Caregivers reluctance to use palliative care practices: Construction of a causal model

peer reviewedObjective To identify any reason for healthcare professionals to resist to provide palliative care and to understand the main interactions between these factors, in order to develop a further work project which could modify them. Definition of resistance The passivity or the unconscious refusal, to reproduce behaviours and/or acts corresponding to the basic principles of the palliative approach when facing palliative patients. Target group Healthcare professionals, i.e all professionals who take care of patients suffering from an advanced or incurable disease. These are doctors, nurses, nursing auxiliaries, and also physiotherapists, psychologists, home carers, etc. Family members of the patient or volunteers were excluded from the target group. Method The causal analysis consists in building a causality tree of a specific problem within a team. The presentation under the form of a tree allows the reading of the identified factors, from the closest to the most distant. The causal analysis is a time-consuming method, but it will form the basis of further work of our team. Result The obtained model is an orderly repertory of the factors which contribute to the cause of the problem. Conclusion The members of the analysis unit have shared their knowledge to create a tool. This tool will be used to determine actions in order to reduce directly or indirectly the resistance to provide palliative care.Objectif Cerner l’ensemble des facteurs de la résistance des soignants à pratiquer les soins palliatifs et appréhender les interactions principales entre ces facteurs dans le but de développer un projet de travail ultérieur, susceptible de les modifier. Définition de la résistance La passivité ou le refus inconscient, devant un patient « palliatif », à mettre en œuvre des attitudes et/ou des actes appris qui s’inscrivent dans les principes de base de l’approche palliative. Public cible Les soignants, c’est-à-dire l’ensemble des professionnels qui s’occupent des patients atteints d’une maladie grave ou incurable. Il s’agit des médecins, des infirmiers, des aides-soignantes mais aussi des kinésithérapeutes, des psychologues, des gardes à domicile, des aides familiales, etc. Sont exclus du public cible les membres de la famille du patient et les volontaires. Méthode L’analyse causale qui consiste à construire, en équipe, un arbre de causalité d’un problème spécifique. La présentation sous forme d’arbre permet la lecture des différents facteurs recensés, des plus proches aux plus éloignés. L’analyse causale est une méthode consommatrice de temps, mais elle va constituer le fondement du travail ultérieur de la Plate-forme. Résultat Le modèle obtenu est un répertoire ordonné des facteurs qui participent à la cause du problème. Conclusion Les membres de la cellule d’analyse ont mis leurs savoirs en commun pour créer un outil de référence. Cet outil servira à définir des actions pour modifier directement ou indirectement la résistance des soignants à appliquer les soins palliatifs

Inflammatory response to strenuous muscular exercise in man

Based on the humoral and cellular changes occurring during strenuous muscular work in humans, the concept of inflammatory response to exercise (IRE) is developed. The main indices of IRE consist of signs of an acute phase response, leucocytosis and leucocyte activation, release of inflammatory mediators, tissue damage and cellular infiltrates, production of free radicals, activation of complement, and coagulation and fibrinolytic pathways. Depending on exercise intensity and duration, it seems likely that muscle and/or associated connective tissue damage, contact system activation due to shear stress on endothelium and endotoxaemia could be the triggering mechanisms of IRE. Although this phenomenon can be considered in most cases as a physiological process associated with tissue repair, exaggerated IRE could have physiopathological consequences. On the other hand, the influence of several factors such as age, sex, training, hormonal status, nutrition, anti-inflammatory drugs, and the extent to which IRE could be a potential risk for subjects undergoing intense physical training require further study

Evaluation of Glomerular Filtration Rate in Clinical Practice

peer reviewedGlomerular filtration rate (GFR) is the most frequently used parameter to evaluate the renal function. GFR may be estimated with serum creatinine, creatinine clearance based on 24 hours urine collection or Cockcroft formula. All these methods have bias. Other approaches have thus been proposed. The limitations and advantages of isotopic methods and recent mathematical approaches (MDRD formula) are reviewed

When the Earth trembles in the americas: the experience of haiti and chile 2010.

The response of the nephrological community to the Haiti and Chile earthquakes which occurred in the first months of 2010 is described. In Haiti, renal support was organized by the Renal Disaster Relief Task Force (RDRTF) of the International Society of Nephrology (ISN) in close collaboration with Médecins Sans Frontières (MSF), and covered both patients with acute kidney injury (AKI) and patients with chronic kidney disease (CKD). The majority of AKI patients (19/27) suffered from crush syndrome and recovered their kidney function. The remaining 8 patients with AKI showed acute-to-chronic renal failure with very low recovery rates. The intervention of the RDRTF-ISN involved 25 volunteers of 9 nationalities, lasted exactly 2 months, and was characterized by major organizational difficulties and problems to create awareness among other rescue teams regarding the availability of dialysis possibilities. Part of the Haitian patients with AKI reached the Dominican Republic (DR) and received their therapy there. The nephrological community in the DR was able to cope with this extra patient load. In both Haiti and the DR, dialysis treatment was able to be prevented in at least 40 patients by screening and adequate fluid administration. Since laboratory facilities were destroyed in Port-au-Prince and were thus lacking during the first weeks of the intervention, the use from the very beginning on of a point-of-care device (i-STAT®) was very efficient for the detection of aberrant kidney function and electrolyte parameters. In Chile, nephrological problems were essentially related to difficulties delivering dialysis treatment to CKD patients, due to the damage to several units. This necessitated the reallocation of patients and the adaptation of their schedules. The problems could be handled by the local nephrologists. These observations illustrate that local and international preparedness might be life-saving if renal problems occur in earthquake circumstances

Effects of methylprednisolone on exercise-induced increases of plasma levels of polymorphonuclear elastase and myeloperoxidase in man. Preliminary results

The aim of the present study was to verify whether a single oral dose of methylprednisolone could modulate the exercise-induced release of polymorphonuclear neutrophil (PMN) elastase and myeloperoxidase. Four healthy, male subjects were submitted to a 20 min downhill run (−20%) at 60% VO2 max, 3 h after oral absorption of a placebo or a single dose of 32 mg methylprednisolone. A marked neutrophilia (+103% of basal PMN count; p < 0.02) was observed 3 h after methylprednisolone ingestion. During both exercise trials, placebo and methylprednisolone, PMN counts were increased by 46% and 19% (p < 0.05), respectively. The running test caused marked and significant (p < 0.05) increases in plasma myeloperoxidase concentration (MPO). The magnitude of MPO changes was the same in the two trials (+110%). Exercise also resulted in significant changes in plasma elastase concentration (EL) in both experimental conditions (placebo: +104%, p < 0.05; methylprednisolone: +338%, p < 0.005). Plasma elastase levels reached at the end of exercise on methylprednisolone were significantly higher than after placebo (p < 0.05). A significant relationship was found between EL and PMN in methylprednisolone trial only (r = 0.72; l0 < 0.005). These results showed that the transient exercise-induced release of elastase and myeloperoxidase were not decreased by methylprednisolone

Piroxicam fails to reduce myocellular enzyme leakage and delayed onset muscle soreness induced by isokinetic eccentric exercise

To test the hypothesis that delayed onset muscular soreness (DOMS) following intense eccentric muscle contraction could be due to increased production of prostaglandin E2 (PGE2), ten healthy male subjects were studied. Using a double-blind randomized crossover design, each subject performed two isokinetic tests separated by a period of at least 6 weeks: once with placebo, and once with piroxicam (Feldene®). They were given one capsule containing either placebo or piroxicam (20 mg) per day for 6 days with initial doses given starting 3 days prior to isokinetic testing. Exercise consisted of eight stages of five maximal contractions of the knee extensor and flexor muscle groups of both legs separated by 1 min rest phases, on a Kin Trex device at 60°/s angular velocity. The subjective presence and intensity of DOMS were evaluated using a visual analogue scale immediately after, and 24 and 48 h after each test. The mean plasma concentration of PGE2 measured at rest and after exercise was significantly lower in the group treated with piroxicam (p < 0.05). However, statistical analysis (two-way ANOVA test) revealed that exercise did not cause any significant change of mean plasma PGE2 over time in either of the two groups. Eccentric work was followed by severe muscle pain in extensor and flexor muscle groups. Maximal soreness was noted 48 h postexercise. Serum creatine kinase activity and the serum concentration of myoglobin increased significantly, and reached peak values 48 h after exercise in both experimental conditions (p < 0.001). By paired t-test, it appeared that there were no significant differences in the serum levels of these two markers of muscle damage between the two groups at any time point. We conclude that: (1) oral administration of piroxicam fails to reduce muscle damage and DOMS caused by strenuous eccentric exercise; and (2) the hypothetical role of increased PGE2 production in eccentric exercise-induced muscle damage, DOMS, and reduced isokinetic performance is not substantiated by the present results