A pattern language of compassion in intensive care and palliative care contexts.

BACKGROUND: Compassion has been identified as important for therapeutic relationships in clinical medicine however there have been few empirical studies looking at how compassion is expressed different contexts. The purpose of this study was to explore how context impacts perceptions and expressions of compassion in the intensive care unit and in palliative care. METHODS: This was an inductive qualitative study that employed sensitizing concepts from activity theory, realist inquiry, phenomenology and autoethnography. Clinicians working in intensive care units and palliative care services wrote guided field notes on their observations and experiences of how suffering and compassion were expressed in these settings. Data were analyzed using constructivist grounded theory. RESULTS: Fifty-eight field notes were generated, along with transcripts from three focus groups. Clinicians conceptualized, observed, and expressed compassion in different ways within different contexts. Patterns of compassion identified were relational, dispositional, activity-focused, and situational. A pattern language of compassion in healthcare was developed based on these findings. CONCLUSIONS: Recognizing compassion as shifting patterns of diverse attitudes, behaviours, and relationships raises numerous questions as to how compassion can be developed, supported and recognized in different clinical settings.

Early surgical abortion: an alternative to and backup for medical abortion.

Surgical abortion by vacuum aspiration is one of the most commonly reported surgical procedures in the United States. The developments of highly sensitive urinary pregnancy tests and transvaginal ultrasonography have encouraged the application of surgical abortion methods at earlier gestational ages. Manual vacuum aspiration with a handheld syringe safely accomplishes early abortion in a variety of settings, from elective abortion in the office or clinic setting to emergency care of a patient with an incomplete abortion. As a wider range of clinicians expresses interest in offering medical abortion, the appropriate use and technique of surgical backup are crucial in safely providing medical abortion. This article reviews vacuum aspiration during the first few weeks of pregnancy, with special attention to manual vacuum aspiration, both for elective surgical abortion and when intervention is required after medical abortion.

A randomized controlled trial of laminaria, oral misoprostol, and vaginal misoprostol before abortion.

OBJECTIVE: To compare the efficacy and acceptability of oral misoprostol, vaginal misoprostol, and laminaria tents for cervical dilation before surgical abortion. METHODS: We conducted a randomized, double-blind, placebo-controlled trial comparing oral misoprostol 400 microg, vaginal misoprostol 400 microg, and one medium laminaria for dilating the cervix over 4 hours before surgical abortion. The study sample consisted of 106 women at 7-14 weeks' gestation who presented to San Francisco General Hospital requesting abortion. The primary outcome was the amount of cervical dilation measured by Pratt dilators. Secondary outcomes were the proportion of subjects needing further manual dilation, difficulty of dilation, duration of the procedure, blood loss, and side effects. RESULTS: The vaginal-misoprostol group had a significantly greater mean dilation (28.0 mm) than the oral misoprostol group (24.2 mm; P < .05) and a greater mean dilation than the laminaria group (25.9 mm), although this difference did not reach significance. Women who received laminaria reported significantly more pain at the time of placement (85.7% reported at least "a little" pain) compared with women who received misoprostol by either route (28.9% of oral-misoprostol and 34.0% of vaginal-misoprostol subjects reported "a little" pain; P < .01). The proportion of subjects who required further manual dilation, ease of dilation, duration of the procedure, and blood loss were not significantly different among the groups. There was no difference in side effects during the 4-hour waiting period among the three groups, and gastrointestinal side effects were rare in all groups. CONCLUSION: Vaginal misoprostol is superior to oral misoprostol and is an acceptable alternative to laminaria tents for cervical dilation before surgical abortion in pregnancies of 7-14 weeks' gestation. It is inexpensive and easy to administer, and achieves equal or greater dilation with less pain on insertion and no increase in side effects compared with laminaria.

Partial liver denervations dissociate the inhibitory effects of pancreatic glucagon and epinephrine on feeding.

We compared the roles of different components of the liver's innervation in the inhibitory effects of pancreatic glucagon and epinephrine on feeding by testing the effects on meal size of intraperitoneal injections of these hormones in rats with selective abdominal vagotomies of only the hepatic branch, with partial liver denervations that spared only the hepatic branch of the vagus, and with sham operations. Pancreatic glucagon (100-400 micrograms/kg) inhibited size of evaporated milk test meals equally in rats with partial liver denervations sparing the hepatic vagus and in sham-operated rats, but had no effect on feeding in rats with selective hepatic vagotomies. In contrast, epinephrine (25-100 micrograms/kg) inhibited meal size equally in all rats. These data suggest that the hepatic vagus is the necessary and sufficient contribution of the liver's innervation to pancreatic glucagon's satiety effect and that hepatic innervation does not contribute to epinephrine's inhibitory effect on meal size. Thus, different peripheral neural mechanisms appear to mediate the effects of these hormones on feeding. Further, the data fail to support the hypothesis that abdominal vagotomies and coeliac ganglionectomies attenuate epinephrine's effect on feeding by disconnecting hepatic afferents.