Abdominal shotgun trauma: A case report

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Ethical and practical challenges in implementing informed consent in HIV/AIDS clinical trials in developing or resource-limited countries

Background/rationale: Ethical issues regarding HIV/AIDS human research in the developing world remain under continuous evaluation; a critical area of concern includes informed consent. This paper reviews several of the most important ethical and practical aspects of informed consent in HIV research in developing countries. Enhancement of overall understanding of such key issues might promote higher ethical standards of future research.Objectives: The major objective was to address informed consent in human research in non-Western societies, and specifically in HIV clinical trials of affected adults. Secondary end-points included the consent complexities in HIV research involving vulnerable patient populations in resource-limited nations, such as children, adolescents and women.Methods: A systematic review of the published literature using MEDLINE and EMBASE from 1998 until December 2008 was performed, using the search terms ‘HIV/AIDS’, ‘informed consent’, ‘clinical trials’, ‘developing world’.Results: Ethical complexities such as participants’ diminished autonomy, coercion or monetary inducement, language difficulties, illiteracy or lack of true understanding of the entire study, cultural barriers mainly due to communitarianism and social diversities were identified in the 44 studies reviewed. Informed consent of vulnerable patient populations must be tailored to their sex and developmental age, while counselling is fundamental. Children and adolescents’ assent must be ensured. Local language is to be used, while trusted community leaders and local cultural representatives may convey information.Discussion: Despite the heterogeneity of studies, similarities were  identified. Providing adequate and comprehensive information and assessing the true understanding of the research represent fundamental prerequisites. Potential solutions to the critical areas of concern include peer counselling and meetings with local community leaders or local cultural representatives. Conclusions: International investigators of HIV human research should bear in mind these ethical issues and their potential solutions, when trying to ensure ethical research conduct, based on a truly informed and culturally relevant consent

Adjacent LSTM-Based Page Scheduling for Hybrid DRAM/NVM Memory Systems

Recent advances in memory technologies have led to the rapid growth of hybrid systems that combine traditional DRAM and Non Volatile Memory (NVM) technologies, as the latter provide lower cost per byte, low leakage power and larger capacities than DRAM, while they can guarantee comparable access latency. Such kind of heterogeneous memory systems impose new challenges in terms of page placement and migration among the alternative technologies of the heterogeneous memory system. In this paper, we present a novel approach for efficient page placement on heterogeneous DRAM/NVM systems. We design an adjacent LSTM-based approach for page placement, which strongly relies on page accesses prediction, while sharing knowledge among pages with behavioral similarity. The proposed approach leads up to 65.5% optimized performance compared to existing approaches, while achieving near-optimal results and saving 20.2% energy consumption on average. Moreover, we propose a new page replacement policy, namely clustered-LRU, achieving up to 8.1% optimized performance, compared to the default Least Recently Used (LRU) policy

Undergraduate nursing students' knowledge about palliative care and attitudes towards end-of-life care: a three-cohort, cross-sectional survey.

Background: Ensuring adequate knowledge about palliative care and positive attitudes towards death and dying are crucial educational aspects when preparing undergraduate nursing students to respond effectively to the complexities of care for people affected by a progressive, life-limiting illness. In undergraduate nursing education in Greece, the level of students' attained knowledge and developed attitudes towards palliative and end-of-life care remain unknown. Purpose: To investigate undergraduate nursing students' knowledge about palliative care and attitudes towards death and end-of-life care, and explore demographic and academic factors as potential moderators of student knowledge and attitudes. Methods: We conducted a descriptive, cross-sectional, questionnaire-based survey. We recruited 2nd, 3rd and 4th year undergraduate nursing students from the country's two University Faculties. Participants completed a demographic form, the Palliative Care Quiz for Nursing (PCQN), and the Frommelt Attitudes Towards Care of the Dying (FATCOD) questionnaire. Results: The final sample was 529 students (response rate = 87.6%). Mean total PCQN scores revealed low levels of knowledge. Knowledge about pain/symptom management and psychosocial/spiritual care was insufficient. Mean total FATCOD scores indicated positive, liberal and supportive attitudes towards end-of-life care, with 60% of respondents keen to care for a dying person and their family. We noted less positive attitudes mainly in relation to student comfort with the care of a dying person and his/her imminent death. Academic parameters (year of study) and student demographic characteristics (older age) were the most significant moderators of both knowledge and attitudes. Greater knowledge about palliative care was a relatively weak, yet significant, predictor of more liberal attitudes towards care of the dying. Conclusion: Our findings suggest that structured courses in palliative care can be a core part of undergraduate nursing education. Specific attention could be given to such areas patient-health professional communication, misconceptions and biases towards death and dying, and comfort in caring for the dying in order to prepare student nurses to psychologically deal with the sensitive and challenging process of death and dying

Paraganglioma of the greater omentum: Case report and review of the literature

<p>Abstract</p> <p>Background</p> <p>Extra-adrenal, intra-abdominal paraganglioma constitutes a rare neoplasm and, moreover, its location in the greater omentum is extremely infrequent.</p> <p>Case presentation</p> <p>A 46-year-old woman with an unremarkable medical history presented with an asymptomatic greater omentum mass that was discovered incidentally during ultrasonographic evaluation due to menstrual disturbances. Clinical examination revealed a mobile, non-tender, well-circumscribed mass in the right upper and lower abdominal quadrant. Blood tests were normal. Contrast-enhanced abdominal computed tomography (CT) scan confirmed a huge (15 × 15 cm), well-demarcated, solid and cystic, heterogeneously enhanced mass between the right liver lobe and right kidney. Exploratory laparotomy revealed a large mass in the greater omentum. The tumor was completely excised along with the greater omentum. Histopathology offered the diagnosis of benign greater omentum paraganglioma. After an uneventful postoperative course, the patient was discharged on the 4^thpostoperative day. She remains free of disease for 2 years as appears on repeated CT scans as well as magnetic resonance imaging (MRI) and scintigraphy performed with radiotracer-labeled metaiodobenzyl-guanidine (MIBG) scans.</p> <p>Conclusion</p> <p>This is the second reported case of greater omentum paraganglioma. Clinical and imaging data of patients with extra-adrenal, intra-abdominal paragangliomas are variable while many of them may be asymptomatic even when the lesion is quite large. Thorough histopathologic evaluation is imperative for diagnosis and radical excision is the treatment of choice. Since there are no definite microscopic criteria for the distinction between benign and malignant tumors, prolonged follow-up is necessary.</p

Infections in a surgical intensive care unit of a university hospital in Greece

SummaryObjectivesWe aimed to evaluate the clinical and microbiological characteristics of the patients who developed an infection in our surgical intensive care unit (SICU).MethodsThis was a prospective study of all patients who sustained an ICU-acquired infection from 2002 to 2004.ResultsAmong 683 consecutive SICU patients, 123 (18.0%) developed 241 infections (48.3 infections per 1000 patient-days). The mean age of patients was 66.7±3.8 years, the mean APACHE II score (acute physiology and chronic health evaluation) on SICU admission was 18.2±2.4, and the mean SOFA score (sepsis-related organ failure assessment) at the onset of infection was 8.8±2. Of the study patients, 51.2% were women. Infections were: bloodstream (36.1%), ventilator-associated pneumonia (VAP; 25.3%, 20.3/1000 ventilator-days), surgical site (18.7%), central venous catheter (10.4%, 7.1/1000 central venous catheter-days), and urinary tract infection (9.5%, 4.6/1000 urinary catheter-days). The most frequent microorganisms found were: Acinetobacter baumannii (20.3%), Pseudomonas aeruginosa (15.7%), Candida albicans (13.2%), Enterococcus faecalis (10.4%), Klebsiella pneumoniae (9.2%), Enterococcus faecium (7.9%), and Staphylococcus aureus (6.7%). High resistance to the majority of antibiotics was identified. The complication and mortality rates were 58.5% and 39.0%, respectively. Multivariate analysis identified APACHE II score on admission (odds ratio (OR) 4.63, 95% confidence interval (CI) 2.69–5.26, p=0.01), peritonitis (OR 1.85, 95% CI 1.03–3.25, p=0.03), acute pancreatitis (OR 2.27, 95% CI 1.05–3.75, p=0.02), previous aminoglycoside use (OR 2.84, 95% CI 1.06–5.14, p=0.03), and mechanical ventilation (OR 3.26, 95% CI: 2.43–6.15, p=0.01) as risk factors for infection development. Age (OR 1.16, 95% CI 1.01–1.33, p=0.03), APACHE II score on admission (OR 2.53, 95% CI 1.77–3.41, p=0.02), SOFA score at the onset of infection (OR 2.88, 95% CI 1.85–4.02, p=0.02), and VAP (OR 1.32, 95% CI 1.04–1.85, p=0.03) were associated with mortality.ConclusionsInfections are an important problem in SICUs due to high incidence, multi-drug resistance, complications, and mortality rate. In our study, APACHE II score on admission, peritonitis, acute pancreatitis, previous aminoglycoside use, and mechanical ventilation were identified as risk factors for infection development, whereas age, APACHE II score on admission, SOFA score at the onset of infection, and VAP were associated with mortality

Interfacility transfers in a non-trauma system setting: an assessment of the Greek reality

<p>Abstract</p> <p>Background</p> <p>Quality assessment of any trauma system involves the evaluation of the transferring patterns. This study aims to assess interfacility transfers in the absence of a formal trauma system setting and to estimate the benefits from implementing a more organized structure.</p> <p>Methods</p> <p>The 'Report of the Epidemiology and Management of Trauma in Greece' is a one year project of trauma patient reporting throughout the country. It provided data concerning the patterns of interfacility transfers. We compared the transferred patient group to the non transferred patient group. Information reviewed included patient and injury characteristics, need for an operation, Intensive Care Unit (ICU) admittance and mortality. Analysis employed descriptive statistics and Chi-square test. Interfacility transfers were then assessed according to each health care facility's availability of five requirements; Computed Tomography scanner, ICU, neurosurgeon, orthopedic and vascular surgeon.</p> <p>Results</p> <p>Data on 8,524 patients were analyzed; 86.3% were treated at the same facility, whereas 13.7% were transferred. Transferred patients tended to be younger, male, and more severely injured than non transferred patients. Moreover, they were admitted to ICU more often, had a higher mortality rate but were less operated on compared to non transferred patients. The 34.3% of transfers was from facilities with none of the five requirements, whereas the 12.4% was from those with one requirement. Low level facilities, with up to three requirements transferred 43.2% of their transfer volume to units of equal resources.</p> <p>Conclusion</p> <p>Trauma management in Greece results in a high number of transfers. Patients are frequently transferred between low level facilities. Better coordination could lead to improved outcomes and less cost.</p