Observational assessment of situation awareness, team differences and training implications.

The two goals were to investigate, first, the practicability and reliability of observational assessment of team situation awareness (SA) and, second, the nature of any team differences, their consistency and training implications. Five shift teams tackled three scenarios, each with three probe events concerning SA, and three observers viewed and rated concurrently each shift. This methodology was found to be practicable and achieved satisfactory rater reliability as indicated by intraclass and inter-rater correlations. Team differences in SA emerged although there was no consistent pattern. A retrospective analysis of individual and team behaviours relating to SA was performed using the Critical Incident Technique. A total of 75 incidents and 20 behavioural dimensions relevant to SA were identified and these were subsumed under planning, problem solving, team coordination, attention, communication and knowledge. These findings are discussed with regard to the nature and measurement of SA, and the content of training to improve SA for control room teams.

A study of elderly suicides in Hong Kong.

Hong Kong has one of the highest rates of suicide among the elderly in the world. Most of the existing suicide prevention programs have had very little effect on the elderly, who rarely utilize these programs. This study aims to help in understanding the problem, so that effective prevention can be provided to this high-risk group of suicidal people. Specifically, the study (1) describes the characteristics of the suicidal elderly, (2) investigates the reason(s) why the elderly are in distress and become suicidal, and (3) formulates a policy and service model to reach the elderly high-risk group. This research project involves secondary data analysis. Police records on elderly suicide cases in 1992 were scrutinized to find out the major reason(s) for fatal death in the elderly. Our study points out those districts that are more crowded and have fewer medical and social facilities tended to have higher suicide rates. Most of the deaths occurred at home or nearby, and the suicidal elderly were alone before their death. The majority of elderly suicide victims suffered from chronic diseases. Very few of them, however, were totally dependent: About 40% of the cases had consulted medical practitioners, and 27% had consulted psychiatrists within one month before their deaths. Close to 70% of the cases had indicated to family members or other their suicidal thoughts, and many of them had revealed numerous suicidal indications. Both policy and practice issues are discussed in light of the findings.

Suicide notes: what do they tell us?

Police investigation records of all suicide cases in 1992 (n = 769) and the suicide notes that had been left (224 notes for 154 subjects) were examined. Note-leavers were characterized as young females, of non-widowed marital status, with no history of previous suicide attempts, no previous psychiatric illness, and with religious beliefs. Suicide notes written by young people were longer, rich in emotions, and often begging for forgiveness. Suicide notes written by the elderly were shorter, contained specific instructions, and were less emotional. A significant proportion of note-leavers did mention their difficulties. Suicide notes may serve some explanatory purpose and may have a therapeutic role in helping the surviving relatives to understand the suicide. A knowledge of the messages contained within suicide notes could be useful for suicide prevention programmes. The significance of suicide notes is best understood within the context of the occurrence of suicides.

A case for synchronous reduction of testicular androgen, adrenal androgen and prolactin for the treatment of advanced carcinoma of the prostate.

The present study was undertaken mainly to investigate whether prolactin manipulation combined with maximal androgen blockage improves the effectiveness of treatment in advanced prostatic cancer. The efficacy of oral hydrocortisone as an alternative to commercial anti-androgens in reducing the adrenal androgens, and of bromocriptine in reducing the prolactin level were also examined. A consecutive series of 30 patients with untreated and advanced prostatic cancer were entered into a three-arm prospective randomised trial. 10 patients received subcapsular orchiectomy alone (arm 1), another 10 had subcapsular orchiectomy plus flutamide (arm 2), and the remaining 10 had subcapsular orchiectomy plus oral hydrocortisone and bromocriptine (arm 3). Clinical and biochemical parameters, including trans-rectal ultrasound-determined prostatic volumes, hormonal profiles and radionuclide bone scan were evaluated at regular intervals. At 12 months, serum testosterone was reduced by more than 90% in all arms, however, maximum suppression of androstenedione, prolactin, and reduction of prostatic volumes were only observed in arm 3; this was reflected by the significant improvement in clinical response in arm 3 compared with other arms. This study suggests that a combined maximal suppression of androgens and prolactin offers a significant improvement in response over conventional treatments without prolactin suppression in the treatment of advanced prostatic cancer. Importantly, a better clinical outcome in arm 3 was still apparent at the end of 36 months.

A technique for venography in chronic venous syndromes.

The technique of venography presented here is given in detail and is intended to distinguish between the specific requirements of venography of chronic and acute venous syndromes. At each of four major sections of the venous return from the lower limb, the major veins requiring evaluation are identified together with variations in technique needed to ensure that no artefacts develop. Central to the technique is the use of sustained, large volume injections of low-osmolality ionized contrast medium. The technique was used in over 2000 examinations without significant complications.

The family, crisis and chronic illness: an evolutionary model.

While chronic illness has a profound impact upon the individual, an immense burden is imposed upon the family. When the competing demands of an illness and the family escalate exponentially, there may be a crisis. Traditionally, crisis theory has been applied to acute care contexts such as emergency, intensive care and mental health nursing. Yet, clinical experience with families and chronic illness supports the notion of periodic crises from the prediagnostic phase to the long-haul of the illness. Moreover, the authors hypothesize that the family's perception of the event determines whether the crisis is perceived as a threat or a challenge. This paper thus addresses the perception of crisis within the framework of chronic illness from a biological and family systems nursing perspective. First, the theory of Humberto Maturana, a Chilean biologist, is explored and applied to clinical observations regarding family, crisis and chronic illness. Second, an evolutionary model for conceptualizing crisis and chronic illness is presented. Third, the role of beliefs in the family perceptions of crisis and chronic illness is discussed.

Development of the postthrombotic syndrome: its management at different stages.

The postthrombotic syndrome consists of clinical features which follow thrombosis of deep venous return of the limb. Patterns of postthrombotic changes remain difficult to predict and once established, difficult to contain and reverse. Following a thrombotic event of the lower limb, 3 clinical stages can be observed which may be followed by intervening quiescent intervals. Stage I, or the early phase, is characterized by the residual obstructive process following acute venous occlusion. This can be manifested by either a bursting type of pain (venous claudication) or edema of the leg. A thrombotic process can involve the calf veins, thigh veins, pelvic veins, or any combination of the three. Specific clinical syndromes develop depending on the venous pump system involved. The venous pump system consists of the plantar calf pump and the thigh pump. These serve to propel blood upward. Involvement of any one or more of the 3 in the thrombotic processes can result in a relative obstruction with a specific pattern of clinical symptoms. Optimally, the venous thrombotic process should be treated during this early phase to prevent the subsequent events which may render the process irreversible. The second stage of the postthrombotic syndrome consists of the development of fat sclerosis. At this stage, the process becomes progressively irreversible as the extravasation of fibrin into the interstitial space results in progressive fibrosis and sclerosis. This results in damage to the skin and subcutaneous tissues which render the process irreversible. Specific treatment, while still introducible at this stage, can halt the progress of the syndrome, but rarely results in complete reversal.(ABSTRACT TRUNCATED AT 250 WORDS)

Patency of femorofemoral venous crossover grafts assessed by duplex scanning and phlebography.

This study was undertaken to determine the accuracy of duplex imaging of femorofemoral venous crossover grafts (Palma-Dale operation) for postthrombotic unilateral occlusion of the iliac vein. Twenty-four patients, 14 men and 10 women with a mean age of 50 years (range 24 to 72 years), were subjected to duplex imaging and phlebography a mean of 5 years after surgery. Scanning was done with patients in an erect position. A graft was reported as patient if it met the following criteria: it could be imaged in continuity, it could be compressed by the scan probe, and blood flow varied with respiration and was augmented by thigh compression on the symptomatic side. Phlebography indicated that 20 grafts were patent and 17 of these were correctly identified with duplex scanning. Three scans were false negative in obese patients in whom the graft could not be imaged. Four grafts, not imaged, were confirmed by phlebography to be occluded. Compared with phlebography, duplex scanning had a sensitivity of 85%, specificity of 100%, and overall accuracy of 88%. Duplex scanning is safe and accurate way to determine patency after femorofemoral venous bypass if the criteria for patency are fulfilled. If not, the true status of the graft must still be established by phlebography.

A controlled study of the effects of a supervised cardiovascular fitness training program on the manifestations of primary fibromyalgia.

Forty-two patients with primary fibromyalgia were randomized into a 20-week program consisting of either cardiovascular fitness (CVR) training or simple flexibility exercises (FLEX) that did not lead to enhanced cardiovascular fitness. Patients were supervised by the same medical fitness instructors. Patients in neither group had contact with members of the other group, and were blinded as to the exercise taught to the alternative group. Groups met for 60 minutes 3 times each week. The compliance rate was 90%. Thirty-eight patients completed the study (18 with CVR training and 20 with FLEX). Blind assessments (standardized in preliminary trials to achieve acceptable inter-rater agreement) were performed by the same 2 examiners. After 20 weeks, patients receiving CVR training showed significantly improved cardiovascular fitness scores compared with those receiving FLEX training (t[35] = -4.22, P less than 0.003). Logistic regression analysis showed clinically and statistically significant improvements in pain threshold scores, which were measured directly over fibrositic tender points, in patients undergoing CVR (t[35] = 2.21, P less than 0.04). There was also a trend toward improvement in pain scores (visual analog scale) in the CVR group, but this did not reach statistical significance. There was no improvement in the percentage of body area affected by fibrositic symptoms or the number of nights per week or hours per night of disturbed sleep (self-report inventories). However, compared with the FLEX group, the CVR-trained patients improved significantly in both patient and physician global assessment scores.(ABSTRACT TRUNCATED AT 250 WORDS)

Subphrenic abscess: a study of 241 patients at the Royal Prince Edward Hospital, 1950-73.

A series of 241 patients with subphrenic abscess was analysed to seek reasons for the continuing mortality. Aspects of pathology, clinical presentation, special investigations and management were affected by therapy with broad spectrum antibiotics to make diagnosis more difficult, particularly in relation to left subphrenic abscesses. When transperitoneal exploration and drainage were employed, high morbidity and mortality resulted. Satisfactory results followed extraserous drainage. The introduction of parenteral hyperalimentation promised control fistulas associated with abscesses, a situation hitherto associated with a poor prognosis.

The surgical management of subphrenic abscess: a historical study.

This paper is a study of the evolution of the management of subphrenic abscess from the earliest reports to the present day. Its purpose is to compare and contrast the attitudes and practices established during the earlier years with those of the present, in particular in relation to changes consequent on the introduction of antibiotics.