Ethics in the treatment of advanced heart failure: palliative care and end-of-life issues.

Advanced heart failure (HF) is a life-shortening condition, yet there are increasing treatments and implantable devices available to clinicians to manage patients with advanced HF. Planning for adverse events and the end of life, formulated as "preparedness planning," can be integrated into HF care early in illness. Discussions that acknowledge the uncertainty of HF course and length of life and incorporate patient and family goals and values facilitates this planning. Clear processes for weighing potential benefits and burdens of interventions and therapies should accompany decision-making. Device implantation decision-making can acknowledge alternative avenues of care to the device and identify situations in which the device might be deactivated in the future. Symptom assessment and management potentially improve quality of life in patients with advanced HF. Management of symptoms should integrate HF therapies as well as other treatments. Collaboration between HF providers, palliative care clinicians, and, if appropriate, hospice clinicians will improve care for HF patients and their families.

Augmented low dye taping changes muscle activation patterns and plantar pressure during treadmill running.

STUDY DESIGN: Randomized, crossover study. OBJECTIVE: To examine changes in muscle activity and plantar pressure during running with the application of augmented low Dye (ALD) taping. BACKGROUND: ALD taping is used clinically as part of management for lower limb injury. As of yet, no studies have examined the effect of this taping method on muscle activity and plantar pressure during running, simultaneously. METHODS: Thirteen healthy recreational runners(mean ± SD age, 31.7 ± 4.9 years; height, 181.7 ± 4.6 cm; body mass, 81.6 ± 5.9 kg) completed a 6-minute run on a treadmill at a speed of 10 km·h⁻¹, with 3 different taping conditions (ALD, control tape, no tape), applied in randomized order. Peak and average EMG signal amplitude, onset time, and burst duration were calculated for the vastus medialis, vastus lateralis, and the gluteus medius. In-shoe plantar pressures were also recorded. All data were calculated based on an average of 20 steps collected after 5 minutes of treadmill running. RESULTS: ALD taping significantly altered muscle activity and plantar pressure during treadmill running by (1) delaying the onset of the EMG signal of the gluteus medius, vastus medialis, and vastus lateralis, and (2) increasing lateral midfoot plantar pressure. CONCLUSION: ALD taping significantly alters plantar pressure and muscle activation patterns during treadmill running. These findings give insight into the neuromuscular effect of a taping procedure that is used commonly in a clinical setting.

Aiming to improve care of older adults: an innovative faculty development workshop.

INTRODUCTION/AIMS: Internists care for older adults and teach geriatrics to trainees, but they often feel ill-prepared for these tasks. The aims of our 1-day Continuing Medical Education workshop were to improve the knowledge and self-perceived competence of general internists in their care of older adults and to increase their geriatrics teaching for learners. SETTING: Two internal medicine training programs encompassing University, Veterans Affairs, and a community-based hospital in Portland, OR, USA. PROGRAM DESCRIPTION: Course faculty identified gaps in assessment of cognition, function, and decisional capacity; managing care transitions; and treatment of behavioral symptoms. To address these gaps, our workshop provided geriatric content discussions followed by small group role plays to apply newly learned content. Forty teaching faculty participated. PROGRAM EVALUATION: Participants completed 13-item multiple-choice pre- and post-workshop geriatric knowledge tests, pre- and post-workshop surveys of self-perceived competence to care for older adults, and completed an open-ended 'commitment to change' prompt after the intervention. Knowledge scores improved following the intervention (61% to 72%, p < .0001), as did self-perceived competence (11 of 14 items significant). Seventy-one percent of participants reported success in meeting their commitment to change goals. DISCUSSION: A 1-day intervention improved teaching faculty knowledge and self-perceived competence to care for older patients and led to self-perceived changes in teaching behaviors.

Uncovering frustrations. A qualitative needs assessment of academic general internists as geriatric care providers and teachers.

BACKGROUND: General internists commonly provide medical care for older adults and geriatric education to trainees, but lack the necessary knowledge and skills to fulfill these tasks. OBJECTIVE: Assess the geriatric training needs of academic general internists in 3 hospital systems in Portland, OR. DESIGN: Ten focus groups and 1 semi-structured interview. Interview transcripts were analyzed using thematic analysis, a well-recognized qualitative technique. PARTICIPANTS: A convenience sample of 22 academic general internists and 8 geriatricians from 3 different teaching hospitals. MEASUREMENTS: We elicited stories of frustration and success in caring for elderly patients and in teaching about their care. We asked geriatricians to recount their experiences as consultants to general internists and to comment on the training of Internists in geriatrics. RESULTS: In addition to deficits in their medical knowledge and skills, our Internists reported frustration with the process of delivering care to older adults. In particular, they felt ill prepared to guide care transitions for patients, use multidisciplinary teams effectively, and were frustrated with health care system issues. Additionally, general internists' approach to medical care, which largely relies on the medical model, is different from that of geriatricians, which focuses more on social and functional issues. CONCLUSIONS: Although our findings may not be broadly representative, improving our general internists' abilities to care for the elderly and to teach learners how to do the same should address deficits in medical knowledge and skills, barriers to the processes of delivering care, and philosophical approaches to care. Prioritizing and quantifying these needs and measuring the effectiveness of curricula to address them are areas for future research.

Comparison of clinical efficacy and side effects for bitemporal and bifrontal electrode placement in electroconvulsive therapy.

OBJECTIVES: Bifrontal (BF) placement of electrodes in electroconvulsive therapy (ECT) has become a popular alternative to bitemporal (BT) placement. This study compares the clinical efficacy, side effects, and rehospitalization rates of BT and BF electrode placement in a community hospital setting. METHODS: Charts from 76 patients receiving ECT treatments at Harborview Medical Center from 1994 to 2000 were reviewed to extract data on the characteristics of the course of ECT, clinical response, total headaches, narcotic and nonsteroidal anti-inflammatory drug doses, as well as documentation of confusion, disorientation, memory loss, and treatment emergent need for assistance with activities of daily living. RESULTS: The BT patients experienced more clinical improvement during their stay (a 7-point greater change in Psychiatric Symptom Assessment Scale score, P < 0.05) and were significantly less likely to be rehospitalized within a 1-year time frame (odds ratio = 4.9, P = <0.05), even after controlling for relevant covariates. Although the two patient groups had equal rates of headache and analgesic administration, the BT placement caused significantly more cognitive impairment. CONCLUSIONS: This study suggests that BT electrode placement offers better efficacy but modestly greater cognitive impairment than BF electrode placement.