Should I stay or should I go? An exploration of the decision-making behavior of acute cardiac patients during the COVID-19 pandemic.

BACKGROUND: During the SARS-COV-2 (COVID-19) pandemic efforts to reduce virus transmission resulted in non-emergency patients being deterred from seeking help. The number of patients presenting with acute cardiac conditions reduced, significantly OBJECTIVES: To explore the decision-making process, and influential factors in that process, of patients and their family during an acute cardiac event. METHODS: A qualitative research design was employed using purposive sampling of patients who experienced an acute cardiac event during the social containment mandates. Semi-structured interviews were conducted, with thematic analysis of interview transcripts. RESULTS: Twenty-five participants were recruited from three UK hospitals. Themes identified were reliance on informal support network, lack of awareness of cardiac symptoms leading to delayed help-seeking, and an indirect COVID-19 effect (e.g. avoiding treatment). CONCLUSIONS: These results highlight the need for informed public health messages, targeting patients and their support networks, that allow those in need of treatment to access care.

Continuous bupivacaine infusion post-iliac crest bone graft harvesting in pediatric cleft surgery: role and comparison with ketorolac.

OBJECTIVE: To investigate the use of intravenous ketorolac and iliac crest bupivacaine infusion in the management of iliac crest donor-site pain in the pediatric cleft population. The null hypothesis was there is no difference with respect to pain scores between ketorolac and iliac crest bupivacaine infusion as analgesic adjuncts to intravenous opioids. METHODS: A total of 54 children and adolescents (27 boys, 27 girls) undergoing alveolar cleft repair or Le Fort I osteotomy were assigned randomly in a prospective, single-blinded fashion to one of three groups: intravenous ketorolac plus iliac crest normal saline infusion, intravenous ketorolac plus iliac crest bupivacaine infusion, or iliac crest bupivacaine infusion alone. Iliac crest infusions and ketorolac were administered for 48 hours or until discharge, whichever occurred first. All patients received morphine via a patient-controlled analgesia device. MAIN OUTCOME MEASURE(S): Primary outcome was pain score, and secondary outcomes were morphine consumption and satisfaction scores. RESULTS: Pain scores, morphine consumption, and satisfaction scores were not significantly different among groups. Estimated costs were significantly higher for bupivacaine infusion than intravenous ketorolac. CONCLUSIONS: Iliac crest donor-site pain is well managed in this patient population. Intravenous ketorolac and iliac crest bupivacaine infusion provide comparable analgesia for iliac crest bone graft donor-site pain in children and adolescents.

Irreversible bronchial goblet cell metaplasia in hamsters with elastase-induced panacinar emphysema.

A single intratracheal instillation of pancreatic elastase in hamsters induces a lesion resembling human panacinar emphysema. This paper reports the occurrence of irreversible goblet cell metaplasia in the bronchial epithelium of hamsters similarly exposed to elastase. The goblet cell change was dose related; a dose of 0.1 mg/100 g body wt or less at 16 days, produced slight or moderate goblet cell metaplasia in fewer than half the animals, whereas 84% of animals treated with a dose between 0.2 and 0.5 mg/100 g body wt developed goblet cell metaplastic lesions, more than half of which were considered to be severe. The percentage of goblet cells in the epithelium of elastase-treated hamsters (32.5) was significantly higher (P less than 0.005) than that of unexposed (12.2) and saline-exposed controls (18.7). All hamsters examined 6 and 12 mo after elastase treatment showed the lesion. The pathogenesis of the changes is unclear but the possibility is raised that the bronchial changes may be due to disturbance of an endogenous protease-antiprotease system. The findings suggest the hypothesis that, under appropriate circumstances, a single pulmonary insult in man could lead to a permanent lung injury demonstrating the anatomic lesions of both chronic bronchitis and panacinar emphysema.

Fat embolism in sickle cell disease. Report of a case with brief review of the literature.

This is a unique instance of fatal fat embolism secondary to bone marrow necrosis in a patient with sickle cell-hemoglobin C disease, systemic lupus erythematosus, and Sjögren's syndrome. An elevated level of IgG and treatment with corticosteroids appeared to be major factors in the death of this patient. This complication occurs most often in patients with sickle cell-hemoglobin C disease, especially in pregnant women near term. It should be suspected in any patient with sickle cell disease in whom unexplained fever, respiratory, and neurologic symptoms typical of fat emboli develop following the onset of bone pain. Exchange blood transfusion may be lifesaving.

Hepatoma presenting as a single cavitary lung mass.

A patient who had had a lobectomy for a large cavitary lung mass died one month later. An autopsy was performed and pathologic review of surgical and postmortem specimens confirmed that the original lung lesion was metastatic hepatoma. Excavating solitary metastases from primary adenocarcinomas represent the rarest form of cavitary metastatic lesion, and this is the first report of hepatocellular carcinoma presenting as a single cavitary lung mass.

Familial type II hyperlipoproteinemia with coronary heart disease: effect of diet-colestipol-nicotinic acid treatment.

Heterozygous familial type II hyperlipoproteinemia (F type II) is primarily manifested in hypercholesterolemia (due to low density lipoprotein-cholesterol [LDL-C] elevation) and premature coronary heart disease (CHD). We studied sequentially the effects of low cholesterol-low saturated fat-low simple carbohydrate diet; diet and colestipol, 30 g/day; and diet, colestipol, plus nicotinic acid (NA) 3 to 7 g/day on plasma cholesterol (Ch), LDL-C, triglyceride (TG), high density lipoprotein-cholesterol (HDL-C) and angiographically documented coronary arterial lesions of 32 F type II patients. Effective control of F type II resulted in arresting the progression of angiographically demonstrated coronary arterial lesions.

Pulmonary insufficiency induced by oleic acid in the sheep: a model for investigation of extracorporeal oxygenation.

Most previous studies of the efficiency of bypass techniques for respiratory support have been conducted in hypoxic but otherwise normal animals. However, mechanisms of improved oxygenation by partial venoarterial bypass in the presence of acute respiratory insufficiency can be better studied with an appropriate pathophysiologic model; for this purpose, acute hemorrhagic pulmonary edema was induced in sheep by injection of oleic acid into the right atrium. The model presented a 3 hour period of elevated pulmonary shunting with stable hemodynamics. This preparation is being employed to the study of the mechanisms of extracorporeal oxygenation.

The use of time step simulations and difference equations (TSSADEQ) in modeling heparin pharmacokinetics.

A model in which the clearance of heparin requires the binding of heparin to a finite and regenerated pool of binding was constructed using time step simulations and difference equations (TSSADEQ). A simulation of a heparin i.v. bolus demonstrated a dose-dependent, triphasic pharmacokinetic curve with (1) an initial log-linear phase representing first-order association of heparin with binding sites, (2) an intermediate plateau phase representing constant regeneration of heparin binding sites, and (3) a terminal log-linear phase occurring when the quantity of regenerated sites exceeded the remaining heparin. Sensitivity analysis based on the literature produced estimates of the k at 1.39 to 2.77 h-1, the pool of binding sites of 50 units/kg, and the regeneration rate of 15 to 20 unit/kg/h--virtually identical to the empirically derived guidelines for the bolus size and infusion rate for unfractionated heparin. A pilot study of bolus dosing of unfractionated heparin in normal volunteers confirmed the model.

Outcome measures for adult critical care: a systematic review.

OBJECTIVES: 1. To identify generic and disease specific measures of impairment, functional status and health-related quality of life that have been used in adult critical care (intensive and high-dependency care) survivors. 2. To review the validity, reliability and responsiveness of the measures in adult critical care survivors. 3. To consider the implications for future policy and to make recommendations for further methodological research. 4. To review what is currently known of the outcome of adult critical care. DATA SOURCES: Searches of electronic databases (MEDLINE, EMBASE, CINAHL, PsycLIT, The Cochrane Library and SIGLE) from 1970 to August 1998. Manual searches of five journals (1985-98) not indexed in electronic databases and relevant conference proceedings (1993-98). Reference lists of six existing reviews, plus snowballing from reference lists of all relevant articles identified. STUDY SELECTION: Randomised trials, non-randomised trials (cohort studies) and case series that included data on outcomes after discharge from adult (16 years and over) critical care. DATA EXTRACTION AND SYNTHESIS: If reported, the following data were extracted from each paper: patient characteristics (age, gender, severity of illness, diagnostic category) number of patients eligible for study, follow-up period, number of deaths before follow-up, number and proportion of survivors included in follow-up method of presentation of outcome data - proportion normal as defined by reference values, or aggregate value (e.g. mean or median), or aggregate values plus an indication of variance (e.g. standard deviation or inter-quartile range). Evidence for three measurement properties was sought for each outcome measure that had been used in at least two studies - their validity, reliability and responsiveness in adult critical care. If the authors did not report these aspects explicitly, an attempt was made to use the data provided to provide these measurement properties. For measures that were used in at least ten studies, information on actual reported outcomes were also extracted. RESULTS: MEASURES USED IN CRITICAL CARE: Measures of impairment were largely confined to the respiratory system so are almost certainly not appropriate for many critical care survivors. They can be categorised as respiratory volumes (e.g. vital capacity), gas flow within the respiratory system (e.g. forced expiratory volume in 1 second (FEV1)), pulmonary diffusing capacity (e.g. carbon monoxide diffusing capacity) and visualisation of the upper airway (e.g. bronchoscopy). Multiple tests are often performed. Eight measures of physical functional status were used, five generic and three disease-specific. The most frequently used generic measures were multi-item scales. Two single-item global measures attempted to capture a person's overall activity level or functional status. Five multi-item measures of mental functional status were used, four generic and one specific to trauma patients. The generic measures were either confined to assessing depressive symptoms or also encompassed a measure of anxiety. Measures of neuropsychological functioning relate to a person's cognition, attention, ability to process information and memory. Apart from one single-item measure, which focused on communication level, six multi-item measures were used with critical care survivors. Such measures are particularly appropriate for use with survivors of head injury or other neurological insult and, in that sense, they are disease-specific rather than generic measures. Single item measures of recovery were frequently used but researchers often invented their own, so there was little consistency in the wording. These measures had five principal foci - return to work, return to own home, degree of recovery, productivity and chronic health status. One multi-item scale was also used. (ABSTRACT TRUNCATED)

Liverpool Seizure Severity Scale revisited.

The purpose of the study was to examine the psychometric properties of the revised Liverpool Seizure Severity Scale. The scale has been adapted to increase its content validity and its potential for detecting change attributable to antiepileptic drug treatment. Ninety-seven patients completed the revised scale of which 32 completed it for both major and minor seizures. Reliability of the revised scale was conducted using assessment of internal consistency and test-retest. T-tests were conducted to assess the ability of patients to differentiate between major and minor seizures on scores of the seizure-severity scale. The psychometric properties of the scale were not adversely affected by either the increase in the number of items or the additional response scores. Patients completing the two scales of major and minor seizures were able to reliably differentiate between the two. We have attempted to improve the Liverpool Seizure Severity Scale in order to enhance its reliability, validity and sensitivity to change. The amendments we have made have not adversely affected its psychometric properties and we hope that it will make it more acceptable for use in clinical trials of new antiepileptic drug treatment. The revised scale is currently being applied to a number of clinical trials.

Delayed fatal pulmonary hemorrhage complicating use of a balloon flotation catheter.

A case of delayed fatal pulmonary hemorrhage caused by a balloon flotation catheter is described. The catheter was inserted preoperatively. The patient died on the 14th postoperative day from massive hemorrhage in the right pleural space after 12 days without any clinical symptoms. Pulmonary artery rupture is documented by the autopsy findings.

The mediating role of cutaneous sensitivity within neonatal psychoneuroimmunology.

Preliminary results of this study have been presented at the ICIS Conferences held in Atlanta, 1998; a Summary of results has been quoted in Adamson-Macedo (1997; 1998). OBJECTIVES: Despite knowledge that preterm infants in intensive care are in distress and need to be provided with appropriate intervention, studies with ventilated babies are still rare particularly during their first weeks of life. This study tested the hypothesis that cutaneous stimulation in the form of TAC-TIC therapy, involving only light stroking and NOT massage or kinesthetic massage, has a mediating role in eliciting beneficial psychoneuroimmunological coactions in the ventilated preterm during the first week of post-natal life. METHODS: A repeated measure, counterbalanced design, was used to collect data twice daily for three consecutive days. This intervention was compared with a control condition consisting of a period of spontaneous activity during which the same infants lay alone with no intervention taking place. For the first time, monitoring facilities were made available for immunological, physiological and behavioral responses to be assessed simultaneously before and after intervention and before and after spontaneous activities. RESULTS. A one tailed t-test indicated that the cutaneous intervention resulted in significantly more episodes of beneficial coactions than matched sessions of spontaneous activity. CONCLUSION: It is suggested that the sensory nerves endings in the skin receive the stimulation from the stroking actions; consequently impulses are being sent via afferent nerve fibers to the limbic system where the sensation is interpreted, by 68% of the neonates, as being comforting or not distressing.

Managing countertransference: what the experts think.

The present study attempted to assess the importance of five factors theorized to play a central role in managing countertransference: Self-integration, Anxiety Management, Conceptualizing Skills, Empathy, and Self-insight. 33 experts provided ratings of 50 characteristics of therapists as to the importance of each in managing countertransference. Analysis indicated that each factor is at least somewhat important to management of countertransference, with two of the factors, Self-integration and Self-insight, rated as playing a particularly important role. Clinical implications are discussed.

Health care as a natural right.

Health care is recognized as a right in the Universal Declaration of Human Rights and by the World Health Organization's Declaration on the Rights of Patients. This article demonstrates that this concept of a 'right' to health care draws strong support from leading modern works on natural law and justice and responds to the arguments, both theoretical and practical, put forward against this proposition. It concludes with two warnings: (a) Even in a system where health care is said to be a right, this can be meaningless if the system does not promote basic health, fails to set proper legal and ethical controls or ignores the important individual rights of patients. (b) Our primary commitment must be to those persons who are denied access to health care. To them, talk of patient's individual rights is superfluous. They cannot claim such rights if they are denied the more fundamental right to be a patient.

Countertransference in group psychotherapy: waking a sleeping dog.

This paper reviews and critiques the literature on countertransference (CT) in group psychotherapy. The literature review is organized within a framework that calls attention to the origins, triggers, manifestations, and effects of CT in groups, as well as CT management factors. An overriding critique is that the present literature lacks a research foundation of any kind. An argument is made for beginning research in this domain, and guidelines for doing so are presented.

Hedging opportunities in health care.

Medical care futures contracts offer new hedging opportunities to increase protection against unexpected price changes. Commodity futures contracts can be designed explicitly to hedge volatile group health insurance premiums and capitated hospital and physician prices. This article describes one way to design and use these hedging instruments.