Trust in physicians among rural Medicaid-enrolled smokers.

PURPOSE: Associations have been found between trusting patient-physician relationships and use of preventive care and a greater adherence to prescribed care. The objectives of this study were to assess the level of trust rural Medicaid smokers have in their physicians and whether trust was related to patient characteristics or physician behavior. METHODS: This was a cross-sectional study of smokers who were enrolled in a tobacco-dependence treatment program. Participants were rural Medicaid-enrolled adults, age 18 and older, who were current smokers. Participants were enrolled from 8 primary care clinics as they came in for an appointment with their physician. The Trust in Physician Scale was completed at the baseline visit. One week later, an interview was conducted with the smoker to determine whether the physician provided tobacco-dependence treatment counseling at the visit. Mixed models were used to model the relationship between trust and participant characteristics and physician behaviors. FINDINGS: Medicaid smokers in this study exhibited a high level of trust in their health care provider, as levels were similar to those reported in the general population of patients. Trust was significantly higher among individuals with better self-reported health. CONCLUSIONS: Rural Medicaid smokers appeared to have similar levels of trust in their physician as other patients. Future research should explore the role trust plays in shaping interactions between underserved populations and physicians within the context of smoking cessation counseling.

Amniotic fluid embolism.

Amniotic fluid embolism (AFE) is an unpredictable and as-of-yet unpreventable complication of maternity. With its low incidence it is unlikely that any given practitioner will be confronted with a case of AFE. However, this rare occurrence carries a high probability of serious sequelae including cardiac arrest, ARDS, coagulopathy with massive hemorrhage, encephalopathy, seizures, and both maternal and infant mortality. In this review the current state of medical knowledge about AFE is outlined including its incidence, risk factors, diagnosis, pathophysiology, and clinical manifestations. Special attention is paid to the modern aggressive supportive care that resulted in an overall reduction in the still alarmingly high mortality rate of this devastating entity. The key factors for successful management and resolution of this disease process continue to be sharp vigilance, a high level of clinical suspicion, and rapid all-out resuscitative efforts on the part of all clinicians involved in the medical care of the parturient.

The James Supportive Care Screening: integrating science and practice to meet the NCCN guidelines for distress management at a Comprehensive Cancer Center.

BACKGROUND: Selecting a measure for oncology distress screening can be challenging. The measure must be brief, but comprehensive, capturing patients' most distressing concerns. The measure must provide meaningful coverage of multiple domains, assess symptom and problem-related distress, and ideally be suited for both clinical and research purposes. METHODS: From March 2006 to August 2012, the James Supportive Care Screening (SCS) was developed and validated in three phases including content validation, factor analysis, and measure validation. Exploratory factor analyses were completed with 596 oncology patients followed by a confirmatory factor analysis with 477 patients. RESULTS: Six factors were identified and confirmed including (i) emotional concerns; (ii) physical symptoms; (iii) social/practical problems; (iv) spiritual problems; (v) cognitive concerns; and (vi) healthcare decision making/communication issues. Subscale evaluation reveals good to excellent internal consistency, test-retest reliability, and convergent, divergent, and predictive validity. Specificity of individual items was 0.90 and 0.87, respectively, for identifying patients with DSM-IV-TR diagnoses of major depression and generalized anxiety disorder. CONCLUSIONS: Results support use of the James SCS to quickly detect the most frequent and distressing symptoms and concerns of cancer patients. The James SCS is an efficient, reliable, and valid clinical and research outcomes measure.

Palliative care.

These guidelines were developed and updated by an interdisciplinary group of experts based on clinical experience and available scientific evidence. The goal of these guidelines is to help patients with cancer experience the best quality of life possible throughout the illness trajectory by providing guidance for the primary oncology team for symptom screening, assessment, palliative care interventions, reassessment, and afterdeath care. Palliative care should be initiated by the primary oncology team and augmented by collaboration with an interdisciplinary team of palliative care experts.

Inpatient palliative care consultation: enhancing quality of care for surgical patients by collaboration.

Hospital-based surgeons will likely encounter palliative care service colleagues more frequently, given the growth of approved fellowships and hospital palliative care programs. Surgeons may consult with palliative care colleagues to help patients and families manage pain and other symptoms, cope with the distress of acute and chronic illness, manage complex decisions at end-of-life, and negotiate through a critical illness (or combinations thereof). Inpatient palliative care consultation has been shown to improve quality of care, including quality of life and satisfaction of patients, families, and referring clinicians.

Palliative critical care in the intensive care unit: A 2011 perspective.

Pain relief and palliative care play an increasingly important role in the overall approach to critically ill and injured patients. Despite significant progress in clinical patient care, our understanding of death and the dying process remains limited. For various reasons, people tend to delay facing questions associated with end-of-life, and the fear of the unknown often creates an environment of avoidance and an atmosphere of taboo. The topic of end-of-life care is multifaceted. It incorporates medical, ethical, spiritual, and religious aspects, among many others. Our ability to sustain the lives of the critically ill may be complicated by continuing life support in medically futile scenarios. This article, as well as the remainder of the IJCIIS Symposium on End-of-Life in Trauma/Intensive Care Unit, will explore the most important issues in the field of modern end-of-life care and palliative medicine, with a focus on critically ill and injured patients.

Intracerebroventricular morphine for refractory cancer pain: transitioning to the home setting.

Refractory cancer pain may be effectively controlled by titrating intracerebroventricular (ICV) preservative-free opioid. In this case report, a continuous infusion of ICV morphine permitted our patient with lung cancer and painful spinal metastases to be discharged to home hospice with family. The approach exploits the high potency of morphine injected into cerebrospinal fluid (CSF). Sterile, injectable, preservative-free morphine is directly infused into CSF through a subcutaneous Ommaya reservoir placed under the scalp by a neurosurgeon, with an attached catheter passed through a burr hole in the skull with its tip in a cerebral ventricle. Although investigators have described home care of patients receiving intraspinal analgesics, no report describes the process of transitioning the patient receiving continuous ICV morphine infusion to the home setting.

Percutaneous-guided pain control: exploiting the neural basis of pain sensation.

The gastroenterologist deals frequently with painful conditions and suffering patients. Performing regular pain assessments and applying basic pain medicine principles will augment the care of patients in pain. Percutaneous-guided pain therapy techniques play a role in the multidisciplinary approach to pain medicine. Systemic opioid analgesia is the primary means of controlling cancer pain. However, 10% to 15% of cancer patients may need additional interventions to control pain. Sympathetic ganglion nerve blocks with neurolytic agents such as alcohol or phenol are reserved mostly for cancer pain. The efficacy and safety of these tools are validated by several decades of clinical application and published studies. Although the procedures are operator-dependent, in the hands of experienced clinicians, patients achieve sustained relief in the majority of cases. Although these techniques have been attempted in some benign conditions,such as chronic pancreatitis, with limited success, studies of newer imaging localization techniques such as endoscopic ultrasonography may expand future indications. Patients of the gastroenterologist who experience malignant abdominal pain may benefit from referral for percutaneous-guided pain control techniques.