RESUMO
Dabigatran is a novel anticoagulation which has been approved as an alternative to warfarin therapy for non-valvular atrial fibrillation. Use of Dabigatran for approved indications as well as off label use has dramatically increased after Federal Drug Administration (FDA) approval. Our patient had left atrial thrombosis even after being on Dabigatran for more than one month which raises question about safety and efficacy of use of dabigatran around cardioversion and ablation.
RESUMO
In May 2011, the clinical ethics group of the Center for Ethics at Washington Hospital Center launched a 40-hour, three and one-half day Clinical Ethics Immersion Course. Created to address gaps in training in the practice of clinical ethics, the course is for those who now practice clinical ethics and for those who teach bioethics but who do not, or who rarely, have the opportunity to be in a clinical setting. "Immersion" refers to a high-intensity clinical ethics experience in a busy, urban, acute care hospital. During the Immersion Course, participants join clinical ethicists on working rounds in intensive care units and trauma service. Participants engage in a videotaped role-play conversation with an actor. Each simulated session reflects a practical, realistic clinical ethics case consultation scenario. Participants also review patients' charts, and have small group discussions on selected clinical ethics topics. As ethics consultation requests come into the center, Immersion Course participants accompany clinical ethicists on consultations. Specific to this pilot, because participants' evaluations and course faculty impressions were positive, the Center for Ethics will conduct the course twice each year. We look forward to improving the pilot and establishing the Immersion Course as one step towards addressing the gap in training opportunities in clinical ethics.
Assuntos
Ética Clínica/educação , Pessoal de Saúde/educação , Capacitação em Serviço/métodos , Ensino/métodos , Adulto , Currículo , District of Columbia , Comitês de Ética Clínica , Consultoria Ética , Feminino , Hospitais Gerais , Hospitais Privados , Humanos , Capacitação em Serviço/organização & administração , Masculino , Pessoa de Meia-Idade , Negociação , Desempenho de Papéis , Ensino/organização & administração , Gravação de VideoteipeRESUMO
This paper presents the behavioral interview model that we developed to formalize our hiring practices when we, most recently, needed to hire a new clinical ethicist to join our staff at the Center for Ethics at Washington Hospital Center.
Assuntos
Eticistas , Entrevistas como Assunto/métodos , Seleção de Pessoal , District of Columbia , Humanos , Administração de Recursos Humanos em HospitaisRESUMO
Curbside ethics consultations occur when an ethics consultant provides guidance to a party who seeks assistance over ethical concerns in a case, without the consultant involving other stakeholders, conducting his or her own comprehensive review of the case, or writing a chart note. Some have argued that curbside consultation is problematic because the consultant, in focusing on a single narrative offered by the party seeking advice, necessarily fails to account for the full range of moral perspectives. Their concern is that any guidance offered by the ethics consultant will privilege and empower one party's viewpoint over-and to the exclusion of-other stakeholders. This could lead to serious harms, such as the ethicist being reduced to a means to an end for a clinician seeking to achieve his or her own preferred outcome, the ethicist denying the broader array of stakeholders input in the process, or the ethicist providing wrongheaded or biased advice, posing dangers to the ethical quality of decision-making. Although these concerns are important and must be addressed, we suggest that they are manageable. This paper proposes using conflict coaching, a practice developed within the discipline of conflict management, to mitigate the risks posed by curbside consultation, and thereby create new "spaces" for moral discourse in the care of patients. Thinking of curbside consultations as an opportunity for "clinical ethics conflict coaching" can more fully integrate ethics committee members into the daily ethics of patient care and reduce the frequency of ethically harmful outcomes.
Assuntos
Conflito Psicológico , Consultoria Ética , Ética Clínica , Resolução de Problemas , Humanos , Relações Interprofissionais , Estados UnidosAssuntos
Reanimação Cardiopulmonar/ética , Conflito de Interesses , Comunicação Interdisciplinar , Consentimento Presumido , Coleta de Tecidos e Órgãos/ética , Obtenção de Tecidos e Órgãos/ética , Comitês Consultivos , Morte Encefálica , Comitês de Ética em Pesquisa , Ética Clínica , Humanos , Relações Interprofissionais , National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division , Preservação de Órgãos/ética , Consentimento Presumido/ética , Consentimento do Representante Legal , Fatores de Tempo , Obtenção de Tecidos e Órgãos/métodos , Estados UnidosRESUMO
BACKGROUND: In upper endoscopy, overtubes protect the hypopharynx and esophagus in patients requiring multiple esophageal intubations. Transesophageal echocardiography (TEE) is frequently used in general cardiology practice to provide high-resolution, real-time images of cardiac structures that are often not visualized by transthoracic imaging alone. Patients with a history of esophageal disorders or difficult esophageal intubations may have increased risk for complications from the echoprobe. An esophageal overtube may facilitate TEE in such patients. OBJECTIVE: We sought to evaluate the usefulness of upper endoscopy with placement of an esophageal overtube to facilitate TEE in patients with prior difficult esophageal intubations. METHODS: We performed upper endoscopy, followed by placement of an esophageal overtube, in 4 patients who had an unsuccessful intubation with the TEE probe. The endoscopic procedures were successfully completed, thus, allowing for uneventful subsequent TEE. CONCLUSIONS: Upper endoscopy with placement of an esophageal overtube may allow for safe successful completion of TEE in patients with previously unsuccessful blind esophageal intubation.
Assuntos
Ecocardiografia Transesofagiana/métodos , Endossonografia/métodos , Aumento da Imagem/métodos , Intubação Intratraqueal/métodos , Idoso , Idoso de 80 Anos ou mais , Ecocardiografia Transesofagiana/instrumentação , Endossonografia/instrumentação , Feminino , Humanos , Aumento da Imagem/instrumentação , Intubação Intratraqueal/instrumentação , MasculinoRESUMO
Although 2-dimensional echocardiography with adjunct intravenous contrast media improves endocardial visualization and enhances quality of spectral Doppler signals, widespread use of contrast agents has not occurred for various reasons. Results from this study indicate that discretionary use of contrast media will enhance endocardial and Doppler signal visualization scores without an impact on total procedure duration, lending credence to an argument for a lower threshold for discretionary use of contrast media.
Assuntos
Ecocardiografia/métodos , Aumento da Imagem/métodos , Disfunção Ventricular Esquerda/diagnóstico por imagem , Idoso , Feminino , Humanos , Masculino , Variações Dependentes do Observador , Prognóstico , Reprodutibilidade dos Testes , Sensibilidade e EspecificidadeAssuntos
Bioética/educação , Comitês de Ética Clínica/organização & administração , Consultoria Ética/tendências , Hospitais Urbanos/ética , Competência Clínica , Dissidências e Disputas , District of Columbia , Educação Médica Continuada , Comitês de Ética Clínica/tendências , Hospitais Urbanos/organização & administração , Humanos , Corpo Clínico Hospitalar/educação , Estudos de Casos Organizacionais , Objetivos Organizacionais , Assistência Terminal/éticaRESUMO
Incidence of breast cancer (BC) varies among ethnic groups, with higher rates in white than in African-American women. Until now, most epidemiological and genetic studies have been carried out in white women. To investigate whether interactions between genetic and reproductive risk factors may explain part of the ethnic disparity in BC incidence, a genetic epidemiology study was conducted, between 1989 and 1994, at the Howard University Cancer Center (Washington, DC), which led to the recruitment of 245 African-American families. Segregation analysis of BC was performed by use of the class D regressive logistic model that allows for censored data to account for a variable age of onset of disease, as implemented in the REGRESS program. Segregation analysis of BC was consistent with a putative dominant gene effect (P < 0.000001) and residual sister-dependence (P < 0.0001). This putative gene was found to interact significantly with age at menarche (P = 0.048), and an interaction with a history of spontaneous abortions was suggested (P = 0.08). A late age at menarche increased BC risk in gene carriers but had a protective effect in non-gene carriers. A history of spontaneous abortions had a protective effect in gene carriers and increased BC risk in non-gene carriers. Our findings agree partially with a similar analysis of French families showing a significant gene x parity interaction and a suggestive gene x age at menarche interaction. Investigating gene x risk factor interactions in different populations may have important implications for further biological investigations and for BC risk assessment.
Assuntos
Negro ou Afro-Americano , Neoplasias da Mama/etiologia , Neoplasias da Mama/genética , Reprodução/fisiologia , Aborto Espontâneo , Adulto , Negro ou Afro-Americano/estatística & dados numéricos , Idade de Início , Idoso , Idoso de 80 Anos ou mais , Neoplasias da Mama/epidemiologia , Feminino , Genes Dominantes , Humanos , Incidência , Funções Verossimilhança , Modelos Logísticos , Menarca , Menopausa , Pessoa de Meia-Idade , Paridade , Gravidez , Fatores de RiscoRESUMO
The Leung-Griffiths model as modified by Moldover and Rainwater is used to correlate high-pressure vapor-liquid equilibria of mixtures of carbon dioxide with n-butane and isobutane. Model correlations are compared against 10 independent experimental sources for these mixtures. Agreement is generally very good and comparable to mutual experimental discrepancies. The utility of the model as a data evaluation technique is demonstrated in that small suspect regions have been identified in certain data sets and the model predictions have been confirmed by subsequent measurements that agree with the model better than the earlier data.