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Rhyl, United Kingdom

Fisher M.,Intensive Care Unit | Fisher M.,University of Sydney | Ridley S.,Glan Clwyd Hospital
Critical Care and Resuscitation

Assessing the appropriateness of continuing life support is a difficult task for intensive care unit staff. Part of this difficulty relates to prognostic uncertainty and the varying reliability of clinical decisions. Uncertainty about prognosis is quickly recognised by patients and families, and can be a source of mistrust and potential conflict. We discuss the reasons for uncertainty and outline key measures to reduce and manage such uncertainty. Practical certainty, where the clinicians are as certain as they can be, with both prognostication and knowledge of patient wishes, may be an appropriate concept for physicians engaged in end-oflife decisions. It involves accurate prognostication, informed surrogates, advance care planning, time to assess response, and the collective wisdom of experienced clinicians. The family conference should develop an agreed plan through shared decision making. The collective wisdom of experienced health care workers with good communication skills and informed patient advocates increases the likelihood of achieving practical certainty and the best decisions. However, greater time and effort seems to be required to improve end-of-life care in the ICU. Source

Lewis S.A.,Glan Clwyd Hospital | Noyes J.,Bangor University | Mackereth S.,Royal Alexandra Hospital
BMC Pediatrics

Background: Young people with neurological impairments such as epilepsy are known to receive less adequate services compared to young people with other long-term conditions. The time (age 13-19 years) around transition to adult services is particularly important in facilitating young people's self-care and ongoing management. There are epilepsy specific, biological and psycho-social factors that act as barriers and enablers to information exchange and nurturing of self-care practices. Review objectives were to identify what is known to be effective in delivering information to young people age 13-19 years with epilepsy and their parents, to describe their experiences of information exchange in healthcare contexts, and to identify factors influencing positive and negative healthcare communication.Methods: The Evidence for Policy and Practice Information Coordinating Centre systematic mixed-method approach was adapted to locate, appraise, extract and synthesise evidence. We used Ley's cognitive hypothetical model of communication and subsequently developed a theoretical framework explaining information exchange in healthcare contexts.Results: Young people and parents believed that healthcare professionals were only interested in medical management. Young people felt that discussions about their epilepsy primarily occurred between professionals and parents. Epilepsy information that young people obtained from parents or from their own efforts increased the risk of epilepsy misconceptions. Accurate epilepsy knowledge aided psychosocial adjustment. There is some evidence that interventions, when delivered in a structured psycho-educational, age appropriate way, increased young people's epilepsy knowledge, with positive trend to improving quality of life. We used mainly qualitative and mixed-method evidence to develop a theoretical framework explaining information exchange in clinical encounters.Conclusions: There is a paucity of evidence reporting effective interventions, and the most effective ways of delivering information/education in healthcare contexts. No studies indicated if improvement was sustained over time and whether increased knowledge was effective in improving in self-care. Current models of facilitating information exchange and self-care around transition are not working well. There is an urgent need for further studies to develop and evaluate interventions to facilitate successful information exchange, and follow young people over time to see if interventions showing early promise are effective in the medium to long-term. © 2010 Lewis et al; licensee BioMed Central Ltd. Source

Pugh R.J.,Glan Clwyd Hospital | Cooke R.P.D.,University of Liverpool | Dempsey G.,University of Liverpool
Journal of Hospital Infection

Hospital-acquired pneumonia (HAP) is a common cause of morbidity and mortality in the critically ill, yet the optimal duration of antibiotic therapy is unknown. Too short a course may lead to treatment failure, whereas too long a course may lead to increased antibiotic resistance, antibiotic-related morbidity and increased costs. Standard duration of antibiotic therapy for Gram-negative (GN-)HAP at our institution is 5 days, significantly shorter than advocated in many current guidelines. We performed a retrospective review of all cases of GN-HAP on our critical care unit fulfilling clinical and microbiological criteria to investigate recurrence rate and mortality following short course antibiotic therapy. Seventy-nine eligible patients with GN-HAP were identified. Of these, 79% were receiving mechanical respiratory support at diagnosis; 42% had GN-HAP due to non-fermenting Gram-negative bacilli (NF-GNB) and 72% were treated with the recommended 5 day course of antibiotics. Two patients had clear evidence of non-resolution of pneumonia after 5 days of therapy. Overall recurrence rate was 14%, with relapse rates significantly higher among patients with NF-GNB when compared to patients with other Gram-negative organisms (17% vs 2%; P= 0.03). The overall recurrence rate was no higher than rates reported in earlier studies (17-41%). Critical care mortality (34.2%) was also not in excess of previously reported values (18-57%). In this limited study, use of a 5 day course of appropriate antibiotics for GN-HAP does not appear to increase risk of recurrence or mortality when pneumonia resolution has been achieved prior to the cessation of therapy. © 2009 The Hospital Infection Society. Source

Vowden P.,University of Bradford | Bond E.,Glan Clwyd Hospital | Meuleneire F.,Wound Care and Diabetic Foot Center
Wounds UK

Wound pain, odour and exudate have a major impact on patient quality of life. Understanding the management of these core components of wound healing is essential if patient outcomes are to be optimised. This paper discusses the role and types of exudate, the impact of high viscosity exudate on management and what to consider when selecting an appropriate dressing with the aim of restoring a satisfactory moist wound environment for healing. Source

Wronka K.S.,Morriston Hospital | Sinha A.,Glan Clwyd Hospital
Foot and Ankle Specialist

This study reports a case of a 57-year-old woman diabetic patient who presented to the authors' institution with signs and symptoms typical of plantar fasciitis. Her condition did not resolve with nonsteroidal anti-inflammatory drug therapy, podiatry, and physiotherapy input and she was given a steroid injection for treatment of plantar fasciitis. She was admitted to the hospital 17 days following injection with signs of acute infection. Diagnostic workup revealed an acute calcaneal osteomyelitis. Infection did not respond to conservative treatment and the patient required a partial calcanectomy. This case highlights the significant risk of steroid injection in plantar fasciitis, especially in diabetic patient. The authors urge surgeons to consider this when obtaining consent for injection and they advise very close follow-up of such patients.Levels of Evidence: Therapeutic, Level IV © 2012 The Author(s). Source

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