BACKGROUND:In ICU, the stay is frequently a stressful experience. Caregivers may help to understand patients' perceptions; however, their reliability is uncertain. Despite the recent recommendations of lighter sedation targets, little is known about the impact of "conscious sedation" on ICU patients memories. Purpose of this prospective, observational study is to analyze the stress perception in consciously-sedated ICU-patients, comparing it to caregivers and staff members.METHODS:Twenty-nine high-risk ICU-patients treated with awake/cooperative sedation were enrolled. Before discharge, patients received a validated questionnaire for ICU stressors evaluation, also administered to their main caregiver (N.=29), to caregivers of other ICU patients not enrolled in the study (N.=33) and to staff members (ICU nurses, attending physicians, residents, medical students, N.=56).RESULTS:Total stress score was: patients 141±41, patient relatives 210±63, other relatives: 202±73, ICU staff: 232±44, P<0.001. Among patients, older age (P=0.031), longer ICU-stay (P=0.018) and awake-sedation (P=0.022) were associated with lower stress; sex and illness severity had no effect; mechanical ventilation length (P=0.021) and agitation (P=0.029) were associated with higher stress. Nurses tended to overestimate stressors more than attending physicians and trainees. Within staff members, age (P=0.021) and years of experience (P=0.069) were positively associated with overestimation.CONCLUSIONS:Conscious sedation is associated with stress perception lower than stress assessed by caregivers: relatives and staff members tend to overestimate ICU patient stress, more so with increasing age or expertise. A number of stressors underestimated by staff and families could be target of specific interventions to ameliorate quality of life during ICU stay.

Background: Even though evidence based medicine, guidelines and algorithms still represent the pillars of the management of chronic diseases (i.e: hypertension, diabetes mellitus), a patient centred approach has been recently proposed as a successful strategy, in particular to improve drug adherence. Aim of the present review is to evaluate the unmet needs in LUTS/BPH management and the possible impact of a patient centered approach in this setting. Methods: A National Center for Biotechnology Information (NCBI) PubMed search for relevant articles published from January 2000 until December 2016 was performed by combining the following MESH terms: patients centred medicine, patient centered care, person centered care, patient centered outcomes, value based care, shared decision making, male, Lower Urinary Tract Symptoms, Benign Prostatic Hyperplasia, treatment. We followed the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA). All studies reporting on patient centred approach, shared decision making and evidence-based medicine were included in the review. All original article, reviews, letters, congress abstracts, and editorials comments were included in the review. Studies reporting single case reports, experimental studies on animal models and studies not in English were not included in the review. Results: Overall 751 abstracts were reviewed, out of them 87 full texts were analysed resulting in 36 papers included. The evidence summarised in this systematic review confirmed how a patient centred visit may improve patient's adherence to medication. Although a patient centred model has been rarely used in urology, management of Low Urinary Tract Symptoms (LUTS) and Benign Prostatic Obstruction (BPO) may represent the perfect ground to experiment and improve this approach. Notwithstanding all the innovations in LUTS/BPO medical treatment, the real life picture is far from ideal. Conclusions: Recent evidence shows a dramatical low drug adherence and satisfaction to medical treatment in LUTS/BPH patients. A patient centred approach may improve drug adherence and some unmet needs in this area, potentially reducing complications and costs. However further well designed studies are needed to confirm this data.

BACKGROUND International guidelines recommend systematic assessment of pain, agitation/sedation and delirium with validated scales for all ICU patients. However, these evaluations are often not done. We have created an e-learning training platform for the continuous medical education, and assessed its efficacy in increasing the use of validated tools by all medical and nursing staff of the participating ICUs during their daily practice. METHODS Multicenter, randomized, before and after study. The eight participating centers were randomized in two groups, and received training at different times. The use of validated tools (Verbal Numeric Rating or Behavioral Pain Scale for pain; Richmond Agitation-Sedation Scale for agitation; Confusion Assessment Method for the ICU for delirium) was evaluated from clinical data recorded in medical charts during a week, with follow-up up to six months after the training. All the operators were invited to complete a questionnaire, at baseline and after the training. RESULTS Among the 374 nurses and physicians involved, 140 (37.4%) completed at least one of the three courses. The assessment of pain (38.1 vs. 92.9%, P<0.01) and delirium (0 vs. 78.6%, P<0.01) using validated tools significantly increased after training. Observation in the follow-up showed further improvement in delirium monitoring, with no signs of extinction for pain and sedation/agitation measurements. CONCLUSIONS This e-learning program shows encouraging effectiveness, and the increase in the use of validated tools for neurological monitoring in critically ill patients lasts over time.

SummaryIllness representations of chronic patients are important to explain adherence and preventive behaviours. However, it is unclear if the patient's objective health status may influence illness representations and perceived adherence. This study explored if health status and socio‐demographic characteristics influence illness representations and perceived adherence in haemophilic patients. Fifty patients (25 on‐demand and 25 on prophylaxis) ageing from 13–73, completed the Illness Perceptions Questionnaire‐Revised and the Morisky Medication Adherence Scale. Patients' cognitive illness representations were influenced by type of treatment, haemophilia severity, presence of inhibitor and co‐morbidity. Perceived chronicity was influenced by patient's age (P = 0.021). Perceived adherence was not influenced by the health status, but was affected by the relationship status (P = 0.048). Perceived adherence was predicted by perceived chronicity (β = 0.412; P = 0.003) and by emotions (β = −0.308; P = 0.023). Patient's health status seems to affect cognitive illness representations but not perceived adherence. Perceived chronicity and negative emotions, which affected perceived adherence, were not influenced by the health status. Physician–patient communication addressing perceived chronicity and emotions rather than patients' health status may influence patient's adherence. Psycho‐educational groups could be offered to promote patient's well‐being and adjustment to haemophilia, and improve adherence.

Background: An increasing amount of literature has studied changes in communication skills in medical and nursing undergraduate students. Aim: To evaluate whether occupational therapists’ communication behaviours change with experience. Material and methods: A total of 45 participants (second-year OT students, final-year OT students, professional OTs) were enrolled and met three simulated clients. The role plays were video-recorded and analysed through OT-RIAS (Occupational Therapy-Roter Interaction Analysis System). Chi-square tests were used to analyse the statistical differences between groups for the OT-RIAS categories. Results: Process represented 30.74% of communication for second-year students, 33.69% for final year students, and 35.58% for professional OTs; Occupational therapy ranged from 30.41% in the second-year students to 32.54% in the undergraduates and 37.04% in the professional OTs; Medical increased from 18.66% to 34.33% of the final-year students and 47.01% of the professional therapists. Personal and Psychosocial slightly decreased through experience. Emotional decreased gradually: 39.8% in the second-year students, 29.54% in final-year students, and 30.66% in professional OTs. Conclusion: During training in occupational therapy the communication skills changed, assuming a more technical shape, increasing control and content-related OT communication. Nevertheless, the therapists’ communication behaviours showed the endurance of attention to the client’s point of view.

This study aimed at exploring the hematologists' internal representation of a difficult encounter with a hemophilic patient, using a written open format. Narrations were analyzed with Interpretative Phenomenological Analysis. Three main issues were identified, each with sub-issues: (1) Inside the relationship: to tell or not to tell, the balance between a normal life and a deviant medical condition, the guilt; (2) The borders of the professional role: professional values, the "do-it-all" doctor; and (3) The existential confrontation. This study reveals the deep involvement of physicians with their patients, at a professional level and, strongly, at a personal level. The experience of being so deeply involved should be considered in the continuing medical programs for physicians dealing with hemophilia.

OBJECTIVE:To verify whether the patient's satisfaction with quality of life (QoL) is similar to or different from the occupational therapist's perception of the patient's satisfaction. MATERIALS AND METHODS:Each patient enrolled was given the Satisfaction Profile (SAT-P) questionnaire to be filled out personally; the same questionnaire, the SAT-P, was given to the respective occupational therapist who was asked to fill it out by evaluating the patient's satisfaction as perceived by the therapist. A descriptive statistic was applied for socio-demographic data to describe the cohort. Differences between patient and therapist answers to the SAT-P were evaluated using a t-test. RESULTS:12 occupational therapists and 69 patients participated in the study. A significant difference between occupational therapist and patient was found for Factor II (physical functioning) (p = 0.048) and for Factor V (social functioning) (p = 0.011). The comparison of patient and therapist mean scores showed that therapists had a tendency to underestimate patient satisfaction levels for all factors except Factor IV. DISCUSSION:The results showed similarities between the therapist and the patient's view of the patient's satisfaction with QoL, confirming occupational therapy as a client-centred discipline. However, as far as physical functioning is concerned, it is possible that the professional makes an "a priori" judgement, considering the objective clinical data regardless of the patient's subjective experience of his/her illness.

In letteratura mancano studi sistematici che descrivano l’utilizzo della metafora nella visita medica. Questo studio ha l’obiettivo di descrivere l’uso della metafora in visite di medicina generale raccogliendo: la frequenza dell’uso delle metafore; il soggetto conversazionale che attiva la metafora; la distribuzione delle metafore sulla base del tempo di comparsa; il contenuto semantico o significato della metafora (di cosa parla) e il contenitore semantico o significante della metafora (come ne parla); le funzioni connesse all’uso della metafora (funzione cognitiva vs funzione emotiva). Lo studio ha considerato 100 visite di medicina generale videoregistrate. Di queste sono state selezionate e trascritte quelle parti in cui comparivano metafore intese come un modo di concepire una cosa nei termini di un’altra. L’analisi dei dati ha previsto un’analisi quantitativa delle frequenze per i parametri: soggetto produttore e tempo, e una qualitativa tramite una categorizzazione del contenuto delle metafore e, a seguire, una tassonomia categoriale delle metafore stesse. Sono state osservate 280 metafore: il 43.2% del medico, e il 56.8% del paziente. In 41 visite il soggetto attivatore e il paziente (55.4%). Su 100 visite studiate, in media, viene utilizzata una metafora ogni 3’30’’. Le categorie rilevate si sovrappongono parzialmente con gli esiti di altri studi. I pazienti usano un numero maggiore di metafore rispetto ai medici, concentrandole nella prima parte della visita con funzione di mediatore emotivo. Nel loro insieme i risultati evidenziano come la metafora sia uno strumento linguistico specifico della comunicazione e relazione medico-paziente. .

Objectives Community pharmacists are the most accessible healthcare professionals. They interact with a large number of patients who often show emotional concern. Their stressful and complex role is widely acknowledged, nonetheless research on their personal life is practically non-existent. Thus, we set out to qualitatively explore the emotional perceptions of pharmacists.Methods Twenty experienced pharmacists were interviewed by a psychologist and a pharmacist. Data were analysed using an interpretative phenomenological analysis and coded using NVivo qualitative data analysis software.Key findings Interviewed pharmacists admitted to different types of difficulties, mostly arising from a series of small, standalone episodes. Their stories describe intrinsic difficulties with their practice, rather than personal experiences. This study reveals the complexity of a community pharmacists' role-divided into health and hygiene advice, counselling and empathic relationships, and entrepreneurship. An important obstacle is the integration and concomitant implementation of these components. Endogenous factors such as personal experiences, personality and academic background, and exogenous factors such as social status of the patient population, legal and administrative issues and location, all affect pharmacists' ability to cope with their role.Conclusions Improving health care can be obtained by incorporating community pharmacists into the healthcare team. Technical training is important in order to improve relationship skills and personal coping strategies. Further studies are recommended to provide a simple tool for measuring aspects of the personal and emotional aspects (inner life) of a community pharmacist.

Background: A great deal of what medical students learn in terms of behaviors, values, and attitudes related to their profession is conveyed by the hidden curriculum.Aim: To explore the messages conveyed by the hidden curriculum as perceived by third-year students of the Milan School of Medicine, Italy, following their first clinical internship.Method: Three group interviews were conducted. Students were asked to reflect on values, attitudes, and implicit rules they noticed during their internship experiences. Verbatim transcripts of the group interviews were analyzed through content analysis using Nvivo8.Results: Of the 81 students, 57 (70%) participated in the group interviews. Six themes were identified within the hidden curriculum: Physicians reassure and protect patients; power differential between physicians and patients; variable respect for patients; disease-centered medicine; respect for hierarchies; and delegation of patients' emotional needs to nurses.Conclusions: Our findings suggest that the hidden curriculum has a strong cultural component. In our students' experience, the hidden curriculum conveyed a paternalistic model of physician-patient relationships. Some of the messages conveyed by the actual hidden curriculum may compromise the standards formally taught in medical schools about doctor-patient relationships. Organizational culture change and student empowerment could be fostered to counteract the negative effects of the hidden curriculum.

Introduction: The literature on the psychological effects of thrombophilia testing is unclear. Little is known about the complex world of significance subjects construct around the. test.Objective: The study explored the peculiar network of implicit meanings that may be linked to the experience of being tested.Materials and methods: The research was designed according to Interpretative Phenomenological Analysis (IPA). 19 patients were interviewed. Integral verbatim reports of the interviews were analyzed through an inductive process aimed at gaining a holistic understanding of the narratives.Results: Two main issues were identified, each with sub-issues: (1) the clinical problem: (1.1) unhealthy blood and (1.2) the family issue; (2) the test: (2.1) knowing for the sake of knowing; (2.2) knowing for the sake of doing; (2.3) not knowing.Conclusions: The thrombophilia test is part of a larger network of meanings, where information about the test and its results seem to be lost.Practice implication: The study suggests the importance of paying greater attention to the process of doctor patient communication at the time of the test. The theme of being informed is important for patients, yet often they ate not able to understand or retain the information they receive, increasing the risk of misunderstandings. (C) 2011 Elsevier Ireland Ltd. All rights reserved.

Purpose: To explore the literature in order to describe the educational strategies aimed at improving adherence in glaucoma patients. Methods: Two investigators independently searched the Medline, Pubmed, Embase and Psychinfo databases using the terms [“glaucoma” (AND) “patient education”] (AND) “patient adherence”. Twenty-six articles met the inclusion criteria. The educational topics were identified and data were extracted concerning the clinical setting, the study design, group size, content source, and the time and personnel involved. Results: Ten of the reviewed articles referred to clinical trials; five to clinical interventions without evaluating efficacy; and eleven discussed general suggestions and practical advice. Of the 15 articles adequately describing features of an educational strategy, three concentrated on adherence; eight on knowledge and understanding; one on persistence and knowledge; one on the accuracy of self reporting medication regimens; one on knowledge and awareness; and one on memory. One article referred to a group programme; four to “one-on-one” programmes; six to individual programmes; two to both “one-on-one” and “individual” programmes; and two to individual and/or one-on-one and group sessions. When specified, the personnel involved were ophthalmic assistants (3), physicians (3) or nurses (2); researchers (1); one programme was based on a multidisciplinary team. The duration of the interventions ranged from six minutes to two hours. Discussion: There are few published papers concerning the education of glaucoma patients. The interventions vary widely in terms of educational content and in strategies and do not seem to follow the strategies used to educate patients with other chronic diseases.

Background: It has been shown that the pineal gland plays a fundamental role in mediating either the spiritual perception or the anticancer immunity by stimulating the endogenous production of anticancer cytokine interleukin (IL)-2. Objective: The present study was performed to evaluate the impact of a spiritual approach consisting of Kriya Yoga program alone or in association with melatonin (MLT) or low-dose IL-2 plus MLT on the survival time in a group of metastatic cancer patients with life expectancy less than 1 year. Materials and Methods: A case-control study was carried out in 240 patients (M/F: 146/94; median age: 62 years, range: 34-71, suffering from non-small-cell lung cancer or gastrointestinal tumors) who were subdivided into 6 groups of 40 patients, treated with supportive care alone as a control group, supportive care plus Yoga, MLT alone, MLT plus Yoga, inteleukin-2 plus MLT, or IL-2 plus MLT plus Yoga. Results: The best results in terms of increased survival time were obtained by the association between neuroimmunotherapy with MLT plus IL-2 and Yoga program (2 years), which was significantly longer with respect to that achieved by supportive care alone, Yoga alone, or IL-2 plus MLT alone (1 year). Conclusions: This study would suggest that a spiritual therapeutic approach may improve the survival time of untreatable metastatic solid tumor patients.

BACKGROUND:The Program to Enhance Relational and Communication Skills (PERCS) was developed at a large hospital in the United States to enhance clinicians' preparedness to engage in difficult conversations. AIM:To describe the implementation of PERCS in an Italian hospital and assess the program's efficacy. METHODS:The Italian PERCS program featured 4-h experiential workshops enrolling 10-15 interdisciplinary participants. The workshops were organized around the enactment and debriefing of realistic case scenarios portrayed by actors and volunteer clinicians. Before and after the workshop, participants rated their perceived preparation, communication and relational skills, confidence, and anxiety on 5-point Likert scales. Open-ended questions explored their reflections on the learning. T-tests and content analysis were used to analyze the quantitative and qualitative data, respectively. RESULTS:146 clinicians attended 13 workshops. Participants reported better preparation, confidence, and communication skills (p < 0.001) after the workshops. The program had a different impact depending on the discipline. Participants valued the emphasis on group feedback, experiential and interdisciplinary learning, and the patient's perspective, and acquired: new communication skills, self-reflective attitude, reframed perspective, and interdisciplinary teamwork. CONCLUSION:PERCS proved culturally adaptable to the Italian context and effective in improving participants' sense of preparation, communication skills, and confidence.