RESUMEN
BACKGROUND: External validation of prognostic model for one-year mortality in patients ventilated for 21 days or more. A measure that identifies patients who are at high risk of mortality after prolonged ventilation will help physicians communicate prognoses to patients or surrogate decision makers. Our objective was to validate a prognostic model developed by Carson et al in a different setting. METHODS: An observational study was conducted from September 2002 to September 2007 in 30 beds Medical/Surgical Intensive Care Unit (ICU) at Mercy Fitzgerald Hospital (MFH) and 20 beds Medical/Surgical ICU at Mercy Philadelphia Hospital (MPH). One hundred and fifty medical and surgical patients requiring mechanical ventilation after acute illness for at least 21 days after initial intubation were enrolled. RESULTS: One year mortality was 45.4%. Area under the receiver operating characteristic curve for three month mortality was 0.90 and for one year mortality was 0.92. For identifying patients who had ≥90% risk of death at 3 month had sensitivity of 40% and specificity of 95% and risk of death at 1 year had sensitivity of 70% and specificity of 99%. Four predictive variables, requirement of vasopressors, hemodalysis, platelet count ≤ 150 x 10 9/L and age ≥50 yrs can be used as a simple prognostic score that clearly identifies low-risk patients and high-risk patients. CONCLUSIONS: Simple clinical variables measured on day 21 of mechanical ventilation can identify patients at highest and lowest risk of death from prolonged mechanical ventilation.
Asunto(s)
Modelos Teóricos , Respiración Artificial/mortalidad , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Unidades de Cuidados Intensivos , Masculino , Persona de Mediana Edad , Philadelphia/epidemiología , Pronóstico , Investigación Cualitativa , Curva ROC , Sensibilidad y Especificidad , Servicio de Cirugía en Hospital , Factores de TiempoRESUMEN
In the "Internet Age," physicians and patients have unique technological resources available to improve the patient physician relationship. How they both utilize online medical information will influence the course of their relationship and possibly influence health outcomes. The decision-making process may improve if efforts are made to share the burden of responsibility for knowledge. Further benefits may arise from physicians who assist patients in the information-gathering process. However, further research is necessary to understand these differences in the patient physician relationship along with their corresponding effects on patient and physician satisfaction as well as clinical outcomes.
Asunto(s)
Internet/estadística & datos numéricos , Relaciones Médico-Paciente , Investigación/organización & administración , Toma de Decisiones Asistida por Computador , Humanos , Informática Médica/organización & administración , Informática Médica/tendencias , Educación del Paciente como Asunto/organización & administración , Educación del Paciente como Asunto/tendenciasRESUMEN
Experience with electronic communication in ethics committees at two hospitals is reviewed and discussed. A listserver of ethics committee members transmitted a synopsis of the ethics consultation shortly after the consultation was initiated. Committee comments were sometimes incorporated into the recommendations. This input proved to be most useful in unusual cases where additional, diverse inputs were informative. Efforts to ensure confidentiality are vital to this approach. They include not naming the patient in the e-mail, requiring a password for access to the listserver, and possibly encryption. How this electronic communication process alters group interactions in ethics committees is a fruitful area for future investigation.
Asunto(s)
Redes de Comunicación de Computadores/estadística & datos numéricos , Comités de Ética Clínica/organización & administración , Consultoría Ética , Hospitales de Veteranos/normas , Derivación y Consulta/estadística & datos numéricos , Chicago , Seguridad Computacional , Confidencialidad , Hospitales Universitarios/normas , Humanos , Derivación y Consulta/organización & administraciónRESUMEN
Advance directives have failed to achieve a substantial completion rate nationwide despite prior efforts. We hypothesize that the continued low completion rate itself inhibits their utility and application. In this commentary we recommend linking the completion of advance directives to the time when health insurance is initiated or renewed by amending the Patient Self Determination Act. This would relocate the time and locus of their completion from the emotional turmoil of hospital admission and acute illness to a more equanimous time when family and others can be consulted and involved. Moreover actuating increased utilization may require non-coercive incentives as well as education. Amending the Patient Self Determination Act to require providing advance directive forms at the initiation of healthcare insurance in conjunction with educational and/or incentives could be more effective than the current arrangements.
Asunto(s)
Planificación Anticipada de Atención/organización & administración , Planificación Anticipada de Atención/estadística & datos numéricos , Directivas Anticipadas , Directivas Anticipadas/legislación & jurisprudencia , Humanos , Seguro de Salud , Pacientes no Asegurados , Motivación , Patient Self-Determination Act , Cuidado Terminal/organización & administración , Estados UnidosAsunto(s)
Manejo de Caso/organización & administración , Prestación Integrada de Atención de Salud/organización & administración , Programas Controlados de Atención en Salud/organización & administración , Pautas de la Práctica en Medicina/organización & administración , Educación Médica/organización & administración , Medicina Basada en la Evidencia/educación , Humanos , Satisfacción en el Trabajo , Satisfacción del Paciente , Calidad de la Atención de Salud , Estados UnidosRESUMEN
Hypocomplementemic urticarial vasculitis (HUV) is often misdiagnosed. The response to drug therapy may be unsatisfactory, and immunosuppressive therapy may be associated with significant side effects. A 35-year-old patient whose condition was resistant to cyclophosphamide, corticosteroids, pentoxyphylline, cyproheptadine, sulindac, and colchicine was maintained in remission with dapsone, which may be the drug of choice for HUV. Emphysema has been reported to complicate HUV, but this is the first account of vasculitis-related emphysema with no confounding history of tobacco smoke exposure. The relationship of proteolytic injury to the pulmonary and other manifestations is considered, as is the possible role for dapsone in reducing it.
Asunto(s)
Dapsona/uso terapéutico , Piel/efectos de los fármacos , Urticaria/complicaciones , Vasculitis Leucocitoclástica Cutánea/tratamiento farmacológico , Adulto , Femenino , Humanos , Piel/irrigación sanguínea , Vasculitis Leucocitoclástica Cutánea/etiologíaRESUMEN
This report proposes a policy for discontinuing dialysis in persistent vegetative state (PVS) patients and attempts to address autonomy and community-based values while maintaining professional moral agency. It is recommended that the policy be adopted at a regional level (eg, the ESRD Network). The involved physicians and ethicists would communicate with the next-of-kin and surrogate decision-makers, and the local ethics committee would perform a double review of the case to assure the appropriateness of the policy to the case. Given the unique nature of PVS with its permanent loss of consciousness and autonomy, we hold that a community-based consensus can form a guideline that limits futile dialysis while respecting patient and professional moral agency. Prior consent of dialysis patients to the regional policy at a time shortly after initiating dialysis will add to its ethical impetus.
Asunto(s)
Inutilidad Médica , Defensa del Paciente , Diálisis Peritoneal , Estado Vegetativo Persistente/terapia , Diálisis Renal , Privación de Tratamiento , Directivas Anticipadas , Beneficencia , Consenso , Toma de Decisiones , Disentimientos y Disputas , Eticistas , Comités de Ética Clínica , Ética Médica , Eutanasia Pasiva , Libertad , Procesos de Grupo , Humanos , Fallo Renal Crónico/complicaciones , Fallo Renal Crónico/terapia , Estado Vegetativo Persistente/complicaciones , Autonomía Personal , Asignación de RecursosRESUMEN
STUDY OBJECTIVE: To assess the efficacy of phlebotomy in the treatment of pulmonary edema in hemodialysis patients. PROCEDURE: Maintenance hemodialysis patients presenting to the emergency room in respiratory distress from apparent pulmonary edema were assessed with regard to clinical response, change in blood pressure, change in hematocrit, and interval until the next hemodialysis treatment, RESULTS: Twenty-one patients underwent phlebotomy and seventeen improved markedly and did not require intubation or emergent dialysis. Hemodialysis was initiated 15.6 +/- 13.6 SD hours later. Four were able to have their treatment 24 or more hours later. Thirteen of 21 (62%) were hypertensive at the time of treatment and blood pressure tended to normalize in this subset. Four of 21 (19%) developed transient hypotension without permanent sequelae. Pre-mean hematocrit = 25.0 + 6.0 and post phlebotomy = 22.6 + 4.6 SD. All patients receiving phlebotomy survived to hospital discharge. CONCLUSION: Phlebotomy can often obviate the need for intubation or emergent dialysis in ESRD patients presenting with pulmonary edema.
Asunto(s)
Fallo Renal Crónico/complicaciones , Flebotomía/métodos , Edema Pulmonar/terapia , Diálisis Renal , Presión Sanguínea , Hematócrito , Humanos , Hipotensión/sangre , Hipotensión/etiología , Hipotensión/fisiopatología , Fallo Renal Crónico/sangre , Fallo Renal Crónico/terapia , Flebotomía/efectos adversos , Edema Pulmonar/complicaciones , Edema Pulmonar/fisiopatología , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
The congruence model is a framework used to analyze organizational strengths and weaknesses and pinpoint specific areas for improving effectiveness. This article provides an overview of organizations as open systems, with examples in the primary care arena. It explains and applies the congruence model in the context of primary care issues and functions, including methods by which the model can be used to diagnose organizational problems and generate solutions. Changes needed in primary care due to the managed care environment, and areas of potential problems and sensitivities requiring organizational changes to meet market and regulatory demands now placed on PCOs are examined.
Asunto(s)
Eficiencia Organizacional , Modelos Organizacionales , Atención Primaria de Salud/organización & administración , Programas Controlados de Atención en Salud/organización & administración , Cultura Organizacional , Pautas de la Práctica en Medicina , Derivación y Consulta , Estados UnidosAsunto(s)
Comparación Transcultural , Violencia , Circuncisión Femenina , Femenino , Salud , Humanos , Modelos TeóricosRESUMEN
By examining the ethical features of dialysis withdrawal as well as tr transcultural differences in attitudes toward withdrawal, one can have a better understanding of the role of autonomy and community-based values on medical decision-making. Three distinctive patterns of withdrawal are described herein. The first concerns patients suffering from an advanced state of physical or mental decline. When a patient or health care surrogate decision maker requests cessation of therapy because it fails to be beneficial for the patient in his or her totality, the physician should be prepared to cooperate, in accord with beneficence and nonmaleficence as well as autonomy. The second pattern occurs when the patient loses decisional capacity, and the surrogate decision maker makes unreasonable requests for nonbeneficial care. At issue is what constitutes nonmaleficence and beneficence in this setting, the provider and surrogate differing on whether continuing dialysis constitutes beneficence. Such a dilemma can alleviated by community-based consensus guidelines with consent of the patient before losing capacity. The dialysis network is potentially a unit of patient and professional community. In third pattern, the patient's decision to withdraw appears to be inappropriate to their potential for benefit from continued therapy. The nephrologist and patient are conflicted on what constitutes beneficence, with the former holding that continuation is morally superior. In such cases, the physician must mediate the situation in a beneficent fashion not solely dictated by a constraining view of patient autonomy.
Asunto(s)
Beneficencia , Defensa del Paciente , Autonomía Personal , Diálisis Renal , Justicia Social , Responsabilidad Social , Valores Sociales , Negativa del Paciente al Tratamiento , Privación de Tratamiento , Discusiones Bioéticas , Canadá , Consenso , Comparación Transcultural , Características Culturales , Diversidad Cultural , Toma de Decisiones , Disentimientos y Disputas , Consultoría Ética , Ética Médica , Europa (Continente) , Procesos de Grupo , Humanos , Internacionalidad , Rol Judicial , Jurisprudencia , Fallo Renal Crónico/terapia , Paternalismo , Estados UnidosRESUMEN
Intravenous pulse cyclophosphamide (IPC) was used to treat lupus interstitial lung disease in 2 patients. Vital capacity increased by 67-110% of baseline values with IPC treatment. Total lung capacity and diffusing capacity also improved. Dyspnea and other manifestations of lupus improved dramatically. This is the first report documenting the efficacy of the early use of IPC for acute and chronic interstitial lung disease associated with lupus.
Asunto(s)
Ciclofosfamida/uso terapéutico , Enfermedades Pulmonares Intersticiales/tratamiento farmacológico , Lupus Eritematoso Sistémico/complicaciones , Adulto , Ciclofosfamida/administración & dosificación , Femenino , Humanos , Inyecciones Intravenosas , Enfermedades Pulmonares Intersticiales/etiología , Enfermedades Pulmonares Intersticiales/fisiopatología , Pruebas de Función RespiratoriaRESUMEN
A retrospective study compared two groups with type IV lupus nephritis with very similar activity and chronicity indices on renal biopsy. One group was treated with intermittent pulse cyclophosphamide (IPC), and the other was not. The IPC group demonstrated a greater decrease in serum creatinine at 6 months, 12 months and most recent follow-up intervals (p < 0.01, p < 0.05, p < 0.001). Reduction in proteinuria was similar in the two groups. Two of eight in the no-IPC group progressed to ESRD while only one of twelve in the IPC group developed ESRD. The findings suggest that IPC preserves renal function in Type IV nephritis. Furthermore it is suggested that a lower cumulative dosage than previously reported may reduce toxicity without a significant loss of efficacy.
Asunto(s)
Ciclofosfamida/administración & dosificación , Nefritis Lúpica/tratamiento farmacológico , Creatinina/sangre , Ciclofosfamida/uso terapéutico , Femenino , Estudios de Seguimiento , Humanos , Inyecciones Intravenosas , Fallo Renal Crónico/epidemiología , Pruebas de Función Renal , Nefritis Lúpica/diagnóstico , Nefritis Lúpica/epidemiología , Masculino , Estudios Retrospectivos , Factores de TiempoAsunto(s)
Inhibidores de la Enzima Convertidora de Angiotensina/efectos adversos , Litio/envenenamiento , Encéfalo/efectos de los fármacos , Confusión/inducido químicamente , Interacciones Farmacológicas , Femenino , Humanos , Persona de Mediana Edad , Poliuria/inducido químicamente , Temblor/inducido químicamenteRESUMEN
Thirty-eight occluded hemodialysis accesses were infused with urokinase on 43 occasions. In 49% of the cases, the access patency was reestablished for a week or longer, although 38% of this subset subsequently rethrombosed. Postthrombolysis angiography detected a stenotic segment in 14 of 22 angiograms (64%). Local bleeding was common, but the thrombolytic therapy was generally well tolerated. Percutaneous thrombolysis in conjunction with angiography and access revision provides a clinically useful means of access preservation.
Asunto(s)
Fibrinólisis , Oclusión de Injerto Vascular/tratamiento farmacológico , Diálisis Renal/efectos adversos , Trombosis/tratamiento farmacológico , Femenino , Oclusión de Injerto Vascular/diagnóstico por imagen , Oclusión de Injerto Vascular/fisiopatología , Humanos , Masculino , Radiografía , Trombosis/diagnóstico por imagen , Trombosis/fisiopatología , Activador de Plasminógeno de Tipo Uroquinasa/uso terapéutico , Grado de Desobstrucción VascularRESUMEN
Two maintenance hemodialysis patients receiving deferoxamine to chelate iron and aluminum developed intestinal mucormycosis. One patient had pulmonary mucormycosis as well. The patients lacked the usual predisposing factors to mucormycosis, ie, diabetes and acidosis, but both had liver disease. The role of siderophores such as deferoxamine in promoting certain infections is discussed with reference to this particular clinical setting.
Asunto(s)
Deferoxamina/efectos adversos , Enfermedades Intestinales/inducido químicamente , Mucormicosis/inducido químicamente , Diálisis Renal , Deferoxamina/uso terapéutico , Humanos , Enfermedades Pulmonares Fúngicas/inducido químicamente , Masculino , Persona de Mediana EdadRESUMEN
A patient with progressive systemic sclerosis (PSS) involving skin, digit, esophagus, and lung developed the nephrotic syndrome and rapidly progressive renal insufficiency. Renal pathology revealed capillary collapse, cellular crescents, arteriolar hyaline deposition, and mesangial proliferation. On immunofluorescence IgM, C3, and fibrinogen were present in mesangium and capillary walls. Prebiopsy coagulation screening revealed a factor X deficiency which caused substantial prolongation of the partial thromboplastin time without an overt bleeding diathesis. The acquired factor X deficiency resolved after fresh frozen plasma and vitamin K administration, although some spontaneous improvement was noted. Nephrotic syndrome may occasionally be seen in the acute fulminant form of PSS and should not deter diagnosis of PSS.