The impact of religion on changes in end-of-life practices in European intensive care units: a comparative analysis over 16 years

PURPOSE

Religious beliefs affect end-of-life practices in intensive care units (ICUs). Changes over time in end-of-life practices were not investigated regarding religions.

METHODS

Twenty-two European ICUs (3 regions: Northern, Central, and Southern Europe) participated in both Ethicus-1 (years 1999-2000) and Ethicus-2 studies (years 2015-2016). Data of ICU patients who died or had limitations of life-sustaining therapy were analysed regarding changes in end-of-life practices and patient/physician religious affiliations. Frequencies, timing of decision-making, and religious affiliations of physicians/patients were compared using the same definitions.

RESULTS

In total, 4592 adult ICU patients (n = 2807 Ethicus-1, n = 1785 Ethicus-2) were analysed. In both studies, patient and physician religious affiliations were mostly Catholic, Greek Orthodox, Jewish, Protestant, or unknown. Treating physicians (but not patients) commonly reported no religious affiliation (18%). Distribution of end-of-life practices with respect to religion and geographical regions were comparable between the two studies. Withholding [n = 1143 (40.7%) Ethicus-1 and n = 892 (50%) Ethicus-2] and withdrawing [n = 695 (24.8%) Ethicus-1 and n = 692 (38.8%) Ethicus-2] were most commonly decided. No significant changes in end-of-life practices were observed for any religion over 16 years. The number of end-of-life discussions with patients/ families/ physicians increased, while mortality and time until first decision decreased.

CONCLUSIONS

Changes in end-of-life practices observed over 16 years appear unrelated to religious affiliations of ICU patients or their treating physicians, but the effects of religiosity and/or culture could not be assessed. Shorter time until decision in the ICU and increased numbers of patient and family discussions may indicate increased awareness of the importance of end-of-life decision-making in the ICU.

Decision-making conversations for life-sustaining treatment with seriously ill patients using a Danish version of the US POLST: a qualitative study of patient and physician experiences

OBJECTIVE

To explore patients' and physicians' perspectives on a decision-making conversation for life-sustaining treatment, based on the Danish model of the American Physician Orders for Life Sustaining Treatment (POLST) form.

DESIGN

Semi-structured interviews following a conversation about preferences for life-sustaining treatment.

SETTING

Danish hospitals, nursing homes, and general practitioners' clinics.

SUBJECTS

Patients and physicians.

MAIN OUTCOME MEASURES

Qualitative analyses of interview data.

FINDINGS

After participating in a conversation about life-sustaining treatment using the Danish POLST form, a total of six patients and five physicians representing different settings and age groups participated in an interview about their experience of the process. Within the main research questions, six subthemes were identified: Timing, relatives are key persons, clarifying treatment preferences, documentation across settings, strengthening patient autonomy, and structure influences conversations. Most patients and physicians found having a conversation about levels of life-sustaining treatment valuable but also complicated due to the different levels of knowledge and attending to individual patient needs and medical necessities. Relatives were considered as key persons to ensure the understanding of the treatment trajectory and the ability to advocate for the patient in case of a medical crisis. The majority of participants found that the conversation strengthened patient autonomy.

CONCLUSION

Patients and physicians found having a conversation about levels of life-sustaining treatment valuable, especially for strengthening patient autonomy. Relatives were considered key persons. The timing of the conversation and securing sufficient knowledge for shared decision-making were the main perceived challenges.KEY POINTSConversations about preferences for life-sustaining treatment are important, but not performed systematically.When planning a conversation about preferences for life-sustaining treatment, the timing of the conversation and the inclusion of relatives are key elements.Decision-making conversations can help patients feel in charge and less alone, and make it easier for health professionals to provide goal-concordant care.Using a model like the Danish POLST form may help to initiate, conduct and structure conversations about preferences for life-sustaining treatment.

Discussing patient preferences for levels of life-sustaining treatment: development and pilot testing of a Danish POLST form

BACKGROUND

Medically frail and/or chronically ill patients are often admitted to Danish hospitals without documentation of patient preferences. This may lead to inappropriate care. Modelled on the American Physician Orders for Life-Sustaining Treatment (POLST) form, the purpose of the study was to develop and pilot test a Danish POLST form to ensure that patients' preferences for levels of life-sustaining treatment are known and documented.

METHODS

The study was a mixed methods study. In the initial phase, a Danish POLST form was developed on the basis of literature and recommendations from the National POLST organisation in the US. A pilot test of the Danish POLST form was conducted in hospital wards, general practitioners' clinics, and nursing homes. Patients were eligible for inclusion if death was assessed as likely within 12 months. The patient and his/her physician engaged in a conversation where patient values, beliefs, goals for care, diagnosis, prognosis, and treatment alternatives were discussed. The POLST form was completed based on the patient's values and preferences. Family members and/or nursing staff could participate. Participants' assessments of the POLST form were evaluated using questionnaires, and in-depth interviews were conducted to explore experiences with the POLST form and the conversation.

RESULTS

In total, 25 patients participated, 45 questionnaires were completed and 14 interviews were conducted. Most participants found the POLST form readable and understandable, and 93% found the POLST form usable to a high or very high degree for discussing preferences regarding life-sustaining treatment. Three themes emerged from the interviews: (a) an understandable document is essential for the conversation, (b) handling and discussing wishes, and (c) significance for the future.

CONCLUSION

The Danish version of the POLST form is assessed by patients, families, physicians, and nurses as a useful model for obtaining and documenting Danish patients' preferences for life-sustaining treatment. However, this needs to be confirmed in a larger-scale study.

Variations in end-of-life practices in intensive care units worldwide (Ethicus-2): a prospective observational study

BACKGROUND

End-of-life practices vary among intensive care units (ICUs) worldwide. Differences can result in variable use of disproportionate or non-beneficial life-sustaining interventions across diverse world regions. This study investigated global disparities in end-of-life practices.

METHODS

In this prospective, multinational, observational study, consecutive adult ICU patients who died or had a limitation of life-sustaining treatment (withholding or withdrawing life-sustaining therapy and active shortening of the dying process) during a 6-month period between Sept 1, 2015, and Sept 30, 2016, were recruited from 199 ICUs in 36 countries. The primary outcome was the end-of-life practice as defined by the end-of-life categories: withholding or withdrawing life-sustaining therapy, active shortening of the dying process, or failed cardiopulmonary resuscitation (CPR). Patients with brain death were included in a separate predefined end-of-life category. Data collection included patient characteristics, diagnoses, end-of-life decisions and their timing related to admission and discharge, or death, with comparisons across different regions. Patients were studied until death or 2 months from the first limitation decision.

FINDINGS

Of 87 951 patients admitted to ICU, 12 850 (14·6%) were included in the study population. The number of patients categorised into each of the different end-of-life categories were significantly different for each region (p<0·001). Limitation of life-sustaining treatment occurred in 10 401 patients (11·8% of 87 951 ICU admissions and 80·9% of 12 850 in the study population). The most common limitation was withholding life-sustaining treatment (5661 [44·1%]), followed by withdrawing life-sustaining treatment (4680 [36·4%]). More treatment withdrawing was observed in Northern Europe (1217 [52·8%] of 2305) and Australia/New Zealand (247 [45·7%] of 541) than in Latin America (33 [5·8%] of 571) and Africa (21 [13·0%] of 162). Shortening of the dying process was uncommon across all regions (60 [0·5%]). One in five patients with treatment limitations survived hospitalisation. Death due to failed CPR occurred in 1799 (14%) of the study population, and brain death occurred in 650 (5·1%). Failure of CPR occurred less frequently in Northern Europe (85 [3·7%] of 2305), Australia/New Zealand (23 [4·3%] of 541), and North America (78 [8·5%] of 918) than in Africa (106 [65·4%] of 162), Latin America (160 [28·0%] of 571), and Southern Europe (590 [22·5%] of 2622). Factors associated with treatment limitations were region, age, and diagnoses (acute and chronic), and country end-of-life legislation.

INTERPRETATION

Limitation of life-sustaining therapies is common worldwide with regional variability. Withholding treatment is more common than withdrawing treatment. Variations in type, frequency, and timing of end-of-life decisions were observed. Recognising regional differences and the reasons behind these differences might help improve end-of-life care worldwide.

FUNDING

None.

Changes in End-of-Life Practices in European Intensive Care Units From 1999 to 2016

IMPORTANCE

End-of-life decisions occur daily in intensive care units (ICUs) around the world, and these practices could change over time.

OBJECTIVE

To determine the changes in end-of-life practices in European ICUs after 16 years.

DESIGN, SETTING, AND PARTICIPANTS

Ethicus-2 was a prospective observational study of 22 European ICUs previously included in the Ethicus-1 study (1999-2000). During a self-selected continuous 6-month period at each ICU, consecutive patients who died or had any limitation of life-sustaining therapy from September 2015 until October 2016 were included. Patients were followed up until death or until 2 months after the first treatment limitation decision.

EXPOSURES

Comparison between the 1999-2000 cohort vs 2015-2016 cohort.

MAIN OUTCOMES AND MEASURES

End-of-life outcomes were classified into 5 mutually exclusive categories (withholding of life-prolonging therapy, withdrawing of life-prolonging therapy, active shortening of the dying process, failed cardiopulmonary resuscitation [CPR], brain death). The primary outcome was whether patients received any treatment limitations (withholding or withdrawing of life-prolonging therapy or shortening of the dying process). Outcomes were determined by senior intensivists.

RESULTS

Of 13 625 patients admitted to participating ICUs during the 2015-2016 study period, 1785 (13.1%) died or had limitations of life-prolonging therapies and were included in the study. Compared with the patients included in the 1999-2000 cohort (n = 2807), the patients in 2015-2016 cohort were significantly older (median age, 70 years [interquartile range {IQR}, 59-79] vs 67 years [IQR, 54-75]; P < .001) and the proportion of female patients was similar (39.6% vs 38.7%; P = .58). Significantly more treatment limitations occurred in the 2015-2016 cohort compared with the 1999-2000 cohort (1601 [89.7%] vs 1918 [68.3%]; difference, 21.4% [95% CI, 19.2% to 23.6%]; P < .001), with more withholding of life-prolonging therapy (892 [50.0%] vs 1143 [40.7%]; difference, 9.3% [95% CI, 6.4% to 12.3%]; P < .001), more withdrawing of life-prolonging therapy (692 [38.8%] vs 695 [24.8%]; difference, 14.0% [95% CI, 11.2% to 16.8%]; P < .001), less failed CPR (110 [6.2%] vs 628 [22.4%]; difference, -16.2% [95% CI, -18.1% to -14.3%]; P < .001), less brain death (74 [4.1%] vs 261 [9.3%]; difference, -5.2% [95% CI, -6.6% to -3.8%]; P < .001) and less active shortening of the dying process (17 [1.0%] vs 80 [2.9%]; difference, -1.9% [95% CI, -2.7% to -1.1%]; P < .001).

CONCLUSIONS AND RELEVANCE

Among patients who had treatment limitations or died in 22 European ICUs in 2015-2016, compared with data reported from the same ICUs in 1999-2000, limitations in life-prolonging therapies occurred significantly more frequently and death without limitations in life-prolonging therapies occurred significantly less frequently. These findings suggest a shift in end-of-life practices in European ICUs, but the study is limited in that it excluded patients who survived ICU hospitalization without treatment limitations.

Therapeutic hypothermia after cardiac arrest in a real-life setting

INTRODUCTION

In 2002, two landmark studies concluded that therapeutic hypothermia (TH) improves survival and neurologic outcome in patients with shockable rhythms and out-of-hospital cardiac arrest (OHCA). However, the evidence on whether TH also improves the prognosis in patients with non-shockable rhythms or in-hospital cardiac arrest (IHCA) is sparse. The aim of this study was to assess the prevalence and prognosis of patients with non-shockable rhythms or IHCA after implementation of TH in a real-life setting.

METHODS

The study included 72 consecutive, unconscious patients that were admitted to Holbaek Hospital after cardiac arrest and successful resuscitation. Patients were included regardless of initial cardiac rhythms and location of the cardiac arrest. All patients were cooled to a temperature of 32-34 °C. The primary outcome was survival with a favourable neurologic outcome within six months.

RESULTS

Almost two thirds (63%) of the included patients had non-shockable rhythms or IHCA and only 8.7% of these patients survived with a favourable neurologic outcome. Nearly a third (29%) of the included patients had OHCA with an initial non-shockable rhythm and none (0%) of these patients survived with a favourable neurologic outcome.

CONCLUSIONS

In a real-life setting, the majority of resuscitated patients receiving TH do not fulfil the criteria of the original studies upon which the current guidelines are based. Furthermore, these patients have a poor outcome, indicating that not all patients may benefit from TH.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

[The use of an inspiratory impedance valve during cardiopulmonary resuscitation does not improve long-term survival or neurologic outcome]

The impedance threshold device (ITD) works by increasing negative intrathoracic pressure, venous return and cardiac output during cardiopulmonary resuscitation. Although animal studies have shown promising results on haemodynamics, randomized studies and metaanalyses in humans have not shown better long-term survival or neurologic outcome. No studies have been done on the use of the ITD during in-hospital cardiac arrest. The ITD combined with active compression-decompression cardiopulmonary resuscitation may result in a better outcome.

Management and outcome of mechanically ventilated patients after cardiac arrest

Introduction

The aim of this study was to describe and compare the changes in ventilator management and complications over time, as well as variables associated with 28-day hospital mortality in patients receiving mechanical ventilation (MV) after cardiac arrest.

Methods

We performed a secondary analysis of three prospective, observational multicenter studies conducted in 1998, 2004 and 2010 in 927 ICUs from 40 countries. We screened 18,302 patients receiving MV for more than 12 hours during a one-month-period. We included 812 patients receiving MV after cardiac arrest. We collected data on demographics, daily ventilator settings, complications during ventilation and outcomes. Multivariate logistic regression analysis was performed to calculate odds ratios, determining which variables within 24 hours of hospital admission were associated with 28-day hospital mortality and occurrence of acute respiratory distress syndrome (ARDS) and pneumonia acquired during ICU stay at 48 hours after admission.

Results

Among 812 patients, 100 were included from 1998, 239 from 2004 and 473 from 2010. Ventilatory management changed over time, with decreased tidal volumes (V_T) (1998: mean 8.9 (standard deviation (SD) 2) ml/kg actual body weight (ABW), 2010: 6.7 (SD 2) ml/kg ABW; 2004: 9 (SD 2.3) ml/kg predicted body weight (PBW), 2010: 7.95 (SD 1.7) ml/kg PBW) and increased positive end-expiratory pressure (PEEP) (1998: mean 3.5 (SD 3), 2010: 6.5 (SD 3); P <0.001). Patients included from 2010 had more sepsis, cardiovascular dysfunction and neurological failure, but 28-day hospital mortality was similar over time (52% in 1998, 57% in 2004 and 52% in 2010). Variables independently associated with 28-day hospital mortality were: older age, PaO₂ <60 mmHg, cardiovascular dysfunction and less use of sedative agents. Higher V_T, and plateau pressure with lower PEEP were associated with occurrence of ARDS and pneumonia acquired during ICU stay.

Conclusions

Protective mechanical ventilation with lower V_T and higher PEEP is more commonly used after cardiac arrest. The incidence of pulmonary complications decreased, while other non-respiratory organ failures increased with time. The application of protective mechanical ventilation and the prevention of single and multiple organ failure may be considered to improve outcome in patients after cardiac arrest.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0922-9) contains supplementary material, which is available to authorized users.

Evolution of mortality over time in patients receiving mechanical ventilation

RATIONALE

Baseline characteristics and management have changed over time in patients requiring mechanical ventilation; however, the impact of these changes on patient outcomes is unclear.

OBJECTIVES

To estimate whether mortality in mechanically ventilated patients has changed over time.

METHODS

Prospective cohort studies conducted in 1998, 2004, and 2010, including patients receiving mechanical ventilation for more than 12 hours in a 1-month period, from 927 units in 40 countries. To examine effects over time on mortality in intensive care units, we performed generalized estimating equation models.

MEASUREMENTS AND MAIN RESULTS

We included 18,302 patients. The reasons for initiating mechanical ventilation varied significantly among cohorts. Ventilatory management changed over time (P < 0.001), with increased use of noninvasive positive-pressure ventilation (5% in 1998 to 14% in 2010), a decrease in tidal volume (mean 8.8 ml/kg actual body weight [SD = 2.1] in 1998 to 6.9 ml/kg [SD = 1.9] in 2010), and an increase in applied positive end-expiratory pressure (mean 4.2 cm H2O [SD = 3.8] in 1998 to 7.0 cm of H2O [SD = 3.0] in 2010). Crude mortality in the intensive care unit decreased in 2010 compared with 1998 (28 versus 31%; odds ratio, 0.87; 95% confidence interval, 0.80-0.94), despite a similar complication rate. Hospital mortality decreased similarly. After adjusting for baseline and management variables, this difference remained significant (odds ratio, 0.78; 95% confidence interval, 0.67-0.92).

CONCLUSIONS

Patient characteristics and ventilation practices have changed over time, and outcomes of mechanically ventilated patients have improved. Clinical trials registered with www.clinicaltrials.gov (NCT01093482).

Transfusion requirements in septic shock (TRISS) trial - comparing the effects and safety of liberal versus restrictive red blood cell transfusion in septic shock patients in the ICU: protocol for a randomised controlled trial

BACKGROUND

Transfusion of red blood cells (RBC) is recommended in septic shock and the majority of these patients receive RBC transfusion in the intensive care unit (ICU). However, benefit and harm of RBCs have not been established in this group of high-risk patients.

METHODS/DESIGN

The Transfusion Requirements in Septic Shock (TRISS) trial is a multicenter trial with assessor-blinded outcome assessment, randomising 1,000 patients with septic shock in 30 Scandinavian ICUs to receive transfusion with pre-storage leuko-depleted RBC suspended in saline-adenine-glucose and mannitol (SAGM) at haemoglobin level (Hb) of 7 g/dl or 9 g/dl, stratified by the presence of haematological malignancy and centre. The primary outcome measure is 90-day mortality. Secondary outcome measures are organ failure, ischaemic events, severe adverse reactions (SARs: anaphylactic reaction, acute haemolytic reaction and transfusion-related circulatory overload, and acute lung injury) and mortality at 28 days, 6 months and 1 year.The sample size will enable us to detect a 9% absolute difference in 90-day mortality assuming a 45% event rate with a type 1 error rate of 5% and power of 80%. An interim analysis will be performed after 500 patients, and the Data Monitoring and Safety Committee will recommend the trial be stopped if a group difference in 90-day mortality with P ≤0.001 is present at this point.

DISCUSSION

The TRISS trial may bridge the gap between clinical practice and the lack of efficacy and safety data on RBC transfusion in septic shock patients. The effect of restrictive versus liberal RBC transfusion strategy on mortality, organ failure, ischaemic events and SARs will be evaluated.

[Various methods for monitoring cardiac output in intensive care patients]

This article presents a mini medical technology evaluation of three less invasive monitoring techniques for monitoring cardiac output, CardioQ, ECOM and PiCCO, with focus on validation, usability and costs in intensive care. In conclusion, when identifying patients with low cardiac output, we suggest starting with simple screening tools (e.g. CardioQ or central venous O2 saturation), and when in doubt, upgrade to better validated, yet more time-consuming techniques (e.g. PiCCO using thermodilution). Also consults should be made to other intensive care units in terms of the practical implementation of the monitors.

Comparing the effect of hydroxyethyl starch 130/0.4 with balanced crystalloid solution on mortality and kidney failure in patients with severe sepsis (6S--Scandinavian Starch for Severe Sepsis/Septic Shock trial): study protocol, design and rationale for a double-blinded, randomised clinical trial

Background

By tradition colloid solutions have been used to obtain fast circulatory stabilisation in shock, but high molecular weight hydroxyethyl starch (HES) may cause acute kidney failure in patients with severe sepsis. Now lower molecular weight HES 130/0.4 is the preferred colloid in Scandinavian intensive care units (ICUs) and 1^st choice fluid for patients with severe sepsis. However, HES 130/0.4 is largely unstudied in patients with severe sepsis.

Methods/Design

The 6S trial will randomise 800 patients with severe sepsis in 30 Scandinavian ICUs to masked fluid resuscitation using either 6% HES 130/0.4 in Ringer's acetate or Ringer's acetate alone. The composite endpoint of 90-day mortality or end-stage kidney failure is the primary outcome measure. The secondary outcome measures are severe bleeding or allergic reactions, organ failure, acute kidney failure, days alive without renal replacement therapy or ventilator support and 28-day and 1/2- and one-year mortality. The sample size will allow the detection of a 10% absolute difference between the two groups in the composite endpoint with a power of 80%.

Discussion

The 6S trial will provide important safety and efficacy data on the use of HES 130/0.4 in patients with severe sepsis. The effects on mortality, dialysis-dependency, time on ventilator, bleeding and markers of resuscitation, metabolism, kidney failure, and coagulation will be assessed.

Trial Registration

ClinicalTrials.gov: NCT00962156

[Discontinuation of futile therapy]

It is now documented that intensive care units do consider whether treatments promote "the good" and serve patients best. Uncritical use of technology to prolong the dying process must be avoided, and palliative principles worked out. Decisions to withhold or withdraw treatment are among the toughest for both patients and physicians. Legislation covering the area is sufficient, both with regard to competent as well as incompetent patients. However, there are major differences as to how the law is acted upon. Guidelines for futile intensive care treatment should therefore be worked out, and uncritical referral of patients to the ICU avoided.

Management of postoperative pain. An intervention study

BACKGROUND

In 1989 a study had shown that the quality of postoperative pain treatment (PPT) in a district general hospital was not satisfactory. Therefore, new instructions for PPT were issued, intra-venous medication with morphine was introduced on the wards, and the staff was educated in PPT. The purpose of this study was to investigate the quality of PPT in 1992 compared to the quality in 1989.

METHODS

Using identical questionnaires, 191 patients in 1989 and 126 patients in 1992 were interviewed before and 2-5 days after surgery regarding postoperative pain. At the postoperative interview patients in pain also filled out the McGill Pain Questionnaire. A questionnaire was also answered by the nurses regarding PPT in 1989 and in 1992.

RESULTS

1992 compared to 1989 (1992/1989): all patients were now medicated (100%/93%), most of them regularly (79%/ 4%) and the majority (94%/15%) also received non-opioid analgesic. Fewer patients (65%/80%) experienced postoperative pain lasting more than one day following surgery. Analgesic prescription was more standardized. In 1992 the nurses were more satisfied than in 1989 with the PPT and the physicians' prescribing patterns. All the above-mentioned parameters were significantly improved from 1989 to 1992. All the different pain-scores showed a reduction (8-30%) but did not reach statistical significance (P = 0.2).

CONCLUSIONS

Our two investigations show that it is possible to improve the quality of pain management with rather simple reforms.

Respiratory changes during treatment of postoperative pain with high dose transdermal fentanyl

This study made a longterm (72 hours) evaluation of the efficacy and possible side-effects of transdermal delivery of fentanyl (TTS-system) for post-operative pain relief. The study was double-blind, placebo-controlled with either a TTS-system delivering fentanyl 100 micrograms.h-1 and rescue analgesic on demand or a placebo system and analgesic on demand. Analgesic consumption, pain, general satisfaction, respiratory rate, and levels of SpO2 and tcCO2 (pulse oximetry and transcutaneous CO2 measuring) were evaluated. Recruitment was stopped after enrolment of 24 patients, on safety grounds. The Fentanyl group was more satisfied with postoperative pain relief (P = 0.008); they had a lower analgesic demand (P < 0.05) but also a lower respiratory rate (P < 0.05) and a higher level of tcCO2 23 hours after application (P < 0.05). There were three cases (25%) of increased PaCO2 (> 6.5 kPa) in the Placebo group but without low PaO2 levels, sedation or bradypnoea. Conversely, there were three cases (33%) in the Fentanyl group with bradypnoea (< 10 breaths/minute), two without influence on PaO2 or PaCO2, but one (no. 24) with bradypnoea, heavy sedation, a marked decrease in PaO2 (5.8 kPa) and increased PaCO2 (7.5 kPa). These findings terminated the study. The 100 micrograms transdermal fentanyl system is agreeable to the patients, but apparently too potent for routine postoperative pain relief due to a risk of respiratory depression. Respiratory frequency can not be relied upon as sole indicator of insufficient respiration.

[Quality assurance in postoperative pain treatment]

One hundred and ninety-one patients were interviewed before and after surgery about their attitude toward and the quality of received pain relief. The nurses working in the same surgical units answered a questionnaire covering attitudes to postoperative pain and pain treatment. Forty-seven percent of the patients were in pain at the time of the postsurgical interview, 10% had not any analgesic prescribed at all, and 15% had received less than prescribed. Fifty-one nurses (71% of the total nursing staff) answered the questionnaire. Of these, 63% were sometimes in doubt about the physicians' prescriptions, 55% would occasionally refuse to give analgesics for various reasons, and 37% were not satisfied with the routines of pain control in their ward. Knowledge of pain treatment and communication between surgeons, anaesthesiologists, nurses and patients must be improved to make postsurgical pain relief adequate.

[Acupuncture treatment of knee arthrosis. A long-term study]

The purpose of this study was to examine acupuncture treatment of patients with osteoarthrosis of the knee. Twenty-nine patients with a total of 42 osteoarthritic knees were randomized to two groups. Group A was treated while group B served as a no treatment control group for nine weeks. Analgesic consumption, pain and objective measurements were registered. In the second part of the study 17 patients (26 knees) continued with treatments once a months. Registrations were continued for a total study period of 49 weeks. Comparing group A with B, there was a significant reduction in pain, analgesic consumption and in most objective measures. In group A + B combined there was an 80% subjective improvement, and a significantly increased range of movement of the knee. Results were significantly better in those who had not been ill for a long time. The second part of the study showed that it was possible to maintain the improvements.

[Loop diuretics. Rational pharmacotherapy]

The pharmacodynamics and -kinetics as well as rational pharmacotherapy of furosemide and bumetanide is reviewed. In renal insufficiency, a reduced response to diuretics is due to altered pharmacokinetics. The optimum dose can be determined within three to four hours by titration and the effect is measured by the amount of excreted sodium. In nephrotic syndrome, both pharmaco-kinetics and--dynamics are altered. The optimum dose is established as above. Starting and ceiling doses are given in tables for both drugs in renal insufficiency and nephrotic syndrome. In congestive heart failure, the difference is greater between oral and intravenous doses than apparent from the bioavailability of the drugs. If potent diuretics are without effect, the heart failure must be treated more vigorously or a combination with thiazides tried out. Potent diuretics are seldom used in the treatment of liver cirrhosis, but, if used, large doses are necessary. Non-steroidal antiinflammatory drugs are usually considered contra-indicated in patients with severe renal insufficiency, since the pharmacodynamics of the diuretics are altered.

CONCLUSION

The general strategy when using potent diuretics is titration to an effective dose and then using this dose as frequently as needed in order to obtain the desired response.

[Infections after insertion of epidural catheters]

Three cases of iatrogenic infection following the insertion and subsequent use of an epidural catheter are described. The development, symptoms, diagnostic possibilities and treatment of epidural abscess are described. It is stressed that patients with decreased immunological defences are more prone to infection. Two patients with epidural abscesses are described. In both cases there was a "doctors-delay" before diagnosis was reached. Despite neurosurgical intervention both patients developed paralysis of the lower extremities, bladder and intestinal function, in one of them irreversibly. We also describe one patient who developed meningitis following eight attempts to insert an epidural catheter. The importance of quick diagnosis and intervention is stressed as well as the importance of strict sterility while inserting and using epidural catheters.

[CT and magnetic resonance imaging and spectroscopy for non-invasive study of regeneration of skeletal musculature after intensive therapy]

A 50 year old man was treated in the intensive care unit. Due to a prolonged catabolic state with a loss of 35 kg of body weight, he was practically paralyzed following 70 days of treatment. After 200 days of intensive physical training, he had recuperated remarkably. CT-scans before and after the physical training revealed 90-180% increase in the muscles examined. At the femoral level the muscle/fat ratio increased from 40% to 70%, indicating less atrophy. MR-imaging of the crural muscles showed a substantial increase in the muscle mass after training. MR-fat/water proton spectra showed a decrease in the relative fat content from 0.31 to 0.13 during training, objectively measuring the remission of the severe atrophy.

CONCLUSION

CT- and MR-techniques can be used for objective, non-invasive, evaluations of muscle condition, and MR-proton spektroscopy can probably be used for following the remission of muscle atrophy during physical training.

Postoperative pain relief, from the patients' and the nurses' point of view

In this prospective, consecutive study, 191 patients were interviewed before and after surgery (orthopaedic, gynaecological, abdominal and urological operations) about their attitude to and the quality of received pain relief, respectively. In addition, nurses working in the surgical units involved in the study were asked to answer a questionnaire covering attitudes to postoperative pain and pain treatment. Of the patients, 47% were in pain at the time of the postsurgical interview, 10% had not any analgesic prescribed at all and 15% had received less than prescribed. In 36% of the cases there was a discrepancy between the amount of analgesic prescribed by the surgeon and the amount prescribed by the anaesthetist. In 80% of the patients the pain outlasted the first postoperative day, but only 64% would always tell the staff if they had pain. Seventeen per cent of the patients had never been asked about their postoperative pain status. Preoperative pain had a significant correlation to postoperative pain. Although the results are not impressive, they do constitute some improvement compared to previously published studies. Fifty-one nurses (71% of the total nursing staff) answered the questionnaire. Of these, 63% were sometimes in doubt about the physicians' prescriptions, 55% would occasionally refuse to give analgesics for various reasons, and 37% were not satisfied with the routines of pain control in their ward.

CONCLUSION

Knowledge of pain treatment and communication between surgeons, anaesthesiologists, nurses and patients must be improved to make postsurgical pain relief adequate.

Acupuncture treatment of severe knee osteoarthrosis. A long-term study

PURPOSE

Acupuncture treatment of patients waiting for arthroplasty surgery.

METHODS

29 patients with a total of 42 osteoarthritic knees were randomized to two groups. Group A was treated while Group B served as a no-treatment control group. After 9 weeks Group B was treated too. Analgesic consumption, pain and objective measurements were registered. All objective measures were done by investigators who were "blinded" as to Group A & B. In the second part of the study 17 patients (26 knees) continued with treatments once a month. Registration of analgesic consumption, pain and objective measurements continued. Total study period 49 weeks.

RESULTS

Comparing Group A to B there was a significant reduction in pain, analgesic consumption and in most objective measures. In Group A + B combined there was an 80% subjective improvement, and a significantly increased knee range movement - an increase mainly in the worst knees. Results were significantly better in those who had not been ill for a long time. In the second part of the study, it was shown that it was possible to maintain the improvements.

CONCLUSIONS

Acupuncture can ease the discomfort while waiting for an operation and perhaps even serve as an alternative to surgery. Seven patients have responded so well that at present they do not want an operation. (USD 9000 saved per operation).

Predictive value of subjective and objective evaluation before acupuncture treatment

To evaluate if it is possible to predict the outcome of acupuncture treatment in patients with knee osteoarthrosis, six treatments were given during a 3 week period. Follow-up time was 9-17 weeks. Seven parameters were evaluated to examine if they had any influence on the outcome of treatment: Age, duration of disease, pain, range of knee movement, analgesic consumption, knee score (an objective and subjective evaluation of the knees) and x-ray changes. Twenty-nine patients were included with a total of 42 osteoarthritic knees waiting for a total knee replacement. The median age was 69.2 years, and median duration of disease was 4.2 years. 85% of the participants reported a subjective effect, and in 88% an objective effect was found. Although there were some significant differences when you looked at the 7 parameters above, the pattern was not a consistent one. Follow up results also indicated that those with the best immediate results, not necessarily were the ones with the best long-term effect. It is not possible to predict the outcome of acupuncture treatment of osteoarthritic knees. Immediate results are not a guide-line for long-term results, which indicate that acupuncture research must include a follow-up period.

[Condoms and adolescents. A prospective study of a new method of teaching]

A prospective investigation was carried out with the object of assessing the effect of supplementary sex education for 1.3 hours in addition to the compulsory sex education in Danish elementary schools. One doctor did the teaching and practice with a condom was introduced as a new method of teaching. On an average, seven weeks before and seven weeks after this teaching session, these pupils completed a questionnaire. Altogether 451 pupils from the eighth and ninth classes participated. Great changes had occurred in the methods of contraception employed by the adolescents and in their attitudes to these from 1982 to date. Many more of the adolescents consider today that condoms provide the best form of contraception as compared with oral contraception. Nevertheless, only 9% of the adolescents were able to use a condom correctly. After the teaching session, knowledge about the correct use of a condom was significantly better and more had a positive attitude to condoms. A balance in information about methods of contraception is recommended and the young people should be sent to their own general practitioners for individual advice. On the basis of the results of this investigation, this teaching should be given already to pupils in the eighth classes.