RESUMEN
BACKGROUND: 'Do Not Attempt Cardiopulmonary Resuscitation' (DNACPR) orders are made frequently for older people in hospital. Sensitive anticipatory discussion is encouraged where possible, but usually this does not happen, despite the evidence suggesting that many older patients would like to be involved in such decisions. METHODS: Current clinical practice in both primary care and secondary care and perceived barriers to patient involvement in resuscitation decisions was assessed using a questionnaire in Medicine for the Elderly physicians in two hospitals, and General Practitioners of teaching practices in Norfolk. RESULTS: Response rate was 51% (n = 24/47). Hospital-based clinicians made DNACPR decisions more frequently, but discussed decisions with patients in less than 25% of cases. By contrast, GPs thought that patient involvement was more important and felt that they had a better understanding of the patient's wishes due to the long-term relationship they shared. Mental capacity was seen as the biggest barrier to patient involvement by both groups. Other barriers included lack of understanding, communication difficulties and practical concerns. CONCLUSION: Further support and training could help clinicians improve their resuscitation decision-making practice. Advanced discussion in Primary Care with older people before they lose capacity may have a role in increasing their involvement in resuscitation decision making.
Asunto(s)
Órdenes de Resucitación/psicología , Adulto , Anciano , Actitud del Personal de Salud , Comprensión , Inglaterra , Femenino , Médicos Generales/psicología , Médicos Generales/estadística & datos numéricos , Estado de Salud , Humanos , Masculino , Cuerpo Médico de Hospitales/psicología , Cuerpo Médico de Hospitales/estadística & datos numéricos , Competencia Mental , Persona de Mediana Edad , Participación del Paciente/psicología , Participación del Paciente/estadística & datos numéricos , Rol del Médico , Relaciones Médico-Paciente , Atención Primaria de Salud , Órdenes de Resucitación/ética , Órdenes de Resucitación/legislación & jurisprudencia , Atención Secundaria de SaludRESUMEN
Back problems are common, expensive, and the few patients who are the crux of the problem are uncomfortable but also an uncomfortable frustration for clinicians and employers alike. We now know that clinicians can greatly improve the patient's response to back symptoms by admitting our diagnostic limitations, demedicalizing the issue, providing assurance, and encouraging a more reasonable approach to improving comfortable activity tolerance.
Asunto(s)
Dolor de Espalda/fisiopatología , Dolor de Espalda/psicología , Dolor de Espalda/terapia , Humanos , Enfermedades Profesionales/fisiopatología , Enfermedades Profesionales/terapia , Relaciones Médico-PacienteAsunto(s)
Asma/terapia , Manejo de la Enfermedad , Guías de Práctica Clínica como Asunto , Sistemas Recordatorios , Planificación en Salud Comunitaria , Servicio de Urgencia en Hospital/estadística & datos numéricos , Costos de la Atención en Salud , Hospitalización/estadística & datos numéricos , Humanos , New York , Estudios de Casos Organizacionales , Evaluación de Programas y Proyectos de Salud , Garantía de la Calidad de Atención de Salud , Calidad de Vida , AutocuidadoRESUMEN
The Clance Impostor Phenomenon Scale (CIPS; Clance, 1985) was compared to the newly developed Perceived Fraudulence Scale (Kolligian & Sternberg, 1991). The two scales were found to have high internal consistency and to correlate in a similar manner with other measures. Further, discriminant validity evidence for the Impostor Phenomenon (IP) was provided by comparing the CIPS to measures of depression, self-esteem, social anxiety, and self-monitoring. The IP was related to, but substantially discriminable from, these constructs. Finally, construct validity evidence for the CIPS was provided through principal components analysis that yielded three stable factors: Fake, Discount, and Luck.
RESUMEN
We describe three cases with known pancreatic or bile duct neoplasia treated by surgery who subsequently presented with obstructive jaundice. In all cases ultrasound demonstrated a fluid-filled obstructed Roux loop and a patent biliary-enteric anastomosis. The cause of the obstruction was seen in two cases. Ultrasound is a safe, fast, reliable and non-invasive method in the assessment of these patients.
Asunto(s)
Anastomosis en-Y de Roux/efectos adversos , Colestasis/diagnóstico por imagen , Colestasis/etiología , Conducto Colédoco/cirugía , Neoplasias del Conducto Colédoco/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Páncreas/cirugía , Neoplasias Pancreáticas/cirugía , UltrasonografíaRESUMEN
Many of the discrepancies reported to date in empirical investigations of the impostor phenomenon (IP) may be due in part to (a) the use of different methods for identifying individuals suffering from this syndrome (impostors), (b) the common use of a median split procedure to classify subjects and (c) the fact that subjects in many studies were drawn from impostor-prone samples. In this study, we compared the scores of independently identified impostors and nonimpostors on two instruments designed to measure the IP: Harvey's I-P Scale and Clance's IP Scale. The results suggest that Clance's scale may be the more sensitive and reliable instrument. Cutoff score suggestions for both instruments are offered.
Asunto(s)
Logro , Inventario de Personalidad/estadística & datos numéricos , Autoimagen , Adulto , Femenino , Humanos , Control Interno-Externo , Masculino , Determinación de la Personalidad , Trastornos de la Personalidad/diagnóstico , Trastornos de la Personalidad/psicología , Reproducibilidad de los Resultados , Sensibilidad y EspecificidadRESUMEN
Angioedema is a known adverse reaction of the angiotensin converting enzyme (ACE) inhibitors. Although current investigations are in progress, the exact pathogenesis of ACE inhibitor-induced angioedema is still unclear. Most cases of angioedema we have seen remitting from the short-acting ACE inhibitor, captopril, have presented with mild angioedema, controlled with antihistamines and glucocorticosteroids. In contrast, the angioedema induced by the long-acting ACE inhibitors have been serious. Our five patients developed angioedema from either lisinopril or enalapril. Three of five patients presented with severe angioedema requiring intubation, and one of these patients had a tracheostomy. One patient with a history of mild angioedema secondary to captopril subsequently required intubation for his enalapril-induced angioedema.
Asunto(s)
Angioedema/inducido químicamente , Inhibidores de la Enzima Convertidora de Angiotensina/efectos adversos , Enalapril/análogos & derivados , Enalapril/efectos adversos , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Lisinopril , Masculino , Persona de Mediana Edad , Insuficiencia Respiratoria/inducido químicamenteAsunto(s)
Infecciones Neumocócicas/complicaciones , Poliarteritis Nudosa/diagnóstico , Púrpura/diagnóstico , Adulto , Antibacterianos/uso terapéutico , Terapia Combinada , Ciclofosfamida/uso terapéutico , Femenino , Humanos , Metilprednisolona/uso terapéutico , Diálisis Peritoneal , Infecciones Neumocócicas/tratamiento farmacológico , Poliarteritis Nudosa/etiología , Poliarteritis Nudosa/terapia , Púrpura/etiología , Púrpura/terapia , EsplenectomíaRESUMEN
A 45-year-old black woman, sputum positive for acid-fast bacilli, developed hypersensitivity to both isoniazid and rifampin. She was admitted to the hospital and desensitized to both medications using modified penicillin protocols. Skin testing was negative to both drugs. Desensitization to isoniazid was complicated by a drug fever that was controlled by prednisone. The patient was able to maintain once-a-day dosing without incident even with steroid taper. To our knowledge, this is the first reported case of dual isoniazid and rifampin hypersensitivity with rapid oral desensitization.
Asunto(s)
Desensibilización Inmunológica/métodos , Hipersensibilidad a las Drogas/terapia , Isoniazida/efectos adversos , Rifampin/efectos adversos , Hipersensibilidad a las Drogas/diagnóstico , Femenino , Humanos , Persona de Mediana Edad , Pruebas CutáneasRESUMEN
A history of a prior hypersensitivity reaction to egg has precluded patients from receiving egg-derived vaccines. We present three cases of successful administration of egg-derived vaccines; specifically influenza and measles, mumps, and rubella (MMR) to patients with egg hypersensitivity. Two were given influenza vaccine without incident and one was successfully desensitized to MMR. Skin testing and desensitization protocols are described. Desensitization to all three components of MMR has not been reported previously.
Asunto(s)
Proteínas del Huevo/inmunología , Hipersensibilidad a los Alimentos/inmunología , Vacunas contra la Influenza/inmunología , Vacuna Antisarampión , Vacuna contra la Parotiditis , Vacuna contra la Rubéola , Adulto , Desensibilización Inmunológica , Combinación de Medicamentos , Femenino , Humanos , Lactante , Pruebas Intradérmicas , Masculino , Vacuna contra el Sarampión-Parotiditis-Rubéola , Persona de Mediana Edad , Prueba de RadioalergoadsorciónRESUMEN
This repeated measures study identified each subject's baseline range of fluctuation in pulmonary artery pressures and used this information to evaluate the effects of changes in backrest elevation (0 degrees and 30 degrees) and position (supine and lateral) on pulmonary artery pressures. Sixteen hemodynamically stable patients were studied. Six measures of pulmonary artery pressure were obtained with subjects in the supine (flat) position. Pulmonary artery systolic pressures fluctuated from 2-16 mm Hg, pulmonary artery diastolic pressures from 0-11 mm Hg, and pulmonary artery mean pressures from 0-13 mm Hg. Only pulmonary artery diastolic pressures were not altered in a statistically significant way with backrest elevation. Even though backrest elevation produced clinically significant changes (those exceeding the subject's baseline range of fluctuation) in some subjects, no other changes in parameters of hemodynamic status were observed. These results suggest that pulmonary artery pressures may be obtained with backrests elevated. Since position changes produced both statistically and clinically significant changes in all pulmonary artery pressures, the use of lateral positions during pulmonary artery pressure measurement is not recommended.
Asunto(s)
Postura/fisiología , Presión Esfenoidal Pulmonar/fisiología , Adulto , Anciano , Cuidados Críticos , Diástole , Femenino , Humanos , Masculino , Persona de Mediana Edad , Supinación , SístoleRESUMEN
We report four patients who developed severe adverse reactions to protamine sulfate following cardiac surgery. Two types of reactions were seen. First, an immediate anaphylaxis which is a complement-dependent IgG antibody-mediated reaction. In the literature, 80% of patients who had similar reactions have had previous exposure to protamine. All patients adequately tested had positive skin tests and there is 6% mortality. The second reaction to protamine during cardiac surgery is characterized by delayed onset and profound vascular damage presenting as noncardiogenic pulmonary edema or total vascular collapse with prolonged hypotension and anasarca. These patients have negative skin tests and in our studies, no evidence of antibody mediated reaction, suggesting some other mechanisms may play a part. The mortality is high (30% of patients reported) and survivors have significant morbidity.