Defining needs and goals of post-ICU care for trauma patients: preliminary study

Background: The aim of this study was to assess the long-term physical and psychological disabilities and their economic impact in severe trauma survivors. Methods: adult patients with injury severity score >15 and Abbreviated Injury Scale ≤3 admitted to the ICU of a level 1 trauma centre in the lazio region and discharged alive from hospital underwent a structured interview 12-24 months after the event. self-reported somatic symptoms, autonomy, anxiety and depression were evaluated using a Likert-type Scale, Barthel Index and Hospital Anxiety and Depression Score (HADS), respectively. Patients’ working and economic status were also investigated. Results: A total of 32/58 patients matching the inclusion criteria were included in the final analysis. eighteen patients (56%) reported at least a partial restriction in daily activities. Most common symptoms included muscle or joint pain, fatigue, and headache. All patients were receiving rehabilitation 1-2 years after the event. Fifty-eight percent of the patients spent more than €3600/year from their family budget for rehabilitation and medical care, however only 25% were receiving financial support from regional social services and 44% were unemployed at the time of the interview. thirty patients (94%) had HADS Depression Score≥11. Conclusion: Survivors of severe trauma in our cohort had limited autonomy and need long-term rehabilitation. Most of them rely on private healthcare services with a significant financial impact on their family budget. Almost all patients had moderate to severe depression. Future post-ICU counseling services should facilitate access to rehabilitation and psychological support for these patient

The Impact of Adherence to Screening Guidelines and of Diabetes Clinics Referral on Morbidity and Mortality in Diabetes

Despite the heightened awareness of diabetes as a major health problem, evidence on the impact of assistance and organizational factors, as well as of adherence to recommended care guidelines, on morbidity and mortality in diabetes is scanty. We identified diabetic residents in Torino, Italy, as of 1st January 2002, using multiple independent data sources. We collected data on several laboratory tests and specialist medical examinations to compare primary versus specialty care management of diabetes and the fulfillment of a quality-of-care indicator based on existing screening guidelines (GCI). Then, we performed regression analyses to identify associations of these factors with mortality and cardiovascular morbidity over a 4 year- follow-up. Patients with the lowest degree of quality of care (i.e. only cared for by primary care and with no fulfillment of GCI) had worse RRs for all-cause (1.72 [95% CI 1.57–1.89]), cardiovascular (1.74 [95% CI 1.50–2.01]) and cancer (1.35 [95% CI 1.14–1.61]) mortality, compared with those with the highest quality of care. They also showed increased RRs for incidence of major cardiovascular events up to 2.03 (95% CI 1.26–3.28) for lower extremity amputations. Receiving specialist care itself increased survival, but was far more effective when combined with the fulfillment of GCI. Throughout the whole set of analysis, implementation of guidelines emerged as a strong modifier of prognosis. We conclude that management of diabetic patients with a pathway based on both primary and specialist care is associated with a favorable impact on all-cause mortality and CV incidence, provided that guidelines are implemented

Effective implementation of research into practice: an overview of systematic reviews of the health literature

<p>Abstract</p> <p>Background</p> <p>The gap between research findings and clinical practice is well documented and a range of interventions has been developed to increase the implementation of research into clinical practice.</p> <p>Findings</p> <p>A review of systematic reviews of the effectiveness of interventions designed to increase the use of research in clinical practice. A search for relevant systematic reviews was conducted of Medline and the Cochrane Database of Reviews 1998-2009. 13 systematic reviews containing 313 primary studies were included. Four strategy types are identified: audit and feedback; computerised decision support; opinion leaders; and multifaceted interventions. Nine of the reviews reported on multifaceted interventions. This review highlights the small effects of single interventions such as audit and feedback, computerised decision support and opinion leaders. Systematic reviews of multifaceted interventions claim an improvement in effectiveness over single interventions, with effect sizes ranging from small to moderate. This review found that a number of published systematic reviews fail to state whether the recommended practice change is based on the best available research evidence.</p> <p>Conclusions</p> <p>This overview of systematic reviews updates the body of knowledge relating to the effectiveness of key mechanisms for improving clinical practice and service development. Multifaceted interventions are more likely to improve practice than single interventions such as audit and feedback. This review identified a small literature focusing explicitly on getting research evidence into clinical practice. It emphasizes the importance of ensuring that primary studies and systematic reviews are precise about the extent to which the reported interventions focus on changing practice based on research evidence (as opposed to other information codified in guidelines and education materials).</p

Sex differences in the relative contribution of social and clinical factors to the Health Utilities Index Mark 2 measure of health-related quality of life in older home care clients

Abstract Background The heterogeneity evident among home care clients highlights the need for greater understanding of the clinical and social determinants of multi-dimensional health-related quality of life (HRQL) indices and of potential sex-differences in these determinants. We examined the relative contribution of social and clinical factors to HRQL among older home care clients and explored whether any of the observed associations varied by sex. Methods The Canadian-US sample included 514 clients. Self-reported HRQL was measured during in-home interviews (2002-04) using the Health Utilities Index Mark 2 (HUI2). Data on clients' sociodemographic, health and clinical characteristics were obtained with the Minimum Data Set for Home Care. The relative associations between clients' characteristics and HUI2 scores were examined using multivariable linear regression models. Results Women had a significantly lower mean HUI2 score than men (0.48, 95%CI 0.46-0.50 vs. 0.52, 0.49-0.55). Clients with distressed caregivers and poor self-rated health exhibited significantly lower HRQL scores after adjustment for a comprehensive list of clinical conditions. Several other factors remained statistically significant (arthritis, psychiatric illness, bladder incontinence, urinary tract infection) or clinically important (reported loneliness, congestive heart failure, pressure ulcers) correlates of lower HUI2 scores in adjusted analyses. These associations generally did not vary significantly by sex. Conclusion For females and males, HRQL scores were negatively associated with conditions predictive or indicative of disability and with markers of psychosocial stress. Despite sex differences in the prevalence of social and clinical factors likely to affect HRQL, few varied significantly by sex in their relative impact on HUI2 scores. Further exploration of differences in the relative importance of clinical and psychosocial well-being (e.g., loneliness) to HRQL among female and male clients may help guide the development of sex-specific strategies for risk screening and care management

Guidelines for management of ischaemic stroke and transient ischaemic attack 2008

This article represents the update of the European Stroke Initiative Recommendations for Stroke Management. These guidelines cover both ischaemic stroke and transient ischaemic attacks, which are now considered to be a single entity. The article covers referral and emergency management, Stroke Unit service, diagnostics, primary and secondary prevention, general stroke treatment, specific treatment including acute management, management of complications, and rehabilitation

Determinanti del successo della raccolta differenziata dei Rifiuti Solidi Urbani nelle Regioni Italiane: Modelli di Governance

OBIETTIVI: Le gestioni virtuose dei rifiuti dovrebbero comprendere efficaci interventi di riduzione a monte della produzione e della nocività del rifiuto, associati ad una puntuale raccolta differenziata. A tal proposito, l’analisi dei dati riferiti alle regioni italiane (APAT, 2007) mostra una situazione di scarsa efficacia delle politiche gestionali dei rifiuti solidi urbani fin ora attuate, con apprezzabili disomogeneità tra le regioni. Obiettivo del presente lavoro è di, attraverso un’analisi comparata delle 20 regioni italiane, individuare e valutare il peso di alcuni determinanti che possono incidere sul successo della Governance Politica e di Sanità Pubblica, relativamente alla raccolta differenziata dei rifiuti. MATERIALI: A partire da una ricerca di letteratura da fonti istituzionali (APAT, Ministero dell’Interno, ISTAT, ecc..) e da fonti primarie, sono stati raccolti ed analizzati indicatori regionali riferiti allo stesso periodo temporale,rispettivamente a: -contesto economico-sociale (ammontare della popolazione; PIL; ecc.); -tessuto produttivo (produzione rifiuti e consumo di energia, ecc.); -governance ambientale (spesa per la protezione ambientale; spesa per comunicazione/educazione ambientale; ecc.); - consumi (per uso domestico, ecc..); -empowerment (capitale sociale, opinione sulla raccolta differenziata, ecc.) -accessibilità (ai contenitori per la raccolta differenziata, ecc.). I dati tra variabili di interesse e di outcome (raccolta percentuale differenziata) sono stati elaborati attraverso il test di Correlazione dei Ranghi di Spearman–adjusted Bonferroni (per una significatività statica p&lt;0.05). RIASSUNTO: L’analisi ha indicato come correlazioni statistiche significative inferenti la raccolta differenziata dei rifiuti: il tessuto produttivo (r=0.8872) e l’accessibilità del cittadino per raccolta differenziata di carta (r=0.8253), di vetro (r=0.8752), di farmaci (r=0.8161), di alluminio (r=0.9216), di plastica (r=0.8838) od altro (r=0.8376). Inoltre la correlazione appare significativa non solo rispetto alle spese per i consumi finali che il cittadino ha (r=0.8647) ma, e fondamentalmente, rispetto all’empowerment (r=0.7949) ed in particolare alla “capacità di sviluppo dei servizi sociali” (r=0.8309). CONCLUSIONI: Considerando l’importanza dell’impatto che la raccolta differenziata ha sull’ambiente, il successo della stessa assume valore basilare in relazione ad una governance virtuosa dell’ambiente. I soli requisiti strutturali (espressione dell’accessibilità ai raccoglitori) possono non essere però gli unici determinanti del successo della policy ambientale, costituendo l’empowerment del singolo cittadino e/o della comunità un aspetto di cui tenere sempre più conto