Language and understanding of cardiopulmonary resuscitation amongst an aged inpatient population.

Greater patient involvement in health decision-making requires exchange of information between the patient and the healthcare professionals. Decisions regarding healthcare at the end of life include consideration of cardiopulmonary resuscitation (CPR). The stated objectives of this study were to determine how often language around concepts of resuscitation is used in the community by examination of the English language corpora (ELC); to explore the understanding of the same language by a group of older hospital patients; and to determine the patients' knowledge of the process and success of CPR, as well as the sources of their information. Medical inpatients aged 75 years and older were surveyed to this end in the setting of a tertiary university teaching hospital. Interrogation of the Australian, British and American English Corpora was accomplished by a linguist, and a questionnaire and semi-structured interview were administered to ascertain patient knowledge. We demonstrated that although medical inpatients have some familiarity with terms relating to resuscitation, there is a lack of understanding of the context, process and outcomes of CPR. The predominant sources of information were television and print media. Examination of the ELC revealed a paucity of the use of terms related to resuscitation. This finding indicates that physicians have a duty of care to determine patients' understanding around resuscitation language, and terms used, in discussions of their preferences before assuming their engagement in shared decision-making. More open public discussion around death and resuscitation would increase the general knowledge of the population and would provide a better foundation for the discussions in times of need.

The impact of intensive care in a private hospital on patients aged 80 and over: health-related quality of life, functional status and burden versus benefit.

BACKGROUND: Greater numbers of persons aged over 80 years are admitted to intensive care units (ICU) compared with 15 years ago. Outcomes other than death such as physical dependence and cognitive impairment and treatment burden are important to older people. AIMS: The aims of this study were to determine the long-term outcomes of functional impairment, health-related quality of life (HRQoL) and the self-reported burden of treatment in a sample of patients aged 80 years and above admitted to ICU. Half of the cohort were admitted for elective cardiac surgery, the rest for non-cardiac surgery and medical conditions. METHODS: In this longitudinal cohort study, in a tertiary level ICU, we measured HRQoL using the SF-36 and functional status using the modified Barthel Index at several time points over a 2-year follow-up period. We also assessed treatment burden by asking participants whether they thought the episode of care was worthwhile. RESULTS: A total of 348 patients was recruited into the study. One-fifth of the cohort had died by the 2-year follow-up data collection point. There was an improvement in physical functioning in the cardiac surgery group at 6 months which was not sustained. There was no change in HRQoL at 2 years in either group. The majority valued the episode of care. CONCLUSION: We demonstrated that HRQoL and previous lifestyle is preserved in the majority following ICU admission, associated with a high level of patient valuation of the episode of care.

Can frailty predict complicated care needs and length of stay?

The Reported Edmonton Frail Scale was used to describe the prevalence of frailty in an acute general medical unit. The relationship between frailty, discharge destination, mortality and length of hospital stay was explored. We found that age was associated with frailty, and frailty correlated to an increasing length of hospital stay. Significantly, frailty was associated with complexity in discharge, and this process created a longer length of hospital stay.

Comparison of not for resuscitation (NFR) forms across five Victorian health services.

BACKGROUND: Within Australian hospitals, cardiac and respiratory arrests result in a resuscitation attempt unless the patient is documented as not for resuscitation. AIM: To examine the consistency of policies and documentation for withholding in-hospital resuscitation across health services. METHOD: An observational, qualitative review of hospital policy and documentation was conducted in June 2013 in three public and two private sector hospitals in metropolitan Melbourne. Not for resuscitation (NFR) forms were evaluated for physical characteristics, content, authorisation and decision-making. Hospital policies were coded for alerts, definition of futility and burden of treatment and management of discussions and dissent. RESULTS: There was a lack of standardisation, with each site using its own unique NFR form and accompanying site-specific policies. Differences were found in who could authorise the decision, what was included on the form, the role of patients and families, and how discussions were managed and dissent resolved. Futility and burden of treatment were not defined independently. These inconsistencies across sites contribute to a lack of clarity regarding the decision to withhold resuscitation, and have implications for staff employed across multiple hospitals. CONCLUSIONS: NFR forms should be reviewed and standardised so as to be clear, uniform and consistent with the legislative framework. We propose a two-stage process of documentation. Stage 1 facilitates discussion of patient-specific goals of care and consideration of limitations of treatment. Stage 2 serves to communicate a NFR order. Decisions to withhold resuscitation are inherently complex but could be aided by separating the decision-making process from the communication of the decision, resulting in improved end-of-life care.

How receptive are patients to medical students in Australian hospitals? A cross-sectional survey of a public and a private hospital.

BACKGROUND: Medical student numbers in Australian universities have more than doubled since 2000. There are concerns about the ability for existing clinical training sites to accommodate this increase in student numbers, and there have been calls to increase training in private hospitals. The receptiveness of patients in private hospitals will influence the success of such placements. AIMS: We aimed to evaluate whether patients in a private hospital are as receptive to medical students as patients in a public hospital. METHODS: Cross-sectional survey of patients conducted at a private and a public teaching hospital in Melbourne, Australia. Main outcome measures were willingness to allow a medical student to participate in an interview, physical examination and procedures (electrocardiogram, venepuncture and digital rectal examination), and patient attitudes towards medical students as assessed by a series of 20 attitude statements and a summative attitude score. RESULTS: Patients at the private hospital were more willing than patients at the public hospital to allow a medical student to take their history unsupervised (112/146, 76.7% vs 90/141, 63.8%; P = 0.02). The distribution of patient willingness did not otherwise differ between hospitals for physical examination or procedures. There was no difference in the mean attitude score between hospitals (15.3 ± 0.8 private vs 15.4 ± 1.2 public, P = 0.38), and responses differed between hospitals for only four of the 20 attitude statements. CONCLUSIONS: Our findings suggest that patients in a private hospital are at least as receptive to medical students as patients in a public hospital.

Barriers to the implementation of evidence in osteoporosis treatment in hip fracture.

An audit at a private tertiary hospital showed low rates of assessment and treatment of osteoporosis in minimal trauma patients of hip fracture. A survey sent to all doctors involved in hip fracture care to establish medical beliefs about effective management of osteoporosis in minimal trauma hip fracture patients showed a lack of ownership for investigation and beliefs influencing treatment choices. Understanding the barriers to the translation of evidence into practice is vital to improve patient care.

A narrow and highly significant linkage signal for severe bipolar disorder in the chromosome 5q33 region in Latin American pedigrees.

We previously reported linkage of bipolar disorder to 5q33-q34 in families from two closely related population isolates, the Central Valley of Costa Rica (CVCR) and Antioquia, Colombia (CO). Here we present follow up results from fine-scale mapping in large CVCR and CO families segregating severe bipolar disorder, BP-I, and in 343 population trios/duos from CVCR and CO. Employing densely spaced SNPs to fine map the prior linkage peak region increases linkage evidence and clarifies the position of the putative BP-I locus. We performed two-point linkage analysis with 1134 SNPs in an approximately 9 Mb region between markers D5S410 and D5S422. Combining pedigrees from CVCR and CO yields a LOD score of 4.9 at SNP rs10035961. Two other SNPs (rs7721142 and rs1422795) within the same 94 kb region also displayed LOD scores greater than 4. This linkage peak coincides with our prior microsatellite results and suggests a narrowed BP-I susceptibility regions in these families. To investigate if the locus implicated in the familial form of BP-I also contributes to disease risk in the population, we followed up the family results with association analysis in duo and trio samples, obtaining signals within 2 Mb of the peak linkage signal in the pedigrees; rs12523547 and rs267015 (P = 0.00004 and 0.00016, respectively) in the CO sample and rs244960 in the CVCR sample and the combined sample, with P = 0.00032 and 0.00016, respectively. It remains unclear whether these association results reflect the same locus contributing to BP susceptibility within the extended pedigrees.

Shoulder injury in the throwing athlete.

Successful nonoperative management of shoulder injury in the throwing athlete requires a comprehensive team approach. The cornerstone of management is physical therapy to restore strength, balance, and endurance to the shoulder girdle musculature followed by a return to a throwing program. The return to competitive throwing is usually a lengthy process requiring patience from the medical team and the athlete.

Transaortic repair of mitral regurgitation.

BACKGROUND: In the operative management of mitral regurgitation (MR) associated with aortic valve disease, a transaortic approach combining the bowtie mitral valve repair with replacement of the aortic valve appears to offer a less invasive and technically simple, expeditious alternative to conventional left atriotomy and Carpentier style repair. METHODS: Between February 1997 and December 1999, four patients underwent a bowtie repair of the mitral valve via the aortic root with concomitant aortic valve replacement. The diagnosis of MR was established and followed postoperatively by echocardiogram. The operative technique involved a transaortic annular approach to the mitral valve with a single edge-to-edge suture approximating the prolapsing posterior mitral leaflet to a normal segment of the anterior leaflet. RESULTS: There were no operative mortalities. Mean cross-clamp time for both valve procedures was 104 +/- 24 min and cardiopulmonary bypass was 155 +/- 31. Mean postoperative cardiac output was 5 +/- 1 L/min. Semiquantitative estimation of mitral regurgitation by doppler improved from a mean of 3.2 +/- 0.5 preoperatively to a mean of 0.25 +/- 0.5 (p = 0.0052) postoperatively, while ejection fraction (EF) remained stable (48 +/- 9% preoperatively and 49 +/- 9% prior to discharge). One patient with rheumatic mitral pathology had a mild increased mitral gradient which did not resolve with takedown of the bowtie repair. Mitral stenosis was not evident in any of the other patients. CONCLUSIONS: Our initial experience with the combined transaortic bowtie repair and aortic valve replacement has demonstrated that this approach is very quick, feasible, effective, and technically simple with gratifying midterm results.

The painful shoulder in the throwing athlete.

Successful nonoperative treatment of shoulder injuries in the throwing athlete requires a team approach. The physician, physical therapist, and athletic trainer work together with the athlete to determine a diagnosis and design a treatment protocol. Injury recovery requires restoration of muscle strength and balance followed by a careful return to a throwing program.

Complete radical nephrectomy and vena caval thrombectomy during circulatory arrest.

PURPOSE: A modification of radical nephrectomy for renal carcinoma and vena caval tumor thrombectomy for supradiaphragmatic tumor extension under hypothermic circulatory arrest is presented. MATERIALS AND METHODS: Nephrectomy was performed during the circulatory arrest time in 16 consecutive patients during the last 4 years. RESULTS: Average hypothermic circulatory arrest time increased by 6 minutes. By elimination of manipulation of tumor and thrombus before circulatory arrest potential thrombus fragmentation and embolization were minimized. There were no significant differences in blood loss or complications compared to a prior series of 10 patients undergoing the procedure using conventional techniques. CONCLUSIONS: Performance of complete radical nephrectomy along with venal caval embolectomy during circulatory arrest increases the safety of the procedure without significant morbidity.

Transfer of behavioral intervention technology to a sexually transmitted disease clinic.

This article describes the authors' approach to introducing a behavioral counseling intervention into a local health department STD clinic setting. The goal of the intervention was to change the sexual practices of clients with STDs. The project was a collaborative effort with a local health department, school of public health, and a community training organization. The authors used an organizational change framework for implementing the intervention.

Endarterectomy for preventing stroke in symptomatic and asymptomatic carotid stenosis. Review of clinical trials and recommendations for surgical therapy.

BACKGROUND: Multicenter, randomized trials have demonstrated advantages for surgery over medical therapy in both symptomatic and asymptomatic carotid stenosis of greater than 70%. Controversial interpretations of these trials are debated between medical and surgical camps. The goal of this review is to summarize the current state of knowledge in carotid stenosis and the role of surgery and several advances in operative management. METHODS: Summaries of seven major controlled trials of carotid endarterectomy versus medical therapy are presented along with supportive data from over 90 related publications. Criticisms, deficiencies as well as strengths are offered. RESULTS: All studies in which trial design, clinical variables, case selection, complication definition, and patient follow-up were well conceived and performed showed statistically significant advantages for surgical therapy within a remarkable short interval of follow-up (less than 3 years). Carotid endarterectomy demonstrated a two to four fold reduction in the late incidence of stroke when compared to optimum medical management (risk factor reduction and initiation of antiplatelet therapy). Reduction in stroke risk over time remains stable in surgically treated patients whereas medically treated patients clearly show progression of stenosis and evolution of new neurologic events with time. Several studies indicate that diabetes is a risk factor for stroke with medical therapy that is eliminated by surgical therapy. Advantages were more clearly demonstrated when symptomatic patients (TIAs, stroke, or amaurosis) were studied, but asymptomatic patients received significant benefit as well. The degree of benefit measured was in direct balance to the perioperative risk. Perioperative stroke and death rates must be low (less than 3% combined for asymptomatic patients) in order for statistically significant differences to be detected. However, most centers now can perform carotid endarterectomy within these outcome parameters. CONCLUSIONS: Randomized trials support the safety and efficacy of carotid endarterectomy for stenosis greater than 70% (with or without symptoms). Advantages of surgery over medical therapy were found in less than three years and there is ample evidence to suggest that the differences between these groups would have been even more pronounced had longer follow-up been obtained. Thus for patients who face many years of risk after diagnosis of a carotid lesion, early surgery is the most important and effective intervention for preventing stroke. The results of these trials raised initial concern over increasing health care expenditures from rising surgical case volumes. However, studies of cost effectiveness confirmed that surgery saves health care dollars when compared to the long term care of stroke victims.

ACL reconstruction in children with open physes.

Nine male patients with wide open physes who underwent intra-articular anterior cruciate ligament (ACL) reconstruction using semitendinosus and gracilis tendon grafts passed through the tibial physis and over the top of the femoral condyles were retrospectively reviewed at an average follow-up of 39 months (range: 24 to 72 months). Five patients underwent reconstruction < 6 weeks following injury (range: 11 days to 41 days); the other four underwent reconstruction 2, 3, 5, and 24 months following injury. Seven patients had excellent results and fully returned to their sport. Mean Lysholm score in these patients was 99 (range: 95 to 100), and the mean maximum KT-1000 difference (available for six patients) was 2.8 mm (range: 0 to 5.5 mm). Four of six intact grafts had a mean maximum KT-1000 difference < or = 3.5 mm. Two grafts ruptured and were considered failures (one complete rupture at 10 months and one partial rupture at 3 years). Postoperative height increase averaged 10.7 cm (range: 4 to 22.9 cm). No patient had a clinically significant leg-length discrepancy, angular deformity, or radiographic evidence of physeal injury.