Acute Occupational and Physical Therapy for Patients With COVID-19: A Retrospective Cohort Study.

OBJECTIVE: To describe the function of patients with COVID-19 admitted to an acute care hospital early in the pandemic and to characterize change in function among those admitted to intensive care units (ICU) and to non-critical care services. DESIGN: This descriptive, retrospective cohort study examined patients infected with SARS-CoV-2 admitted to a tertiary care medical center during the first wave of the pandemic in 2020. Included patients were stratified into 4 cohorts based on whether or not they received therapy during their hospitalization and whether or not their hospitalization included time in the ICU. Data on demographic characteristics, functional impairments, medical interventions, and functional outcomes were collected. SETTING: Hospital. PARTICIPANTS: 432 adult patients were included in this study (N=432). RESULTS: ICU patients receiving therapy were more likely to have impaired cognition, impaired strength, and impaired sensation than non-ICU patients receiving therapy. Patients made improvements from evaluation to discharge on the Functional Status Score for the ICU, Activity Measure for Post-Acute Care Daily Activity, and AM-PAC Basic Mobility Short Forms. CONCLUSION: Patients admitted with COVID-19 experienced significant functional impairments but also demonstrated improvement during the course of their hospitalizations. This study can facilitate health care provider awareness of the detrimental functional effects of COVID-19 and the potential role of rehabilitation services for these patients.

Putting ethics and clinical decision making before politics: requiring COVID-19 immunization for Solid Organ Transplantation (SOT) Candidates and their Support Team.

We recommend that vaccination for COVID-19 should be a requirement for waitlist activation for solid organ transplant (SOT). We also recommend that such vaccination be required of the primary member of the in-home support team. We argue that these requirements are consistent with current standard practices that draw on a well-established ethical framework. As a result, these recommendations should be easily received and are only controversial owing to the inflamed and politicized state of public discourse.

Insights into the molecular pathogenesis of ocular tuberculosis.

Unclear pathogenic mechanisms underlying the ocular tuberculosis (OTB) has resulted in perplexity related to the diagnosis and management of the disease. Developments in experimental research and innovations in molecular diagnostics have recently provided a new understanding of disease pathogenesis and natural history. The current review focuses on the new insights into OTB pathogenesis, derived from in vivo and in vitro studies on Mycobacterium tuberculosis dissemination and localization into the eye, in combination with histopathological studies on chorioretinal tissue and vascular network. Advances in the knowledge of OTB have influenced disease management in the clinical setting and lead to reconsideration of the role of existing treatments and suggesting potential new therapeutic approaches.

Navigating Clinical Ethics: Using Real Case Constellations to Guide Learners and Teachers in Medicine.

Case-based learning is a staple of clinical ethics education in medicine. The sources for medical educators generally are lengthy case books or single, often rare, case analyses in the literature. Busy clinicians may not have the time or inclination to sift through case books to find suitable teaching material, and the latter present unusual cases that many physicians may never encounter in their own practice. Relatively few articles present multiple cases involving ethical issues that are likely to appear in everyday practice in an accessible format for teaching. To fill this gap, we developed a series of paradigmatic cases based on the recurrent themes we identified through a systematic analysis of our clinical ethics consultations in a 5-year period and our collective clinical ethics judgment. We constructed four amalgam "bread-and-butter" ethics cases that are not overly service specific and can be used in medical and residency education along with specific questions for discussion. Topics include decision-making capacity, withholding and withdrawing life-sustaining treatment, patient wishes and do not resuscitate orders, and brain death. Our objective was to help a range of residents and other physicians become more confident and facile in identifying and addressing recurrent ethical issues in their practice.

Dimensions and Role-Specific Mediators of Surrogate Trust in the ICU.

OBJECTIVE: In the ICU, discussions between clinicians and surrogate decision makers are often accompanied by conflict about a patient's prognosis or care plan. Trust plays a role in limiting conflict, but little is known about the determinants of trust in the ICU. We sought to identify the dimensions of trust and clinician behaviors conducive to trust formation in the ICU. DESIGN: Prospective qualitative study. SETTING: Medical ICU of a major urban university hospital. SUBJECTS: Surrogate decision makers of intubated, mechanically ventilated patients in the medical ICU. MEASUREMENTS AND MAIN RESULTS: Semistructured interviews focused on surrogates' general experiences in the ICU and on their trust in the clinicians caring for the patient. Interviews were audio-recorded, transcribed verbatim, and coded by two reviewers. Constant comparison was used to identify themes pertaining to trust. Thirty surrogate interviews revealed five dimensions of trust in ICU clinicians: technical competence, communication, honesty, benevolence, and interpersonal skills. Most surrogates emphasized the role of nurses in trust formation, frequently citing their technical competence. Trust in physicians was most commonly related to honesty and the quality of their communication with surrogates. CONCLUSIONS: Interventions to improve trust in the ICU should be role-specific, since surrogate expectations are different for physicians and nurses with regard to behaviors relevant to trust. Further research is needed to confirm our findings and explore the impact of trust modification on clinician-family conflict.

Direct and extended intergenerational contact and young people's attitudes towards older adults.

Research suggests that positive intergenerational contact can improve young people's attitudes towards older adults. However, today's age-segregated society may not provide ample opportunities for positive contact between younger and older adults to occur on a regular basis. In three studies, we investigated whether the positive attitudinal outcomes associated with direct contact might also stem from a more indirect form of intergenerational relationship: extended contact. In Study 1 (N = 70), extended contact was associated with more positive attitudes towards older adults even when controlling for direct intergenerational contact (contact frequency and contact quality). In Study 2 (N = 110), the positive effects of direct and extended contact on young people's age-related attitudes were mediated by reductions in intergroup anxiety and ageing anxiety. The mediational effects of intergroup anxiety were replicated in Study 3 (N = 95) and ingroup norms additionally emerged as a mediator of the positive effects of extended contact on young people's attitudes towards older adults. Discussion focuses on the implications for strategies aimed at tackling ageism.

A qualitative study of unmet healthcare needs in chronic obstructive pulmonary disease. A potential role for specialist palliative care?

RATIONALE: Patients with chronic obstructive pulmonary disease (COPD) have high symptom burdens and poor health-related quality of life. The American Thoracic Society issued a consensus statement outlining the need for palliative care for patients with chronic respiratory diseases. A better understanding of the unmet healthcare needs among patients with COPD may help determine which aspects of palliative care are most beneficial. OBJECTIVES: To identify the unmet healthcare needs of patients with COPD hospitalized for exacerbation using qualitative methods. METHODS: We conducted 20 semistructured interviews of patients admitted for acute exacerbations of COPD focused on patient understanding of diagnosis and prognosis, effect of COPD on daily life and social relationships, symptoms, healthcare needs, and preparation for the end of life. Transcribed interviews were evaluated using thematic analysis. MEASUREMENTS AND MAIN RESULTS: Six themes were identified. (1) Understanding of disease: Most participants correctly identified their diagnosis and recognized their symptoms worsening over time. Only half understood their disease severity and prognosis. (2) SYMPTOMS: Breathlessness was universal and severe. (3) Physical limitations: COPD prevented participation in activities. (4) Emotional distress: Depressive symptoms and/or anxiety were present in most participants. (5) Social isolation: Most participants identified social limitations and felt confined to their homes. (6) Concerns about the future: Half of participants expressed fear about their future. CONCLUSIONS: There are many unmet healthcare needs among patients hospitalized for COPD exacerbation. Relief of symptoms, physical limitations, emotional distress, social isolation, and concerns about the future may be better managed by integrating specialist palliative care into our current care model.

Corralling the ingroup: deviant derogation and perception of group variability.

Two experiments investigated the relationship between the evaluation of a deviant group member and the perceived group variability among participants with varying degrees of ingroup identification. In Experiment 1 (N = 79) ingroup identification was negatively associated with perceived ingroup variability following the presentation of a deviant ingroup member. This relationship was mediated by ratings of the deviant: the stronger the identification, the more negatively the deviant was evaluated, and the more homogeneous the ingroup was perceived. These effects were replicated in Experiment 2 (N = 169), which also showed that there was no association between ingroup identification and the representation of the outgroup following exposure to a deviant outgroup member. The findings suggest that deviant derogation may serve to isolate undesirable members from the rest of the ingroup and protect the group's identity.

Innovation credit: when can leaders oppose their group's norms?

Two preliminary studies and 5 experiments examined judgments of leaders who challenge their group's norms. Participants viewed information about group members whose attitudes were normative or deviated in a pronormative or antinormative direction. The antinorm member was identified as (a) either a nonleader or an established leader (Study 1), (b) an ex-leader (Studies 2 and 5), or (c) a future leader (Studies 3, 4, and 5). Antinorm future leaders were judged more positively and were granted greater innovation credit (license to innovate and remuneration) relative to antinorm members, ex-leaders, and established leaders. Results are discussed in terms of the idea that leadership can accrue from prototypicality and can also confer the right to define prescriptive norms. However, innovation credit is only granted in the case of future leaders.

Perioperative guidelines for elective surgery in the human immunodeficiency virus-positive patient.

BACKGROUND: Human immunodeficiency virus (HIV)-positive patients with changes in body morphology can be challenging for the plastic surgeon. Uncertainty about the advisability of elective procedures for these patients and fears of infection transmission may cause trepidation. Plastic surgeons are likely to encounter these patients in increasing numbers. The authors provide an overview of HIV lipodystrophy and treatment options. Clinical parameters are established that must be met before elective procedures on HIV-positive patients. In addition, ethical and legal considerations are discussed. METHODS: A literature review was conducted to identify articles reporting specific, identifiable factors influencing operative risk in HIV-positive patients. Legal and ethical experts were consulted. RESULTS: Specific risk factors influencing operative morbidity include an absolute CD4 count of less than 200 cells/cc3 or viral load greater than 10,000 copies/ml. Patients with CD4 counts greater than 200 cells/cc3 and a low viral load have a risk of postoperative complications similar to that of the general population and should therefore be evaluated on established preoperative parameters (e.g., American Society of Anesthesiologists class, nutrition, and age). CONCLUSIONS: Patients with HIV-associated body morphology changes can be safely treated by the plastic surgeon, provided that a thorough preoperative workup is performed. There is minimal risk of disease transmission. There is an ethical and legal obligation to treat these patients if the patient is suitable and the procedure in question falls under the expertise of the consulting surgeon.

Protecting threatened identity: sticking with the group by emphasizing ingroup heterogeneity.

In two studies (Ns=163, 164), the authors tested the prediction that perceptions of group variability can steer and guide the way that loyalty is expressed in times of identity threat. In both studies, participants were classified as lower or higher identifiers on the basis of their scores on a group identification measure, and manipulations involved group variability perceptions (homogeneous ingroup vs. heterogeneous ingroup) and threat to the ingroup. Higher identifiers presented with a homogeneous ingroup perceived more ingroup homogeneity under threat than when there was no threat. In contrast, higher identifiers who perceived the ingroup initially as heterogeneous perceived more ingroup heterogeneity under threat than in no threat conditions. Lower identifiers perceived more ingroup heterogeneity under threat (vs. no threat) irrespective of manipulated group variability perceptions. Discussion focuses on different ways that group loyalty can be expressed in times of identity threat.

A population-based study of the prevalence and influence of gifts to radiation oncologists from pharmaceutical companies and medical equipment manufacturers.

PURPOSE: Hospital-based physicians are responsible for the purchase of expensive equipment. Little is known about the influence of gift giving on their behavior. We wanted to ascertain the prevalence of gift giving from the pharmaceutical industry and medical equipment manufacturers to radiation oncologists and determine whether or not the size of accepted gifts influences their opinions regarding gifts. METHODS AND MATERIALS: A population-based survey of hospital-based physicians conducted between 2002 and 2003. The study population consisted of all radiation oncologists who were members of the American Society of Therapeutic Radiology and Oncology between 2000 and 2001. A random number generator was used to identify 20% of the population. This group was invited by e-mail and conventional mail to complete a Likert scale questionnaire. Those asked to complete the questionnaire electronically were directed to a specially designed web site. RESULTS: Of 640 individuals who were asked to participate, 241 (38%) completed the questionnaire. 96% admitted accepting gifts. The most commonly accepted low value gifts were: pen or pencil (78%), drug samples for patient's use (70%), meal (66%), and a note pad (59%). The most commonly accepted high value gifts were trips to "equipment-users meetings" (15%), honoraria for speaking at a conference (10%), and participation in a conference call (9%). Only 5% of radiation oncologists agreed with the statement "my prescribing practices are affected" by gifts; however, 33% agreed with the statement "I believe that other physicians prescribing practices are affected." Similarly, although only 4% felt that their recommendations concerning purchases of medical equipment are affected by gifts, 19% felt that other physicians would be influenced. A test of the hypothesis that physicians believe that their conduct is less affected than those of their colleagues (i.e., "I am not influenced by gifts but someone else is" was strongly affirmed by a correlation statistic) (p < 0.0001). Of the radiation oncologists surveyed, 74% felt that they should be free to accept gifts of small value, 31% felt they should be free to accept meals or gifts of any type, 16% felt that residency programs should ban free meals provided by companies, 13% felt professional associations should discourage companies from hosting parties at the annual meeting, 17% felt that gift giving should stop, and 66% agreed that clinical information provided by companies provides a useful continuing medical education service. Those who accepted larger gifts were far more likely to disagree with statements such as "professional societies should actively discourage companies from hosting parties and providing free meals and giving gifts to physicians attending the annual meeting" (p = 0.0003) and "the practice of gift giving by companies should stop" (p = 0.0017); they were slightly more likely to agree with statements such as "clinical information provided to radiation oncologists by companies provides a useful continuing medical education service." CONCLUSIONS: To our knowledge, this study represents the first large-scale population based study of a hospital-based specialty and gift giving. This study demonstrates that: (1) Gift giving in radiation oncology is endemic. (2) Although each physician is likely to consider himself or herself immune from being influenced by gift giving, he or she is suspicious that the "next person" is influenced. (3) There is a correlation between the willingness of individual physician to accept gifts of high value and their sympathy toward this practice.