To assess the impact of a nurse-driven patient empowerment intervention on anxiety and depression of patients during ICU discharge.
A prospective, multicenter, randomized clinical trial.
Three ICUs ...(1 medical, 1 medical and surgical, and 1 coronary) of three tertiary hospitals.
Adults admitted to the ICU greater than 18 years old for greater than or equal to 48 hours with preserved consciousness, the ability to communicate and without delirium, who were randomized to receive the nurse-driven patient empowerment intervention (NEI) (intervention group IG or standard of care control group (CG)) before ICU discharge.
The NEI consisted of an individualized intervention with written information booklets, combined with verbal information, mainly about the ICU process and transition to the ward, aimed at empowering patients in the transition process from the ICU to the general ward.
Patients completed the Hospital Anxiety and Depression Scale before and after (up to 1 wk) ICU discharge. IG ( n = 91) and CG ( n = 87) patients had similar baseline characteristics. The NEI was associated with a significant reduction in anxiety and depression ( p < 0.001) and the presence of depression ( p = 0.006). Patients with comorbidities and those without family or friends had greater reductions in anxiety and depression after the NEI. After the intervention, women and persons with higher education levels had lower negative outcomes.
We found that a NEI before ICU discharge can decrease anxiety and depression in critically ill survivors. The long-term effect of this intervention should be assessed in future trials.
NCT04527627 ( https://clinicaltrials.gov/ct2/show/NCT04527627 ).
Background
Intensive care unit (ICU) patients can experience emotional distress and post‐traumatic stress disorder when they leave the ICU, also referred to as post‐intensive care syndrome. A deeper ...understanding of what patients go through and what they need while they are transitioning from the ICU to the general ward may provide input on how to strengthen patient‐centred care and, ultimately, contribute to a positive experience.
Aim
To describe the patients' experience while transitioning from the ICU to a general ward.
Design
A descriptive qualitative study.
Method
Data were gathered through in‐depth interviews and analysed using a qualitative content analysis. The qualitative study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research guidelines.
Findings
Forty‐eight interviews were conducted. Impact on emotional well‐being emerged as a main theme, comprising four categories with six subcategories.
Conclusion
Transition from the ICU can be a shock for the patient, leading to the emergence of a need for information, and an impact on emotional well‐being that has to be planned for carefully and addressed prior to, during, and following transition from the ICU to the general ward.
Relevance to clinical practice
It is essential that nurses understand patients' experiences during transfer, identifying needs and concerns to be able to develop and implement new practices such as ICU Liaison Nurse or Nurse Outreach for the follow‐up of these patients, the inclusion of a consultant mental health nurse, and the application of patient empowerment during ICU discharge.
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•Patients achieve high SVR12 rates with sofosbuvir/velpatasvir/voxilaprevir after prior DAA failures.•Sofosbuvir/velpatasvir/voxilaprevir is a very safe and well tolerated ...combination.•GT3 cirrhotic patients with previous treatment with NS5A-inhibitors are poor responders.•GT3 is the only factor that impacts SVR12 rates in retreatment with sofosbuvir/velpatasvir/voxilaprevir.
Around 5% of patients with chronic hepatitis C virus (HCV) infection treated with direct-acting antiviral (DAA) agents do not achieve sustained virological response (SVR). The currently approved retreatment regimen for prior DAA failure is a combination of sofosbuvir, velpatasvir, and voxilaprevir (SOF/VEL/VOX), although there is little data on its use in clinical practice. The aim of this study was to analyse the effectiveness and safety of SOF/VEL/VOX in the real-world setting.
This was a prospective multicentre study assessing the efficacy of retreatment with SOF/VEL/VOX in patients who had experienced a prior DAA treatment failure. The primary endpoint was SVR 12 weeks after the completion of treatment (SVR12). Data on safety and tolerability were also recorded.
A total of 137 patients were included: 75% men, 35% with liver cirrhosis. Most were infected with HCV genotype (GT) 1 or 3. The most common prior DAA combinations were sofosbuvir plus an NS5A inhibitor or ombitasvir/paritaprevir/r+dasabuvir. A total of 136 (99%) patients achieved undetectable HCV RNA at the end of treatment. Overall SVR12 was 95% in the 135 patients reaching this point. SVR12 was lower in patients with cirrhosis (89%, p = 0.05) and those with GT3 infection (80%, p <0.001). Patients with GT3 infection and cirrhosis had the lowest SVR12 rate (69%). Of the patients who did not achieve SVR12, 1 was reinfected and 7 experienced treatment failure (6 GT3, 1 GT1a). The presence of resistance-associated substitutions did not impact SVR12. Adverse effects were mild and non-specific.
Real-world data show that SOF/VEL/VOX is an effective, safe rescue therapy for patients with prior DAA treatment failure despite the presence of resistance-associated substitutions. However, patients with liver cirrhosis infected by GT3 remain the most-difficult-to-treat group.
Treatment with sofosbuvir/velpatasvir/voxilaprevir (SOF/VEL/VOX) for 12 weeks is the current recommendation for the 5% of patients infected with HCV who do not achieve eradication of the virus under treatment with direct-acting antivirals. In a Spanish cohort of 137 patients who failed a previous combination of direct-acting antivirals, a cure rate of 95% was achieved with SOF/VEL/VOX. Genotypic characteristics of the virus (genotype 3) and the presence of cirrhosis were factors that decreased the rate of cure. Treatment with SOF/VEL/VOX is an effective and safe rescue therapy due to its high efficacy and very good safety profile.
To assess short- and long-term outcomes from non-surgical management of diverticulitis with abscess formation and to develop a nomogram to predict emergency surgery.
This nationwide retrospective ...cohort study was performed in 29 Spanish referral centers, including patients with a first episode of a diverticular abscess (modified Hinchey Ib-II) from 2015 to 2019. Emergency surgery, complications, and recurrent episodes were analyzed. Regression analysis was used to assess risk factors, and a nomogram for emergency surgery was designed.
Overall, 1,395 patients were included (1,078 Hinchey Ib and 317 Hinchey II). Most (1,184, 84.9%) patients were treated with antibiotics without percutaneous drainage, and 194 (13.90%) patients required emergency surgery during admission. Percutaneous drainage (208 patients) was associated with a lower risk of emergency surgery in patients with abscesses of ≥5 cm (19.9% vs 29.3%, P = .035; odds ratio 0.59 0.37-0.96). The multivariate analysis showed that immunosuppression treatment, C-reactive protein (odds ratio: 1.003; 1.001-1.005), free pneumoperitoneum (odds ratio: 3.01; 2.04-4.44), Hinchey II (odds ratio: 2.15; 1.42-3.26), abscess size 3 to 4.9 cm (odds ratio: 1.87; 1.06-3.29), abscess size ≥5 cm (odds ratio: 3.62; 2.08-6.32), and use of morphine (odds ratio: 3.68; 2.29-5.92) were associated with emergency surgery. A nomogram was developed with an area under the receiver operating characteristic curve of 0.81 (95% confidence interval: 0.77-0.85).
Percutaneous drainage must be considered in abscesses ≥5 cm to reduce emergency surgery rates; however, there are insufficient data to recommend it in smaller abscesses. The use of the nomogram could help the surgeon develop a targeted approach.
We compared 48 week effectiveness and safety of first-line antiretroviral regimens.
We analysed HIV treatment-naive adults from the Cohort of the Spanish HIV/AIDS Research Network (CoRIS) starting ...the most commonly used antiretroviral regimens from 2014 to 2018. We used multivariable regression models to assess the impact of initial regimen on: (i) viral suppression (VS) (viral load <50 copies/mL); (ii) change in CD4 cell count; (iii) CD4/CD8 normalization (>0.4 and >1); (iv) CD4 percentage normalization (>29%); (v) multiple T-cell marker recovery (MTMR: CD4 > 500 cells/mm3 plus CD4 percentage >29% plus CD4/CD8 > 1); (vi) lipid, creatinine and transaminase changes; and (vii) discontinuations due to adverse events (AE).
Among 3945 individuals analysed, the most frequently prescribed regimens were ABC/3TC/DTG (34.0%), TAF/FTC/EVG/CBT (17.2%), TDF/FTC + DTG (11.9%), TDF/FTC/EVG/CBT (11.7%), TDF/FTC/RPV (11.5%), TDF/FTC + bDRV (8.3%) and TDF/FTC + RAL (5.3%). At 48 weeks, 89.7% of individuals achieved VS with no significant differences by initial regimen. CD4 mean increase was 257.8 (249.3; 266.2) cells/mm3, and it was lower with TAF/FTC/EVG/CBT and TDF/FTC/RPV compared with ABC/3TC/DTG. CD4 percentage normalization was less likely with TAF/FTC/EVG/CBT, and MTMR was less likely with TAF/FTC/EVG/CBT and TDF/FTC + RAL. The proportion of discontinuations due to AE was higher with TDF/FTC + bDRV (9.7%), followed by TDF/FTC/EVG/CBT (9.5%) and TDF/FTC + DTG (7.9%). Compared with ABC/3TC/DTG, cholesterol and LDL mean increases were higher with TAF/FTC/EVG/CBT and lower with TDF/FTC + DTG, TDF/FTC/RPV and TDF/FTC + RAL. Higher mean increases in triglycerides were significantly associated with TAF/FTC/EVG/CBT. Regimens containing DTG showed higher creatinine increases.
The significantly greater immunological response and safety of some combinations may be useful for making decisions when initiating treatment.
Sedation is necessary in the management of critically ill patients, both to alleviate suffering and to cure patients with diseases that require admission to the intensive care unit. Such sedation ...should be appropriate to the patient needs at each timepoint during clinical evolution, and neither too low (undersedation) nor too high (oversedation). Adequate sedation influences patient comfort, safety, survival, subsequent quality of life, bed rotation of critical care units and costs. Undersedation is detected and quickly corrected. In contrast, oversedation is silent and difficult to prevent in the absence of management guidelines, collective awareness and teamwork. The Zero Oversedation Project of the Sedation, Analgesia and Delirium Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units aims to offer a practical teaching and collective awareness tool for ensuring patient comfort, safety and management with a view to optimizing the clinical outcomes and minimizing the deleterious effects of excessive sedation. The tool is based on a package of measures that include monitoring pain, analgesia, agitation, sedation, delirium and neuromuscular block, keeping patients pain-free, performing dynamic sedation according to clinical objectives, agreeing upon the multidisciplinary protocol to be followed, and avoiding deep sedation where not clinically indicated.
La sedación es necesaria en el tratamiento de los pacientes críticos, tanto para aliviar el sufrimiento como para curar a los pacientes con enfermedades que precisan el ingreso en unidades de cuidados intensivos. Esta sedación debe ser la adecuada a las necesidades del paciente en cada momento de su evolución clínica, ni por debajo (infrasedación) ni por encima (sobresedación). Una sedación adecuada influye en la comodidad, la seguridad, la supervivencia, la calidad de vida posterior, la rotación de camas de las unidades de críticos y los costes. La infrasedación se detecta y corrige rápidamente. Sin embargo, la sobresedación es silente y difícil de prevenir sin unas pautas de actuación, una concienciación colectiva y un trabajo en equipo. El proyecto «Sobresedación Zero» del Grupo de Trabajo de Sedación, Analgesia y Delirium de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias pretende ser una herramienta docente, práctica y de concienciación colectiva de comodidad, seguridad y gestión para maximizar el resultado clínico y minimizar los efectos perjudiciales de la sedación excesiva. Se basa en un paquete de medidas que se incluye monitorizar el dolor, la analgesia, la agitación, la sedación, el delirium y el bloqueo neuromuscular, mantener a los pacientes sin dolor, realizar una sedación dinámica según objetivos clínicos, consensuar el protocolo multidisciplinar a seguir y evitar la sedación profunda no indicada clínicamente.
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