[Risk factors associated with the complications of surgical treatment of intracranial arachnoid cysts in adult patients. Retrospective case series analysis]. / Factores de riesgo asociados a las complicaciones del tratamiento quirúrgico de los quistes aracnoideos intracraneales en pacientes adultos. Análisis retrospectivo de una serie de casos.

INTRODUCTION: We analyzed the surgical results in patients operated for an arachnoid cyst evaluating the different surgical techniques employed, the average life of each procedure and the rate of postoperative complications. This study describes the results from our institution. MATERIAL AND METHODS: We included all patients operated with a diagnosis of intracranial arachnoid cyst from January 2001 to December 2006. We evaluated the effectiveness of each surgical technique and the average life of each procedure, as well as adverse events associated with surgical treatment. RESULTS: The gender distribution was 15 men and 13 women, with an average of 34 years and with a range of 17 to 65 years at time of surgery. The predominant symptom was headache. The location of the arachnoid cyst was 24 supratentorial and 4 infratentorial. 48 surgeries were performed. There were complications in 11 patients in the study group; the craniotomy was the procedure with a longer life (1245 days). The half-life of the craniotomy more fenestration was significantly higher than the rest of the procedures (853 vs. 193 days with a P: 0.0333) and the arachnoid cyst grade III of Galassi is a risk factor for reoperative in our study group with an odds ratio of 13,417. CONCLUSION: In our experience the fenestration by craniotomy was the procedure with fewer complications and increased time of effectiveness. Treatment complications are strongly related to cyst location and size.

Existential medicine: Martin Buber and physician-patient relationships.

Martin Buber's (1878-1965) social existentialist thought offers a unique lens through which physician-patient relationships may be interpreted. Buber develops concepts of relationships and dialogue that provide insight into physician-patient relationships. His notions of I-Thou and I-It relationships have relevance for contemporary medical education and practice. Current medical practice is situated in the It-realm of order, objectivity, detachment, abstraction, and experience. This perspective is necessary for medical education and practice but can result in the progressive decline of the interhuman relationships that define medicine. I-Thou relationships, characterized by spontaneity, subjectivity, reciprocity, and recognition and acceptance of the unique other, are essential for humanhood. However, physicians and patients may be constrained from achieving I-Thou relationships by the very nature of their interactions, which are planned and purposive. Buber describes the possibility of a therapeutic relationship that approaches the I-Thou realm. Buber's thought suggests three conceptual shifts that facilitate the development of therapeutic relationships in medical practice and have implications for medical education: (1) from disease-centered to person-centered care, (2) from crisis to everyday management, and (3) from principles and contracts to relationships.

Ineffectiveness of the SUPPORT intervention: review of explanations.

BACKGROUND: The aim of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments -- SUPPORT -- was to improve the care of seriously ill patients by improving decision-making for patients with life-threatening illnesses. Several theories have been proposed to explain why the SUPPORT intervention was unsuccessful at improving outcomes. OBJECTIVE: To review and discuss explanations offered by others regarding why the SUPPORT intervention failed to have a discernible impact on its prespecified outcome measures. DESIGN: A descriptive review of published articles and book chapters, with synthesis of data-based and conceptual insights. METHODS: The Medline, Bioethicsline, and Ethx databases were searched for citations to SUPPORT articles between 1994 and the end of 1998. This search was supplemented by other published materials that had come to the authors' attention. RESULTS: The critiques and explanations regarding the reasons the SUPPORT intervention did not improve outcomes were catalogued and organized into 11 major categories, the first 10 of which are explored in the present study: (1) the inception cohort was biased against an effect of the intervention, (2) the intervention was not implemented as designed, (3) the intervention failed because nurses were too readily ignored, (4) the intervention was too polite, (5) the intervention presented information ineffectively, (6) the intervention did not focus on primary care physicians, (7) the intervention falsely dichotomized do not resuscitate (DNR) decisions, (8) the intervention needed more years on site or an earlier start with each patient, (9) the intervention required more appropriate outcome measures, (10) the intervention was irrelevant because usual care is not seriously flawed, (11) the conceptual model behind SUPPORT was fundamentally flawed in aiming to improve individual, patient-level decision-making as the way to improve seriously ill, hospitalized patients' experiences. CONCLUSIONS: Although some of the critiques were found to raise important concerns, we conclude in each case that the explanation offered is inadequate to explain the failure of the intervention. We urge further reflection on the fundamental assumptions that informed the design of that intervention and refer the reader to a more comprehensive treatment of that issue in the companion paper in this volume.

Rethinking fundamental assumptions: SUPPORT's implications for future reform. Study to Understand Prognoses and Preferences and Risks of Treatment.

BACKGROUND: The intervention in SUPPORT, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments, was ineffective in changing communication, decision-making, and treatment patterns despite evidence that counseling and information were delivered as planned. The previous paper in this volume shows that modest alterations in the intervention design probably did not explain the lack of substantial effects. OBJECTIVE: To explore the possibility that improved individual, patient-level decision-making is not the most effective strategy for improving end-of-life care and that improving routine practices may be more effective. DESIGN: This paper reflects our efforts to synthesize findings from SUPPORT and other sources in order to explore our conceptual models, their consistency with the data, and their leverage for change. RESULTS: Many of the assumptions underlying the model of improved decision-making are problematic. Furthermore, the results of SUPPORT suggest that implementing an effective intervention based on a normative model of shared decision-making can be quite difficult. Practice patterns and social expectations may be strong influences in shaping patients' courses of care. Innovations in system function, such as quality improvement or changing the financing incentives, may offer more powerful avenues for reform. CONCLUSIONS: SUPPORT's intervention may have failed to have an impact because strong psychological and social forces underlie present practices. System-level innovation and quality improvement in routine care may offer more powerful opportunities for improvement.

Medical education about end-of-life care in the pediatric setting: principles, challenges, and opportunities.

OBJECTIVE: To identify the opportunities for and barriers to medical education about end-of-life (EOL) care in the pediatric setting. METHODS: A working group of pediatric specialists and ethicists was convened at the National Consensus Conference on Medical Education for Care Near the End-of-Life sponsored by the Open Society Institute's Project Death in America and the Robert Wood Johnson Foundation. The charge to the working group was to consider the unique aspects of death in childhood, identify critical educational issues and effective instructional strategies, and recommend institutional changes needed to facilitate teaching about EOL care for children. CONCLUSIONS: Although providing EOL care can be challenging, the cognitive and psychologic skills needed can be taught effectively through well-planned and focused learning experiences. The ultimate goals of such instruction are to provide more humane care to very sick children, enhance bereavement outcomes for their survivors, and develop more confident clinicians. Six specific principles regarding EOL care in the pediatric setting emerged as essential curricular elements that should be taught to all medical care providers to ensure competent patient-centered care. 1) Cognitively and developmentally appropriate communication is most effective. 2) Sharing information with patients helps avoid feelings of isolation and abandonment. 3) The needs of the patient are served when the ethical principles of self-determination and best interests are central to the decision-making process. 4) Minimization of physical and emotional pain and other symptoms requires prompt recognition, careful assessment, and comprehensive treatment. 5) Developing partnerships with families supports them in their caregiving efforts. 6) The personal and professional challenges faced by providers of EOL care deserve to be addressed. These principles actually transcend patient age and can be used to inform medical education about the care of any terminally ill patient. Similarly, these principles of effective communication, ethical decision-making, and attention to the quality of life of patients, families, and providers apply to the care of all children regardless of diagnosis and prognosis. With this in mind, teaching about EOL care does not require a new and separate curriculum, but rather taking better advantage of the many teachable moments provided by caring for a dying patient.

Ethical issues in aging and renal disease.

The incidence of elderly patients reaching end-stage renal disease (ESRD) and requiring renal replacement is increasing. Better medical care is helping patients live longer but, at the same time, is raising ethical questions. Treatment decisions for ESRD patients present a forum for the consideration of ethical questions surrounding the issues of scarce health care resource allocation and the withholding or withdrawal of life-sustaining treatment. As background for the consideration of ethical issues in ESRD patients, the quality of life they experience and what they may expect as death approaches also are discussed.

The ethics of end-of-life care for prison inmates.

Author contends that the philosophical arguments involving the value of persons, social contract theory, the definition of justice, the notion of just desserts, and a utilitarian calculus of societal benefits and burdens provide support for an ethical imperative to provide end-of-life care to dying prisoners.

Capitated risk-bearing managed care systems could improve end-of-life care.

Capitated or salaried managed care systems offer an important opportunity to provide high quality, cost-effective end-of-life care. However, capitated healthcare delivery systems have strong incentives to avoid patient populations in need of such care. Care currently provided at the end of life in fee-for-service practice is commonly deficient, with high rates of avoidable pain and other burdens. Only hospice offers a better track record, yet access to hospice is limited, and length of stay is short. Traditional staff- or group-model managed care plans, with their emphasis on prevention, patient education, cost efficiency, service coordination, and integrated provider networks, present a dynamic set of conditions and organizational structures that would support real change. Advantages derived from managed care systems providing quality end-of-life care include coordinated care across delivery sites, interdisciplinary teams, integrated services, and opportunities to develop innovative care programs, service arrays, utilization controls, and accountability for care standards. We propose a special comprehensive system of managed care, which we call MediCaring, for seriously ill persons nearing the end of life. MediCaring would encompass the best elements of palliative care within a managed care structure: comprehensive, supportive, community-based services that meet personal and medical needs, a focus on patient preferences, symptom management, family counseling, and support. Other programs, such as hospice, have shown that continuity and coordinated care, financed through a capitated payment and directed at a special population, are both feasible and effective. There are obstacles to improving care at the end of life. Managed care systems, like most of medical care, have largely ignored the terminally ill patient. Current financing arrangements make it financially undesirable for insurers to recruit or retain the very sick; very ill patients can be costly over a prolonged time. In addition, inertia and habit inhibit change, and there are few criteria by which to judge whether care at the end-of-life is "good." Nevertheless, capitated or salaried managed care systems committed to enhanced end-of-life care seem well positioned to achieve it if payment reimbursements were revised to encourage this end.

Prognoses of seriously ill hospitalized patients on the days before death: implications for patient care and public policy.

Troubling aspects of the experiences of patients at the ends of their lives have fueled interest in special benefits or privileges for this group. There is a presumption that being "at the end of life" is discernible. This study examines this presumption using data from two previously collected databases: the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) and the Acute Physiology and Chronic Health Evaluation III (APACHE III). Both studies generated multivariable estimates of survival prognosis for hospitalized patients. SUPPORT included 9,105 patients with one of nine serious illnesses in five hospitals over 4 yrs, of whom 2,360 died in the hospital and 4,537 died within 180 days of entry into the study. The APACHE III database describes 2,750 deaths in 16,622 ICU patients in 40 hospitals. The relationship of median estimates with time to death were examined for each source of data, for different diseases, and for ICU settings of care. In SUPPORT, the median predicted chance of survival for 2 months on the day before actual death was .17 (interquartile range, .02-.40) and was .51 (.31-.66) 1 wk before death. Median prognoses varied substantially among diseases: the median for congestive heart failure patients was a .62 chance of living 2 months on the day before death, while lung cancer had only a .17 chance and coma patients only an .11 chance. Median prognostication estimates were not much different when given by physicians and were only a little more pessimistic in APACHE (median estimate for hospital survival on the day before death was .14 and 7 days before was .45). To make plans about care and to optimally support most dying persons and families, conversations must occur while the patient still has a considerable chance of surviving the current episode of illness. Using statistical estimates of prognosis to designate a category of "terminally ill" patients for public policy purposes is unavoidably arbitrary, will often be contested, and will have differential effects upon those dying with differing diseases.

Quantification of tissue plasma volume in the rat by contrast-enhanced magnetic resonance imaging.

Magnetic resonance imaging enhanced with a macromolecular contrast medium (MMCM), albumin-Gd-DTPA, was used to estimate the plasma volume in vivo in the myocardium, lung, liver, and skeletal muscle of 10 normal rats. The plasma volumes of the same tissues in a parallel group of six rats were estimated in vitro by a conventional radioisotopic technique (111In-transferrin). Plasma volumes of myocardium, lung, liver, and skeletal muscle estimated by the MR technique (microliter plasma cc-1 of tissue) were 101, 109, 163, and 11.0, respectively, while plasma volumes measured by the 111In-transferrin radioisotope technique (mg plasma g-1 of tissue) were 78.6, 215, 143, and 11.2, respectively. Assuming a ratio of densities of aerated lung to blood of 0.45 and of other tissues to blood of 1.0, correlation between the methods was excellent (R2 = 0.99) indicating that MR imaging enhanced with MMCM permits reliable in vivo estimation of tissue plasma volume in the rat.

Term pregnancy in an unattached rudimentary uterine horn.

A case of pregnancy in an unattached rudimentary uterine horn is presented. The pregnancy carried to term, ruptured without causing shock, resulted in fetal demise, and was discovered 6 weeks later at laparotomy. Some of the factors associated with rudimentary uterine horns are discussed.