RESUMEN
PURPOSE: To observe how residents are engaging in goals of care discussions with patients and identify thematic patterns that inhibited (barriers) and promoted discussion (facilitators) about goals of care. DESIGN: Admission encounters between residents and patients admitted to a tertiary care academic hospital were recorded and analysed using a qualitative descriptive method. Patients included in the study were individuals over the age of 65 being admitted to the internal medicine service. Residents were eligible if they were trainees in family medicine, emergency medicine, general surgery or internal medicine who were on call for the inpatient medicine rotation. RESULTS: A total of 15 resident-patient encounters were recorded and analysed, of which 12 encounters included a goals of care discussion. Barriers to goals of care discussions were due to missed opportunities to clarify patient's preferences for life-sustaining treatment and missed opportunities to engage the patient in further discussion. Facilitators to goals of care discussions were use of simple language and exploration of patient's previous experiences with life-sustaining treatment. CONCLUSIONS: Asking about patients' previous experiences with life support can be an effective strategy to gauge the patient's understanding and goals of care preferences. This knowledge can improve residents' skill in communicating with their patients about goals of care and inform future education initiatives.
Asunto(s)
Pacientes Internos , Medicina Interna/educación , Internado y Residencia , Planificación de Atención al Paciente , Relaciones Médico-Paciente , Anciano , Femenino , Humanos , Masculino , Cuerpo Médico de HospitalesRESUMEN
BACKGROUND: In the war against the Taliban, Canada was the lead North Atlantic Treaty Organization (NATO) nation to provide medical and surgical care to NATO soldiers, Afghanistan National Army soldiers, Afghanistan Nation Police, civilians working in and outside Kandahar Airfield and Afghanistan civilians at the Role 3 Multinational Medical Unit (R3MMU) from February 2006 to October 2009. METHODS: We obtained data from the Joint Theatre Trauma Registry between May 1 and Oct. 15, 2009; 188 patients were admitted to the R3MMU intensive care unit (ICU). We analyzed the ICU data according to types and causes of trauma, mechanical ventilation prevalence, ICU medical and surgical complications, blood products utilization, length of stay in the ICU and mortality. RESULTS: The admitting services were general surgery (35%), neurosurgery (29%), orthopedic surgery (18%) and internal medicine (3%). Improvised explosive devices (46%) and gunshot wounds (26%) were the main causes of ICU admissions. The mean injury severity score for all patients admitted to the ICU was 37, and 81% of ICU patients required mechanical ventilation for a mean duration of 3 days. The main ICU complications were coagulopathy (6.4%), aspiration pneumonia (4.3%), pneumothorax (3.7%) and wound infection (2.7%). The following blood products were most used: packed red blood cells (55%), fresh frozen plasma (54%), platelets (29%) and cryoprecipitate (23%). The average length of stay in the ICU was 4.3 days, and the survival rate was 93%. CONCLUSION: The high survival rate suggests that ICU care is a necessary and vital resource for a trauma hospital in a war zone.
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Campaña Afgana 2001- , Hospitales Militares/estadística & datos numéricos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Centros Traumatológicos/estadística & datos numéricos , Adolescente , Adulto , Afganistán , Transfusión Sanguínea/estadística & datos numéricos , Canadá , Niño , Femenino , Hospitales Militares/normas , Humanos , Puntaje de Gravedad del Traumatismo , Tiempo de Internación/estadística & datos numéricos , Masculino , Personal Militar , Calidad de la Atención de Salud , Sistema de Registros , Respiración Artificial/estadística & datos numéricos , Estudios Retrospectivos , Centros Traumatológicos/normas , Heridas y Lesiones/complicaciones , Heridas y Lesiones/etiología , Heridas y Lesiones/mortalidad , Adulto JovenRESUMEN
Some chiral lanthanide complexes of the Schiff base adducts of: a) bis(2-pyridylcarboxaldehyde) and (1R),(2R)-trans-1,2-diaminocyclohexane (Pyr-R,R'-chxn: 3); b) 6-methyl-2-pyridylcarboxaldehyde and (1R),(2R)-trans 1,2-diaminocyclohexane (MePyr-chxn, 4); and c) 2,6-pyridyldicarboxaldehyde and (1R),(2R)-trans-1,2-diaminocyclohexane ((Pyr-R,R'-chxn)(2), 5) have been screened for their utility to promote kinetic resolution via metal catalyzed alcoholyses of the p-nitrophenyl esters of chiral D- and L-Boc-protected glutamine and phenylalanine. Solvents were varied to optimize the kinetic selectivity values, defined as k(2)(L)/k(2)(D) or k(2)(D)/k(2)(L), for the methanolysis and in some cases, ethanolysis of these substrates. At ambient temperature the greatest selectivity was found for the ethanolysis of Boc-Gln-OPNP, catalyzed by 3:Yb(3+):((-)OEt) (k(2)(L)/k(2)(D) = 7.2). The greatest selectivity for Boc-Phe-OPNP is k(2)(D)/k(2)(L) = 3.9 for its methanolysis promoted by 5:La(3+):((-)OMe). A kinetic method is introduced for the determination of both d and l rate constants for catalyzed alcoholysis from a single kinetic experiment. The activation parameters DeltaH(double dagger) and DeltaS(double dagger) were determined for the metal catalyzed methanolysis and ethanolysis of the Boc-Gln-OPNP substrates, and selectivity factors were found to increase at lower temperatures. A low temperature time course for the ethanolysis of racemic Boc-Gln-OPNP catalyzed by 3:Yb(3+):((-)OEt) at -15 degrees C indicated that after 3 hours 60% residual d-enantiomer was observed having an enantiomeric excess of >95% ee. The activation parameters for the ethanolysis of the same substrate catalyzed by (Pyr-R,R'-chxn)(2):La(3+):((-)OEt) predict a k(2)(D)/k(2)(L) = 40.4 at -40 degrees C with a large ee of >99% with approximately 80% of l isomer remaining at that temperature which has been experimentally confirmed.
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The entrapment of silica-based microspheres, commonly used as stationary phases in chromatography, with an organic porous polymer based on poly(butyl acrylate-co-1,3-butanediol diacrylate) was explored. The spheres were immobilized by photopolymerization leading to entrapped beds within 75 microm i.d. fused silica capillaries, and were mechanically stable, resisting pressure drops of over 5600 psi (38.6 MPa) for only 1 cm of material. The morphology of the polymer formation around the spheres was investigated by SEM and corroborated with back pressure measurements, which indicated that the spheres were held together by encapsulating polymer. The entrapped material was extruded from the capillary in some cases to facilitate imaging. The entrapment conditions were explored, varying the polarity of the sphere surface, the solvent, and the monomers, revealing that polymer formation is based on partitioning of the monomers between the surface and solvent. The resulting polymer morphology is discussed with respect to the effects of confinement, supported by experiments with varying microsphere diameters. The columns described here have favourable properties for use in capillary chromatography and supported catalysis among other applications, and is suitable for lab-on-a-chip devices.