RESUMO
Precise characterization of cardiac anatomy and physiology through fetal echocardiography can predict early postnatal clinical course. Some neonates with prenatally defined critical congenital heart disease have anticipated precipitous compromise during perinatal transition for which specialized, diagnosis-specific delivery room care can be arranged to expeditiously stabilize cardiopulmonary hemodynamics. In this article, we describe our institutional approach to the delivery room care of neonates with prenatally diagnosed congenital heart disease, emphasizing our diagnosis-specific care pathways for newborns with critical disease.
Assuntos
Salas de Parto , Cardiopatias Congênitas , Ecocardiografia , Feminino , Cardiopatias Congênitas/diagnóstico por imagem , Cardiopatias Congênitas/terapia , Hemodinâmica , Humanos , Recém-Nascido , Gravidez , Diagnóstico Pré-Natal , Ultrassonografia Pré-NatalRESUMO
BACKGROUND: The TOPP Registry has been designed to provide epidemiologic, diagnostic, clinical, and outcome data on children with pulmonary hypertension (PH) confirmed by heart catheterisation (HC). This study aims to identify important characteristics of the haemodynamic profile at diagnosis and HC complications of paediatric patients presenting with PH. METHODS AND RESULTS: HC data sets underwent a blinded review for confirmation of PH (defined as mean pulmonary arterial pressure ≥ 25 mmHg, pulmonary capillary wedge pressure ≤ 12 mmHg and pulmonary vascular resistance index [PVRI] of >3 WU × m(2)). Of 568 patients enrolled, 472 who fulfilled the inclusion criteria and had sufficient data from HC were analysed. A total of 908 diagnostic and follow-up HCs were performed and complications occurred in 5.9% of all HCs including five (0.6%) deaths. General anaesthesia (GA) was used in 53%, and conscious sedation in 47%. Complications at diagnosis were more likely to occur if GA was used (p=0.04) and with higher functional class (p=0.02). Mean cardiac index (CI) was within normal limits at diagnosis when analysed for the entire group (3.7 L/min/m(2); 95% confidence interval 3.4-4.1), as was right atrial pressure despite a severely increased PVRI (16.6 WU × m(2,) 95% confidence interval 15.6-17.76). However, 24% of the patients had a CI of <2.5L/min/m(2) at diagnosis. A progressive increase in PVRI and decrease in CI was observed with age (p<0.001). CONCLUSION: In TOPP, haemodynamic assessment was remarkable for preserved CI in the majority of patients despite severely elevated PVRI. HC-related complication incidence was 5.9%, and was associated with GA and higher functional class.
Assuntos
Hemodinâmica/fisiologia , Hipertensão Pulmonar/fisiopatologia , Avaliação de Resultados em Cuidados de Saúde , Artéria Pulmonar/fisiopatologia , Sistema de Registros , Medição de Risco/métodos , Adolescente , Cateterismo Cardíaco/efeitos adversos , Criança , Pré-Escolar , Feminino , Seguimentos , Saúde Global , Humanos , Hipertensão Pulmonar/diagnóstico , Lactente , Masculino , Estudos Prospectivos , Artéria Pulmonar/lesões , Fatores de TempoRESUMO
Practice guidelines, which are assistive tools for clinicians, have a long tradition in clinical medicine. Traditionally, these documents were developed by physicians to improve quality of care and can provide practitioners with valuable medical information and improve objectivity in medical decision making. Guidelines development by nonphysician groups is increasing. Guidelines are now intended to assist in decreasing costs, in reducing liability risk, and in utilization review, among other activities. Despite this enthusiasm for guidelines, their development is variable and validity remains largely untested. The intended clinical and nonclinical applications of guidelines require critical analysis. Practice guidelines are not inherently unethical. However, applications of nonmedical values combined with intense pressures on health care provision create an environment for guideline misuse. The ethical implications of practice guidelines are examined in our article.
Assuntos
Ética Médica , Guias de Prática Clínica como Assunto , Valores Sociais , Beneficência , Humanos , Seleção de Pacientes , Autonomia Pessoal , Alocação de RecursosRESUMO
Medical errors occur and are sometimes unavoidable. Physicians generally, but not always, have ethical and moral obligations to disclose their errors to the patient. Because common medical errors can be expected, physicians are obligated to work within health systems toward reducing systems flaws that promote errors. However, the obligations of physicians to disclose errors made by others are less clear. This article discusses the professional ethics involved in disclosing and preventing medical errors.
Assuntos
Erros Médicos/prevenção & controle , Relações Médico-Paciente , Revelação da Verdade , Ética Médica , Humanos , Imperícia/legislação & jurisprudência , Erros Médicos/classificação , Erros Médicos/legislação & jurisprudência , Moral , Princípios Morais , Defesa do Paciente , Papel do Médico , Guias de Prática Clínica como Assunto , Gestão da Qualidade TotalRESUMO
In June 1997, the Supreme Court of the United States found that the Constitution does not guarantee a right to physician-assisted suicide, thereby allowing states the opportunity to variously prohibit or permit such practice. The Court's findings notwithstanding, physician-assisted death remains a topic of intense medical, legal and philosophical discussion. Principled discourse variously supports both an ethical prohibition against assisted death and an ethical obligation to help some patients achieve death. Both theoretical and practical concerns are raised by the practice of physician-assisted death. This essay reviews recent events and developments concerning assisted suicide and euthanasia. The discussion which follows was generated by the members of the Committee on Bioethical Issues of the Medical Society of the State of New York and builds upon a previous Committee report.
Assuntos
Ética Médica , Suicídio Assistido , Diretivas Antecipadas , Humanos , Fatores Socioeconômicos , Suicídio Assistido/legislação & jurisprudência , Assistência Terminal , Estados UnidosRESUMO
Pharmaceutical industry spending on direct-to-consumer advertising has been increasing rapidly. While the primary goal of direct-to-consumer advertising is to sell drugs, supposed secondary goals include patient education and improved health. However, these benefits of direct-to-consumer advertising are unproved. Moreover, such advertising may create unnecessary tension between the patient and the patient's physician and insurer, and may divert physicians' efforts away from important patient concerns, and toward marketing-generated discussions. On the other hand, direct-to-consumer advertising may lead to patient-doctor encounters that would not have occurred otherwise. Direct-to-consumer advertising should be modified to unambiguously benefit the health-care interests of consumers and patients.
Assuntos
Publicidade , Participação da Comunidade , Defesa do Consumidor , Indústria Farmacêutica/economia , Ética Médica , Humanos , Relações Médico-Paciente , Estados Unidos , United States Food and Drug AdministrationRESUMO
This study assessed the stability of nursing home residents' preferences for medical treatments. Thirty-seven nondemented, nondepressed residents were surveyed serially over a six-month period. Preferences were elicited for CPR, i.v. antibiotics, mechanical ventilation, and artificial nutrition. Subjects preferred more treatment for their current health concerns than for all hypothetical conditions (p = .001). Subjects disvalued indefinite artificial nutrition and mechanical ventilation compared to time-limited trials (p < .001). All preference changes were toward less intervention; residents preferred limited treatment. Most preferences remained stable. Residents clearly distinguished between time-limited and indefinite treatment, desired i.v. antibiotics and limited mechanical ventilation, and rejected most other treatments.
Assuntos
Diretivas Antecipadas , Atitude Frente a Saúde , Cuidados para Prolongar a Vida/psicologia , Casas de Saúde , Idoso , Idoso de 80 Anos ou mais , Análise de Variância , Tomada de Decisões , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , New YorkRESUMO
Approximately one-half of all patients admitted to the intensive care unit are over the age of 65, even though elderly people comprise about 12% of the population. This article defines the special needs of the geriatric patient within the critical care setting. Developing an approach to the care of critically ill geriatric patients based on knowledge of their medical and psychosocial needs is discussed.
Assuntos
Cuidados Críticos , Geriatria , Idoso , Idoso de 80 Anos ou mais , Ética Médica , Feminino , Avaliação Geriátrica , Humanos , Unidades de Terapia Intensiva , Masculino , Equipe de Assistência ao Paciente , Relações Médico-PacienteRESUMO
Good care for dying patients has always been an obligation in medicine. To fulfill this obligation, physicians must embrace the integralness of dying in life, must recognize when to submit to death and dying with equanimity, and must develop attentive and individualized plans of care for each patient. Approaches to care should have, at their core, a reinvigorated commitment to communication between health professionals and patients and their intimates.
Assuntos
Negro ou Afro-Americano , Terapias Complementares , Diversidade Cultural , Cultura , Comportamentos Relacionados com a Saúde , Obtenção de Tecidos e Órgãos , População Branca , Diretivas Antecipadas , Autopsia , Viés , Tomada de Decisões , Humanos , Padrões de Prática Médica , Doadores de Tecidos , Recusa do Paciente ao Tratamento , Revelação da Verdade , Estados Unidos , Suspensão de TratamentoAssuntos
Demência/psicologia , Ética Médica , Instituição de Longa Permanência para Idosos/normas , Amor , Casas de Saúde/normas , Comportamento Sexual/psicologia , Parceiros Sexuais/psicologia , Atividades Cotidianas , Idoso , Atitude do Pessoal de Saúde , Comportamento de Escolha , Feminino , Avaliação Geriátrica , Humanos , Estilo de Vida , Competência Mental , Defesa do Paciente , Preconceito , Qualidade de VidaAssuntos
Diretivas Antecipadas/legislação & jurisprudência , Diversidade Cultural , Cuidados para Prolongar a Vida/legislação & jurisprudência , Preconceito , Planejamento Antecipado de Cuidados , Comparação Transcultural , Pesquisa Empírica , Humanos , New York , Autonomia Pessoal , Valores Sociais , Confiança , Suspensão de TratamentoAssuntos
Condução de Veículo/psicologia , Demência/psicologia , Ética Médica , Competência Mental/psicologia , Papel do Médico , Idoso , American Medical Association , Confidencialidade , Conflito Psicológico , Família/psicologia , Humanos , Saúde Pública , Segurança , Responsabilidade Social , Estados UnidosAssuntos
Confidencialidade/legislação & jurisprudência , Ética Médica , Infecções por HIV/diagnóstico , Infecções por HIV/transmissão , Testes Obrigatórios/legislação & jurisprudência , Medição de Risco , Programas Voluntários , Comitês Consultivos , Testes Anônimos , Proteção da Criança , Revelação , Feminino , Humanos , Recém-Nascido , Transmissão Vertical de Doenças Infecciosas , Consentimento Livre e Esclarecido , New York , Consentimento dos Pais , Autonomia Pessoal , Formulação de Políticas , Gravidez , Gestantes , Saúde Pública , Populações VulneráveisRESUMO
The use of placebo medication, long recognized by clinicians, often has serious practical implications, such as patient deception. Past evidence has suggested that resident physicians tend to misuse placebo medication. Interns from two consecutive years of a residency program were surveyed anonymously to assess their knowledge and use of placebos. Of the 74 interns surveyed, 44 (59%) were familiar with placebo use in patient care. Fifty percent of these interns familiar with placebo use had learned about placebos from another physician. All interns who had learned about placebos during their internships had learned from another physician, whereas interns who had gained their knowledge of placebos as medical students were as likely to have learned from the medical literature as they were to have learned from a physician (P = 0.027). Interns aware of placebo use were more likely to consider placebo administration for suspected, factitious pain (P = 0.022). The present study uncovered no relationship between interns' estimations of placebo efficacy and the utility they attributed to placebos in assessing a complaint of pain. This suggests that conceptual inconsistencies underlie their use of placebos. Interns often learn of placebos as medical students and are influenced by physician-mentors. Placebo use in patient care is an area of attention for medical educators.
Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Internato e Residência , Assistência ao Paciente/métodos , Placebos , Humanos , Efeito Placebo , Inquéritos e QuestionáriosRESUMO
Fibrin glue pleurodesis has been used to treat bronchopleural fistulas in adults. We report the successful use of fibrin glue in a premature infant to seal a pneumothorax that had persisted for more than 3 weeks despite high-frequency ventilation.
Assuntos
Adesivo Tecidual de Fibrina/uso terapêutico , Doenças do Prematuro/terapia , Pneumotórax/terapia , Feminino , Humanos , Recém-NascidoRESUMO
Physicians routinely care for patients whose ability to operate a motor vehicle is compromised by a physical or cognitive condition. Physician management of this health information has ethical and legal implications. These concerns have been insufficiently addressed by professional organizations and public agencies. The legal status in the United States and Canada of reporting of impaired drivers is reviewed. The American Medical Association's position is detailed. Finally, the Bioethics Committee of the Medical Society of the State of New York proposes elements for an ethically defensible public response to this problem.
Assuntos
Condução de Veículo/legislação & jurisprudência , Fatores Etários , American Medical Association , Confidencialidade , Ética Médica , Humanos , New York , Política Organizacional , Papel do Médico , Transtornos Psicomotores , Sociedades Médicas , Estados UnidosRESUMO
Lung carcinoma cell lines are being used in many laboratories to study various airway epithelial functions, including mucin gene expression. To identify model systems for investigating regulation of MUC5/5AC gene expression and secretion of MUC5/5AC mucins in airway epithelial cells, we evaluated the expression of several mucin genes in six carcinoma cell lines of respiratory tract origin. RNA was extracted from A549, Calu-3, NCI H292, Calu-6, RPMI 2650, and A-427 cells; MUC1, MUC2, MUC4, MUC5/5AC, and MUC5B messenger RNA (mRNA) expression was determined. By Northern analyses, all cell lines expressed MUC1 mRNA, whereas MUC2 mRNA was not detectable in any of the cell lines. RPMI 2650 cell lines expressed only MUC1 mRNA. NCI-H292 cells expressed MUC4 and low levels of MUC5/5AC mRNA. Calu-3 and A549 cells expressed MUC5/5AC mRNA; A549 cells also expressed MUC5B mRNA. Glycoconjugates secreted by lung carcinoma cells were also examined. By wheat germ lectin analysis, Calu-3, H292, and A549 cells secreted high molecular weight glycoproteins having N-acetylglucosamine and/or sialic acid moieties. Western blot analyses with an anti-MUC5:TR-3A antibody demonstrated that Calu-3 and A549 cells secreted MUC5/5AC mucins. All six carcinoma cell lines secreted large, radiolabeled, sulfated macromolecules; the majority were proteoglycans that were digested by hyaluronidase. However, Calu-3 cells also secreted sulfated high molecular-weight glycoproteins that were immunoprecipitated by anti-MUC5:TR-3A antibody. These studies demonstrated that Calu-3 and A549 cell lines expressed high and moderate amounts of MUC5/5AC mRNA and MUC5/5AC mucins, whereas H292 cells expressed lesser amounts. These cell lines should prove useful for studies of MUC5/5AC gene expression and MUC5/5AC biosynthesis, trafficking, and secretions in airway epithelial cells.