[Out-of-hospital airway management with a laryngeal tube or endotracheal intubation for out-of-hospital cardiac arrest : Influence on in-hospital mortality]. / Präklinisches Atemwegsmanagement mit Larynxtubus oder Endotrachealtubus bei präklinischem Herz-Kreislauf-Stillstand : Einfluss auf die Krankenhausmortalität.

BACKGROUND: Endotracheal (ET) intubation has been the gold standard in out-of-hospital airway management for a long time. Recent guidelines suggest an alternative airway management with supraglottic airway devices like the laryngeal tube (LT) especially for less experienced rescue personnel. However, scientific evidence on the prognostic impact of the laryngeal tube in the setting of cardiopulmonary resuscitation is limited. METHODS: We aimed to compare mortality outcomes in out-of-hospital cardiac arrest (OHCA) patients after preclinically initiated airway management with either ET or LT in a propensity score matched, single-center retrospective analysis. RESULTS: A total of 208 patients with OHCA were resuscitated and intubated with either ET (n = 160; 77%) or LT (n = 48; 23%) in the urban area of Frankfurt am Main, Germany, and treated thereafter on the intensive care unit of the University Hospital Frankfurt from 2006-2014. In-hospital mortality was 84% versus 85% in the ET and LT group (p = 0.86). No difference regarding in-hospital mortality has been observed between the two airway management techniques in univariate as well as in multivariate mortality analysis (HR = 0.98, 95% confidence interval [CI] 0.69-1.39; p = 0.92; adjusted HR = 1.01, 95% CI 0.76-1.56; p = 0.62). To adjust for potential confounders, propensity score matching was additionally performed resulting in a cohort of 120 matched patients in a 3:1 ratio (ET:LT). Again, survival to hospital discharge was comparable between the two patient groups (propensity-adjusted HR = 0.99, 95% CI 0.65-1.51, p = 0.97). Further, preclinical airway management with LT or ET showed no difference in mortality within first 24 h (propensity-adjusted HR = 1.02; 95% CI 0.44-2.36; p = 0.96). CONCLUSION: Preclinical airway management with LT shows similar mortality outcomes in direct comparison to intubation with ET in OHCA patients. Further randomized studies are warranted.

Assessment of practical knowledge of self-management of acute asthma.

AIMS: To develop an instrument for the measurement of, and to determine the level of, practical knowledge of self-management of acute asthma. METHODS: Eighty patients with moderate/severe asthma attending a hospital-based asthma clinic responded to an interviewer-administered questionnaire. Subjects were asked to describe the action they would take in response to each of two hypothetical evolving attacks: (1) one of gradually increasing severity and (2) the other developing rapidly. Responses were scored according to the appropriateness of actions taken relevant to the stage of the attack. Transcripts of the responses were scored independently by three of the investigators according to a system based on Thoracic Society of Australia and New Zealand (TSANZ) and British Thoracic Society (BTS) consensus statements on asthma management. A 25-point scale was used on which 0 represented a total lack of appropriate responses and a score of 25 was an optimal response. RESULTS: Interrater and intrarater reliability were excellent. Mean (+/- SD) scores for the slow and rapid onset attacks were 12.8 +/- 4.0 and 13.9 +/- 4.8, respectively. The scores for the two scenarios were predicted by each other (p = 0.002) and by the interviewer's rating of asthma management knowledge (p = 0.0004, p = 0.0001), but not by age, sex, race, previous asthma morbidity, depression, or anxiety. In both scenarios, most patients indicated that they would increase inhaled beta-agonist (85% for slow-onset scenarios and 94% for rapid-onset scenarios, respectively) and use their action plan and/or seek urgent medical advice at an appropriate time (74% and 70%). Although some would measure peak expiratory flow (PEF) initially (54% and 30%), only a minority would continue to monitor PEF in the context of worsening acute asthma (30% and 24%). When a severe life-threatening situation was described, only 50% and 64%, respectively, indicated that they would call emergency services. CONCLUSIONS: Scenarios describing hypothetical asthma attacks are a useful and reproducible method of assessing practical knowledge of self-management of acute asthma. Patients presented with scenarios frequently made errors in their hypothetical responses. The errors made with scenarios, which parallel errors reported in real clinical situations, occurred despite the fact that this patient population had received considerable education and training about how to manage asthma. Most indicated they would not monitor PEF even in an exacerbation of asthma and would not call emergency services despite life-threatening asthma. These scenarios may allow us to explore the gap between knowledge about treatment and actual practice, and perhaps to help close that gap and thus reduce asthma morbidity and mortality.

Differential influences on asthma self-management knowledge and self-management behavior in acute severe asthma.

AIM: While asthma education increases knowledge, it is less clear whether education influences actual patient behavior. To determine whether there are differences between asthma self-management knowledge and the actual behavior of patients during an acute severe asthma attack and to determine which clinical and psychosocial factors are associated with knowledge and behavior. METHODS: Validated hypothetical scenarios describing the development of life-threatening asthma and patients' reported actual behavior were scored (out of 25) using a system based on Thoracic Society of Australia and New Zealand and British Thoracic Society criteria. RESULTS: In 137 patients admitted to the hospital with severe asthma, the pattern of the index attack was slow onset (> or = 6 h) in 96%. The score for the hypothetical attack (knowledge) was 13.8 +/- 4.6, while that for the timeline (behavior) was 10.2 +/- 3.9 (p < 0.001) with 56% and 84%, respectively, having a score of less than 15 (regarded as inadequate). Certain components showed marked discrepancy (eg, appropriately seeking medical help 82% vs 52% (p < 0.001) and calling ambulance 61% vs 23% (p < 0.001). Factors such as physician-patient relationship, previous asthma morbidity, availability of peak flowmeter, action plan, and oral steroids correlated positively with both measures. Knowledge was negatively associated with being non-European, with anxiety, pessimism, and stigmatization. Behavior (but not knowledge) was negatively associated with lack of knowledge of what to do in the index attack, previous emotional counseling, and business failure. Those factors associated with the difference between knowledge and behavior scores (knowledge-behavior gap) were being non-European, anxiety, pessimism, and stigmatization, concerns about medical costs, and the only income for the household being a Social Security benefit. CONCLUSION: There are marked differences between patients' self-management knowledge and their actual behavior, particularly in terms of potentially life-saving actions. Psychological, health-care, and socioeconomic factors have a powerful and differential influence on knowledge and behavior. Improved understanding of the discrepancies between knowledge and behavior and which factors influence them may lead to more effective asthma educational interventions.

The bereaved therapist and her patients.

Discussions on the role of self-disclosure during times of personal crisis have been mostly confined to the theoretical. Little clinical material has been published. For the writer, this lack contributed further to the sense of loneliness following bereavement, and to uncertainty in terms of how to provide adequate information to patients while protecting herself at a time of great vulnerability. Using case vignettes, the impact of a therapist's bereavement on patients treated in an outpatient consultation-liaison service is explored. Four patients are described--one woman and two men with very serious physical conditions bringing their own frailty and death very near, and one woman with a psychophysiological condition as part of a borderline personality disorder. The impact of personal crisis is discussed, in an attempt to review how such a situation should be handled, and particularly whether and how patients should be informed.

Triggering necroptosis in cisplatin and IAP antagonist-resistant ovarian carcinoma.

Ovarian cancer patients are typically treated with carboplatin and paclitaxel, but suffer a high rate of relapse with recalcitrant disease. This challenge has fostered the development of novel approaches to treatment, including antagonists of the 'inhibitor of apoptosis proteins' (IAPs), also called SMAC mimetics, as apoptosis-inducing agents whose action is opposed by caspase inhibitors. Surprisingly, IAP antagonist plus caspase inhibitor (IZ) treatment selectively induced a tumor necrosis factor-α (TNFα)-dependent death among several apoptosis-resistant cell lines and patient xenografts. The induction of necroptosis was common in ovarian cancer, with expression of catalytically active receptor-interacting protein kinase-3 (RIPK3) necessary for death, and in fact sufficient to compromise survival of RIPK3-negative, necroptosis-resistant ovarian cancer cells. The formation of a necrosome-like complex with a second critical effector, receptor-interacting serine-threonine kinase-1 (RIPK1), was observed. RIPK1, RIPK3 and TNFα were required for the induction of death, as agents that inhibit the function of any of these targets prevented cell death. Abundant RIPK3 transcript is common in serous ovarian cancers, suggesting that further evaluation and targeting of this RIPK3-dependent pathway may be of clinical benefit.

Body image in chronic illness--a reconceptualization.

OBJECTIVE: Was to construct a classification system of the body image specifically relevant to patient experience of chronic physical disorder. METHOD: To review both previous writings on body image and also data on psychosocial factors relevant to a variety of chronic illnesses. From this were derived four component parts of body image: comfort, competence, appearance and predictability. These are discussed in general and disease-specific terms. RESULTS: Using this format, a classification system is offered. This is intended to be simple enough for routine clinical use and yet to offer some insight into body experience. An example is given. CONCLUSION: Separating out the aspects of body image relevant to physical illness provides a clinically useful classification system. Further work is needed to determine its applicability as a research tool.

Survivor guilt and chronic illness.

OBJECTIVE: To examine the grief reactions that may result in patients after a death occurs within a treatment setting for chronic illness, and in particular to look at the applicability of the concept of survivor guilt in these situations. CLINICAL PICTURE: Two patients with endstage renal disease are described. Both presented states of pathological grief for fellow patients. Vulnerability existed in both patients in terms of previous unresolved mourning and in terms of strong feelings of comradship with the dead patients. Both demonstrated features reminiscent of what has been termed the 'survivor syndrome'. TREATMENT: The treatment involved supportive psychotherapy allowing exploration of grief and its relationship to current psychosomatic crises. OUTCOME: Supportive psychotherapy successfully aided the resolution in one patient and made some difference in the other. CONCLUSION: The impact of death within a treatment unit is emphasised. Surviving patients may have significant distress relating to such bereavement and may need appropriate intervention.

The concept of appropriate professional boundaries in psychiatric practice: a pilot training course.

OBJECTIVE: The aim was to design and run a three-session training module for psychiatric registrars on professional practice with particular emphasis on boundary setting. This included the concept of boundary transgression, an understanding of how it occurs and how it may be avoided. METHOD: Drawing on North American experience a curriculum was designed and trialed for trainees at all levels. A variety of media were employed to present a range of common clinical and professional issues. Evaluated were trainee satisfaction, trainee responses to target vignettes at the beginning and at the end of the course, and supervisor awareness and involvement in the process. RESULTS: High attendance and high satisfaction ratings in most areas confirmed that a course such as this is attractive and relevant for psychiatric trainees. Vignette responses suggested some change may have occurred by the end of the course, with a more limited tendency to avoid potentially challenging situations and a higher capacity to explore them. Supervisor involvement remains largely unaddressed despite interest and enthusiasm. CONCLUSION: The area of interpersonal relatedness in psychiatry, including the issue of sexual attraction and the possibility of sexual misconduct, can be introduced as a training package in a way which is acceptable to trainees and their supervisors in an Australian setting. The impact of the training module on actual registrar behaviour is uncertain.

Mania and AIDS: a psychodynamic emphasis.

Two cases of mania in homosexual men with AIDS are presented. Particular emphasis is placed on the psychodynamic and psychosocial factors thought to be aetiologically significant. AIDS is seen both as an example of a terminal illness, and also as creating unique difficulties. It is suggested that integrative rather than reductionist thinking is needed in cases which under DSM-III-R would simply be classified as "organic mood disorder", that is, that all causal and contributory factors need to be considered in affective disorder occurring in the physically ill.

Psychological factors in severe chronic asthma.

OBJECTIVE: Levels of psychological distress, social support factors, and emotional adjustment to illness were measured in a sample of patients with severe asthma. These were then examined in terms of their interrelationships and their ability to predict self-management knowledge. METHOD: A sample of 80 patients was recruited from a hospital-based asthma clinic designed for patients with severe asthma. Thirty-four percent of consecutive attenders approached took part. Morbidity and asthma management were recorded from case records. Anxiety, depression, social support, emotional adjustment to asthma and asthma knowledge were measured using self-report instruments selected for their acceptability and ease of administration. RESULTS: Twenty-five percent of the sample had possible or definite caseness for anxiety; 10.3% had possible or definite caseness for depression. Twenty-five percent had inadequate social support in some way. Three independent attitudinal factors were found: emotional maladjustment to asthma, the doctor-patient relationship, and asthma-related stigma. Level of asthma knowledge was very low. None of the measures of psychosocial function chosen were predictive of asthma knowledge. CONCLUSIONS: Levels of asthma knowledge were dangerously low, despite apparently adequate educational initiatives. In addition, patients with severe asthma have high levels of distress, particularly of anxiety, even between attacks. Their attitudes to their illness are multifactorial, and are significantly correlated with emotional distress, morbidity indices and some demographic factors. While this may point the way to interventions designed to relieve patients' distress, the hypothesis that this might in turn relate to practical asthma knowledge was not confirmed.

Socio-economic disadvantage, quality of medical care and admission for acute severe asthma.

BACKGROUND: In asthma, socio-economic and health care factors may operate by a number of mechanisms to influence asthma morbidity and mortality. AIM: To determine the quality of medical care including the patient perception of the doctor-patient relationship, and the level of socio-economic disadvantage in patients admitted to hospital with acute severe asthma. METHODS: One hundred and thirty-eight patients (15-50 years) admitted to hospital (general ward or intensive care unit) with acute asthma were prospectively assessed using a number of previously validated instruments. RESULTS: The initial subjects had severe asthma on admission (pH = 7.3 +/- 0.2, PaCO2 = 7.1 +/- 5.0 kPa, n = 90) but short hospital stay (3.7 +/- 2.6 days). Although having high morbidity (40% had hospital admission in the last year and 60% had moderate/severe interference with sleep and/or ability to exercise), they had indicators of good ongoing medical care (96% had a regular GP, 80% were prescribed inhaled steroids, 84% had a peak flow meter, GP measured peak flow routinely in 80%, 52% had a written crisis plan and 44% had a supply of steroids at home). However, they were severely economically disadvantaged (53% had experienced financial difficulties in the last year, and for 35% of households the only income was a social security benefit). In the last year 39% had delayed or put off GP visit because of cost. Management of the index attack was compromised by concern about medical costs in 16% and time off work in 20%. CONCLUSION: Patients admitted to hospital with acute asthma have evidence of good quality on-going medical care, but are economically disadvantaged. If issues such as financial barriers to health care are not acknowledged and addressed, the health care services for asthmatics will not be effectively utilised and the current reductions in morbidity and mortality may not be maintained.

Carbon monoxide, amnesia and hyperbaric oxygen therapy.

A case of carbon monoxide poisoning, initially misdiagnosed as conversion disorder, is presented. Cognitive deficits demonstrated at the time of psychiatric assessment were successfully reversed by hyperbaric oxygen therapy despite the 1 week delay. The clinical manifestations of carbon monoxide poisoning and the rationale for and timing of hyperbaric oxygen therapy are discussed. Emphasis is placed on the need for a high index of suspicion for carbon monoxide poisoning in the clinical situation of profound memory disturbance.

Effects of methylphenidate in normal adults with reference to drug action in hyperactivity.

Methylphenidate was administered to each of 12 adult volunteers in a double-blind, placebo-controlled, crossover study for purposes of comparison with previous studies in hyperactive children. Statistically significant changes occurred only on a minority of measures, but the results were generally in the direction of facilitated performance, reduced physical activity and increased emotional responsivity. As these results are similar to those in hyperactive and normal children, this appears to support the contention that stimulant drug effects in hyperactive children are not paradoxical or atypical.

Determinants of management errors in acute severe asthma.

BACKGROUND: It is hypothesised that, despite recent initiatives to improve asthma self-management including asthma education, detailed investigation of the sequence of events culminating in hospital admission will lead to the identification of important management errors and thus the likelihood that the majority of severe asthma attacks are preventable by currently available strategies, and that psychological, health care and socioeconomic factors are risk factors for such management errors. METHODS: A cross sectional study was undertaken of 138 patients aged 15-50 years admitted to hospital (general ward or intensive care unit) with acute severe asthma who were assessed within 24-72 hours of admission using a number of previously validated instruments. A detailed history of events of the attack was assessed against predetermined criteria for non or delayed use of oral corticosteroids and non or delayed use of emergency ambulance services. RESULTS: Subjects had evidence of severe chronic asthma and had acute severe asthma at presentation (n = 90, pH = 7.3 (0.2), PaCO2 = 7.2 (5.0) kPa) but duration of hospital stay was short (3.7 (2.6) days). Serious management errors occurred very frequently and most were deemed to have been made by the patient. Forward stepwise regression revealed that delayed or non-use of oral corticosteroids was predicted independently by lack of paying job (p = 0.02), high total use of inhaled beta agonists in the 24 hours before index admission (p = 0.04), loss of a job in the last year (p = 0.04), low frequency of use of oral corticosteroids in the last year (p = 0.06), concerns during the index attack about medical expenses (p = 0.07), and delay in the use of ambulance services (p = 0.05)--the model being responsible for 23% of the variance. Delayed or non-summoning of emergency ambulance services was predicted independently by total life events (p = 0.03), having something stolen in the last year (p = 0.003), panic during the index attack (p = 0.01), and concerns during the index attack about taking time off work (p = 0.07)--the model being responsible for 21% of the variance. CONCLUSIONS: The results of this study show that, despite recent educational advances, serious management errors are common in those admitted to hospital with acute severe asthma and that most management errors relate to patient self-management behaviour. Serious management errors are predicted by a variety of socio-economic and psychological factors. While the results of this study are consistent with the widely held view that most acute severe attacks are theoretically preventable, the challenge for the future is to change patients' behaviour in the face of considerable adverse socioeconomic and psychological factors.

Body image in rheumatoid arthritis: the relevance of hand appearance to desire for surgery.

To investigate the importance of body image concerns relating to hand appearance in rheumatoid arthritis, a questionnaire was devised and administered to 80 female out-patients. Subjective judgements of hand attractiveness, feelings about hands, and behaviours relating to hand adornment and concealment were sought. Objective ratings of hand attractiveness were obtained from photographs taken at this time of the women's hands. Factor analysis indicated four principal orthogonal factors describe these body image items. Evaluative and affective elements were found to be independent of each other. The hypothesis that body image, thus rated, is relevant to desire for reparative hand surgery was tested using a two-stage general linear modelling procedure. Body image concerns, particularly negative feelings about hands, emerged as significant predictors of desire for surgery, and remained significant after the removal of variance accounted for by duration of arthritis, age, grip strength and objectively rated hand attractiveness. It is suggested that in rheumatoid arthritis, self-perception of hands and the associated emotional response, may be a covert agenda in women's decision to have surgery, and need specific clinical consideration.

Case-control study of severe life threatening asthma (SLTA) in adults: demographics, health care, and management of the acute attack.

BACKGROUND: Severe life threatening asthma (SLTA) is important in its own right and as a proxy for asthma death. In order to target hospital based intervention strategies to those most likely to benefit, risk factors for SLTA among those admitted to hospital need to be identified. A case-control study was undertaken to determine whether, in comparison with patients admitted to hospital with acute asthma, those with SLTA have different sociodemographic and clinical characteristics, evidence of inadequate ongoing medical care, barriers to health care, or deficiencies in management of the acute attack. METHODS: Seventy seven patients with SLTA were admitted to an intensive care unit (pH 7.17 (0.15), PaCO(2) 10.7 (5.0) kPa) and 239 matched controls (by date of index attack) with acute asthma were admitted to general medical wards. A questionnaire was administered 24-48 hours after admission. RESULTS: The risk of SLTA in comparison with other patients admitted with acute asthma increased with age (odds ratio (OR) 1.04/year, 95% CI 1.01 to 1.07) and was less for women (OR 0.36, 95% CI 0.20 to 0.68). These variables were controlled for in all subsequent analyses. There were no differences in other sociodemographic features. Cases were more likely to have experienced a previous SLTA (OR 2.04, 95% CI 1.20 to 3.45) and to have had a hospital admission in the last year (OR 1.86, 95% CI 1.09 to 3.18). There were no differences between cases and controls in terms of indicators of quality of ongoing asthma specific medical care, nor was there evidence of disproportionate barriers to health care. During the index attack cases had more severe asthma at the time of presentation, were less likely to have presented to general practitioners, and were more likely to have called an ambulance or presented to an emergency department. In terms of pharmacological management, those with SLTA were more likely to have been using oral theophylline (OR 2.14, 95% CI 1.35 to 3.68) and less likely to have been using inhaled corticosteroids in the two weeks before the index attack (OR 0.69, 95% CI 0.47 to 0.99). While there was no difference in self-management knowledge or behaviour scores, those with SLTA were more likely to have inappropriately used oral corticosteroids during the acute attack (OR 2.09, 95% CI 1.02 to 4.47). CONCLUSIONS: In comparison with those admitted to hospital with acute severe asthma, patients with SLTA were indistinguishable on sociodemographic criteria (apart from male predominance), were more likely to have had a previous SLTA or hospital admission in the previous year, had similar quality ongoing asthma care, had no evidence of increased physical, economic or other barriers to health care, but had demonstrable deficiencies in the management of the acute index attack. Educational interventions, while not losing sight of the need for good quality ongoing care, should focus on providing individual patients with better advice on self-management of acute exacerbations.

Case-control study of severe life threatening asthma (SLTA) in adults: psychological factors.

BACKGROUND: Severe life threatening asthma (SLTA) is important in its own right and as a proxy for asthma death. In order to target hospital based intervention strategies to those most likely to benefit, risk factors for SLTA among those admitted to hospital need to be identified. Adverse psychological factors are purported risk factors for asthma death and SLTA /near fatal asthma. A study was undertaken to determine whether, in comparison with patients admitted to hospital with acute asthma, those with SLTA have specific adverse psychological factors. METHODS: A case-control study was undertaken. Cases (n=77) were admitted to the intensive care unit with SLTA (mean (SD) pH 7.17 (0.15), PaCO(2) 10.7 (5.0) kPa). Controls (n=239) were admitted to general wards with acute asthma and were matched only by date of index attack. An interviewer administered questionnaire was undertaken 24-48 hours after admission. A random sample of community based asthmatics was recruited to provide normative data on asthmatics for comparison with cases and hospital controls. RESULTS: The risk of SLTA increased with age (OR 1.04/year, 95% CI 1.01 to 1.07) and was less for women (OR 0.36, 95% CI 0.20 to 0.68). These variables were controlled for in all further analyses. There was a high prevalence of psychological disorder in both cases and matched controls, but there was no difference in prevalence of caseness for anxiety or depression, total (or individual) life events in last 12 months, availability of general or disease specific social support, nor in any of the domains of the Attitudes and Beliefs about Asthma Questionnaire (emotional (mal) adjustment, doctor-patient relationship, stigma, self-efficacy). Cases (SLTA) were less likely to have had previous emotional counselling (25% v. 35%, p<0.05). However, when comparison was made with a community based group of asthmatic patients, those admitted to hospital with acute asthma (SLTA and hospital controls) had a higher prevalence of anxiety and depression, higher total life events, and higher prevalence of certain specific life events. CONCLUSIONS: There was considerable psychological morbidity generally (and anxiety specifically) in those admitted with acute asthma. Specific adverse psychological factors were not risk factors for SLTA, when comparison was made with those admitted to hospital with acute asthma, but adverse psychological factors were a risk factor for hospitalisation for acute asthma (including SLTA). Psychological risk factors for adverse events in asthma are dependent both on the type of event under study and the comparison group used.