES: The digital databases of the Cochrane Library, PubMed and Cinahl have been searched up to September 2011 for relevant articles. REVIEW METHODS: After a systematic selection process, included studies were quality assessed by three researchers. We extracted the study characteristics using the EPOC Data Collection Checklist and Data Abstraction Form. Strategy content was extracted and coded by using the Coding Manual for Behavioural Change Techniques. This manual groups the behaviour change techniques under relevant behavioural determinants. RESULTS: Twenty studies were included in this review. Implementation strategies were delivered by dental hygienists or dentists. Oral health care was performed by nurses and nurse assistants in all studies. All studies addressed knowledge, mostly operationalized as one educational session. Knowledge was most often combined with interventions addressing self efficacy. Implementation strategies aimed at knowledge (providing general information), self-efficacy (modelling) or facilitation of behaviour (providing materials to facilitate behaviour) were most often identified as successful in improving oral health. CONCLUSIONS: Knowledge, self-efficacy and facilitation of behaviour are determinants that are often addressed in implementation strategies for successful improvement of oral health care in older patients. Strategies addressing increasing memory, feedback of clinical outcomes, and mobilizing social norm are promising and should be studied in the future. However, as the quality and heterogeneity of studies is a reason for concern, it is not possible to unequivocally recommend strategies or combinations of strategies for improving oral health care in the older population. When choosing strategies to improve oral health care, care professionals should thoroughly examine the setting and target group, identify barriers to change and tailor their implementation strategies to these barriers for oral health care.

Development and validation of PRE-DELIRIC (PREdiction of DELIRium in ICu patients) delirium prediction model for intensive care patients: observational multicentre study.

OBJECTIVES: To develop and validate a delirium prediction model for adult intensive care patients and determine its additional value compared with prediction by caregivers. DESIGN: Observational multicentre study. SETTING: Five intensive care units in the Netherlands (two university hospitals and three university affiliated teaching hospitals). PARTICIPANTS: 3056 intensive care patients aged 18 years or over. MAIN OUTCOME MEASURE: Development of delirium (defined as at least one positive delirium screening) during patients' stay in intensive care. RESULTS: The model was developed using 1613 consecutive intensive care patients in one hospital and temporally validated using 549 patients from the same hospital. For external validation, data were collected from 894 patients in four other hospitals. The prediction (PRE-DELIRIC) model contains 10 risk factors-age, APACHE-II score, admission group, coma, infection, metabolic acidosis, use of sedatives and morphine, urea concentration, and urgent admission. The model had an area under the receiver operating characteristics curve of 0.87 (95% confidence interval 0.85 to 0.89) and 0.86 after bootstrapping. Temporal validation and external validation resulted in areas under the curve of 0.89 (0.86 to 0.92) and 0.84 (0.82 to 0.87). The pooled area under the receiver operating characteristics curve (n=3056) was 0.85 (0.84 to 0.87). The area under the curve for nurses' and physicians' predictions (n=124) was significantly lower at 0.59 (0.49 to 0.70) for both. CONCLUSION: The PRE-DELIRIC model for intensive care patients consists of 10 risk factors that are readily available within 24 hours after intensive care admission and has a high predictive value. Clinical prediction by nurses and physicians performed significantly worse. The model allows for early prediction of delirium and initiation of preventive measures. Trial registration Clinical trials NCT00604773 (development study) and NCT00961389 (validation study).

Nursing phenomena in inpatient psychiatry.

Little is known about the question if the nursing diagnosis classification of North American Nursing Association-International (NANDA-I) describes the adult inpatient psychiatric nursing care. The present study aimed to identify nursing phenomena mentioned in journal articles about the psychiatric inpatient nursing care and to compare these phenomena with the labels and the definitions of the nursing diagnoses to elucidate how well this classification covers these phenomena. A search of journal articles took place in the databases MedLine, PsychInfo, Cochrane and CINAHL. A qualitative content analysis approach was used to identify nursing phenomena in the articles. Various phenomena were found in the articles. The study demonstrated that NANDA-I describes essential phenomena for the adult inpatient psychiatry on the level of labels and definitions. However, some apparently important nursing phenomena are not covered by the labels or definitions of NANDA-I. Other phenomena are assigned as defining characteristics or as related factors to construct nursing diagnoses. The further development of the classification NANDA-I will strengthen the application in the daily work of psychiatric nurses and enhance the quality of nursing care in the inpatient setting.

Assessment of memory function: the relation between daily observation and neuropsychological test performance.

BACKGROUND: The aim of the study was to explore the value of a daily observation scale in the assessment of patients' memory function by nurses on a geriatric ward. METHODS: An observational study of 50 geriatric inpatients was carried out. The relationship between the memory items of the Nurses' Behavioral Rating Scale for Geriatric Inpatients (GIP) and four types of neuropsychological memory tests was examined: visual paired-associate learning (Visual Association Test, VAT), word-list learning (Eight Word Test, 8WT from the Amsterdam Dementia Screening, ADS), and the subtests Route Recall and Story Recall from the Rivermead Behavioural Memory Test (RBMT). Correlations with the overall measures assessing level of dementia such as the Mini-mental State Examination (MMSE), Clinical Dementia Rating scale (CDR) and the 15-item Geriatric Depression Scale (GDS-15) were examined as well. RESULTS: The Pearson's correlation coefficients between GIP and the four memory tests were between 0.45 and 0.71 (p < 0.01). The GIP correlations with the MMSE and CDR were 0.63 and 0.46, respectively (p < 0.01). No significant correlation was found with the GDS-15. Statistically significant differences in GIP memory scores between patients with dementia and non-demented patients were found (p < 0.01). CONCLUSIONS: Results indicate that an observation scale of memory function may have value for providing information about the underlying memory impairment. The results of nurses' observations may be used in triage contributing to the diagnostic process by selecting patients requiring further neuropsychological assessment.

Effects of educational interventions on primary dementia care: A systematic review.

OBJECTIVE: To determine the effects of educational interventions about dementia, directed at primary care providers (PCPs). DESIGN: We searched Medline, Embase, PsycInfo, Cinahl and the Cochrane library for relevant articles. Two researchers independently assessed the citations identified against the following inclusion criteria: educational intervention on dementia directed at PCPs and study designs being randomized controlled trials (RCTs), controlled clinical trials (CCTs), controlled before and after studies (CBAs) or interrupted time series (ITS) analyses. Outcomes of interest were PCPs' knowledge and attitude on dementia, and quality of dementia care at PCP and patient level. RESULTS: Of 3953 citations identified, six articles representing five studies (four cluster RCTs and one CBA) were eligible, describing educational interventions directed at 1904 PCPs. Compliance to the interventions varied from 18 to 100%. Systematic review of the studies showed moderate positive results. Five articles reported at least some effects of the interventions. A small group workshop and a decision support system (DSS) increased dementia detection rates. An interactive 2-h seminar raised GPs' suspicion of dementia. Adherence to dementia guidelines only improved when an educational intervention was combined with the appointment of dementia care managers. This combined intervention also improved patients' and caregivers' quality of life. Effects on knowledge and attitudes were minor. CONCLUSION: Educational interventions for PCPs that require active participation improve detection of dementia. Educational interventions alone do not seem to increase adherence to dementia guidelines. To effectively change professionals' performance in primary dementia care, education probably needs to be combined with adequate reimbursement or other organizational incentives.

Recognising prodromes of manic or depressive recurrence in outpatients with bipolar disorder: a cross-sectional study.

BACKGROUND: There is some evidence that teaching patients to recognise prodromes of manic and depressive episodes improved time to recurrence and hospitalization, social function, and performance in employment. Little information is available about which prodromal symptom patients with bipolar disorder recognise as being the very first symptom of recurrence. OBJECTIVES: The aims of this study were to describe the very first symptoms in manic or depressive recurrence reported by patients with bipolar disorder and to explore associations between the ability to recognise these prodromal symptoms and the clinical characteristics of these patients. DESIGN: A cross-sectional, descriptive design. SETTINGS: Five psychiatric outpatient clinics in the Netherlands. PARTICIPANTS: 111 outpatients diagnosed with bipolar disorder, currently not in an episode. METHODS: Data were obtained through a face-to-face interview with open ended questions and a questionnaire for demographic and clinical characteristics. Reported prodromes were categorised in an instrument inductively constructed and based on literature review and expert opinion. Associations were calculated with chi squares. RESULTS: The first recognised symptom of recurrence in mania was change in energy level (21%), sleep (17%), and social functioning (16%). In depression it was change in thought (15%), mood stability (12%), energy level (12%), social functioning (11%), and sleep (10%). Twenty-eight percent of the patients were not able to recognise prodromes of recurrence in mania. Also 28% was not able to recognise prodromes of depression, and 12% was not able to recognise either of them. A significant association (p=0.033) was found between the ability to recognise prodromes of depression and the lifetime number of depressive episodes. CONCLUSIONS: The majority of euthymic patients with bipolar disorder are able to recognise prodromes of recurrence. These warning signs often emerge early in the process of recurrence. Our results suggest that patients learn to recognise prodromes of recurrence rather by experience than from therapeutic interventions. Talking to patients and their relatives closely after recovered from an episode to construct the early phase of recurrence can be important to improve recognition and prevent future episodes of mania or depression.

The effect of communication skills training on patient outcomes in cancer care: a systematic review of the literature.

The objective of this review was to determine whether communication training for healthcare professionals (HCP), including nurses and medical doctors, in cancer care improves patient outcomes. Eligible studies with a focus on patient outcomes and a controlled or single group pretest-posttest design were identified according to Cochrane Collaboration Guidelines. Seven studies, encompassing 10 papers and involving five randomised controlled trials, were included. Studies involved 411 HCP, including a total of 1677 encounters with adult cancer patients. Forty-nine papers were excluded, primarily because no patient outcomes were reported. Regarding patient satisfaction outcomes, estimated effects in favour of communication training ranged from 0.07 (95% CI: -0.30 to 0.44) for satisfaction with information and support to 0.70 (95% CI: 0.16 to 1.24) for satisfaction with assessment of concerns. No evidence was found for the effectiveness of communication training on patient distress outcomes. We concluded that the current review reveals inconclusive evidence to prove the effectiveness of communication training on patient satisfaction and patient distress. More high-quality studies are needed.

Internal medicine residents' knowledge about sepsis: effects of a teaching intervention.

The short- and long-term effects of a single teaching intervention for internal medicine residents are not known. Since sepsis is a prevalent and important disease and both therapeutic and diagnostic interventions have been protocolized, we investigated the effects of a sepsis-based single teaching intervention. A prospective before-and-after education study was performed among residents who attended a regional professional training for internal medicine. All residents who participated were invited to complete a questionnaire about the assessment of symptoms and the diagnosis and treatment of sepsis. The questionnaire was filled out before, directly after, and four to six months after the teaching intervention. The overall questionnaire score was expressed on a 0 to 10 scale. A total of 253 questionnaires from 109 training-grade doctors were collected. At baseline, the 'assessment of symptoms of sepsis' score was significantly lower than the 'diagnosis and treatment' score. Following the education session, training-grade doctors' knowledge about sepsis definitions and diagnosis and treatment of sepsis increased from (mean +/- SD ) 6.1 +/- 1.6 to 8.2 +/- 1.2 (p<0.0001. Moreover, four to six months after the teaching intervention, this effect was sustained (p<0.0001 compared with test 1), resulting in a mean score of 7.6 +/- 1.1. Our single teaching intervention resulted in improved and sustained knowledge on the assessment of symptoms, diagnosis and treatment of sepsis.