Respiratory poliomyelitis: a follow-up study.

Data from the medical records of 113 patients living in Manitoba who had contracted respiratory poliomyelitis between 1952 and 1959 were compared with information obtained from interviews with these patients in 1980. The study was designed to determine whether the patients'' respiratory function, mobility, ability to perform daily tasks, and employment, residential and marital status had changed between 1 year after the onset of polio and 1980. The patients'' dependence on mechanical aids and other people was also studied. More than half (56%) of the patients perceived their respiratory impairment to be the same as it was 1 year after the onset of polio, 27% perceived the impairment to be increased, and 17% perceived it to be decreased. There was an association between level of respiratory function, mobility and ability to perform daily tasks. The 69 patients who lived at home had better respiratory function, mobility and ability to perform daily tasks than the 24 patients who were assisted by a home care program and the 20 who lived in hospital. The latter group had the lowest levels of respiratory and functional ability.     

Monoclonal antibodies to endotoxin in the management of sepsis.

New monoclonal antibodies directed against the lipid A moiety of the endotoxin present in gram-negative bacteria have been developed to improve the clinical outcome in patients with sepsis. Two studies of monoclonal antibodies HA-1A and E5 retrospectively identified specific patient subgroups showing benefit with therapy. I analyze and summarize the new sepsis nomenclature, the structure of endotoxin, the data implicating endotoxin as a causative agent in septic patients'' morbidity and mortality, and specific data from the 2 clinical studies of monoclonal antibody therapy.     

Awareness of Memory Deficits in Early Stage Huntington's Disease

Patients with Huntington''s disease (HD) are often described as unaware of their motor symptoms, their behavioral disorders or their cognitive deficits, including memory. Nevertheless, because patients with Parkinson''s disease (PD) remain aware of their memory deficits despite striatal dysfunction, we hypothesize that early stage HD patients in whom degeneration predominates in the striatum can accurately judge their own memory disorders whereas more advanced patients cannot. In order to test our hypothesis, we compared subjective questionnaires of memory deficits (in HD patients and in their proxies) and objective measures of memory dysfunction in patients. Forty-six patients with manifest HD attending the out-patient department of the French National Reference Center for HD and thirty-three proxies were enrolled. We found that HD patients at an early stage of the disease (Stage 1) were more accurate than their proxies at evaluating their own memory deficits, independently from their depression level. The proxies were more influenced by patients'' functional decline rather than by patients'' memory deficits. Patients with moderate disease (Stage 2) misestimated their memory deficits compared to their proxies, whose judgment was nonetheless influenced by the severity of both functional decline and depression. Contrasting subjective memory ratings from the patients and their objective memory performance, we demonstrate that although HD patients are often reported to be unaware of their neurological, cognitive and behavioral symptoms, it is not the case for memory deficits at an early stage. Loss of awareness of memory deficits in HD is associated with the severity of the disease in terms of CAG repeats, functional decline, motor dysfunction and cognitive impairment, including memory deficits and executive dysfunction.     

Ward meetings: a forum for patients' concerns.

A series of meetings between patients and staff were held on two general medical wards to discuss the concerns of patients. Issues ranged from the quality of hospital food, ward facilities, and visiting arrangements to the medical and nursing care provided and patients'' views on medical students. Most issues were raised by the patients themselves and the outcome was either acceptance or rejection of a suggestion, an explanation by the staff, or a general discussion if a specific decision was inappropriate. Most staff and patients considered the meetings to be valuable. Ward meetings thus seem to provide a way of making hospitals more responsive to patients'' concerns.     

Consultations in general practice: a comparison of patients' and doctors' satisfaction.

OBJECTIVE--To provide an objective means of assessing patients'' and doctors'' satisfaction with a consultation. DESIGN--Questionnaire study of patients and general practitioners after consultations. SETTING--Urban general practice. SUBJECTS--250 Patients attending consecutive consultations conducted by five general practitioners. MAIN OUTCOME MEASURE--Identification of deficiencies within a consultation as perceived by both doctors and patients. RESULTS--The doctor''s and patient''s questionnaires for each consultation were matched and the results analysed on a group basis. The response rate for individual questions was high (81-89%). The doctors and patients significantly disagreed about the doctors'' ability to assess and put patients at ease, to offer explanations and advice on treatment, and to allow expression of emotional feelings and about the overall benefit that the patients gained from the consultation. In all cases of disagreement the doctor had a more negative view of the consultation than the patient. CONCLUSIONS--The results of giving structured questionnaires on consultations to both patients and doctors could be a useful teaching tool for established doctors or those in training to improve the quality and sensitivity of care they provide.     

Do personal computers make doctors less personal?

Ten months after the installation of a computer in a general practice surgery a postal survey (piloted questionnaire) was sent to 390 patients. The patients'' views of their relationship with their doctor after the computer was introduced were compared with their view of their relationship before the installation of the computer. More than 96% of the patients (n=263) stated that contact with their doctor was as easy and as personal as before. Most stated that the computer did not influence the duration of the consultation. Eighty one patients (30%) stated, however, that they thought that their privacy was reduced.Unlike studies of patients'' attitudes performed before any actual experience of use of a computer in general practice, this study found that patients have little difficulty in accepting the presence of a computer in the consultation room. Nevertheless, doctors should inform their patients about any connections between their computer and other, external computers to allay fears about a decrease in privacy.     

鼻咽癌放疗患者心理弹性的影响因素及与自我感受负担的关系分析

摘要 目的：观察鼻咽癌放疗患者心理弹性的影响因素,并分析心理弹性与自我感受负担（SPB）的关系。方法：选取2019年3月~2020年8月期间我院收治的鼻咽癌患者100例,采用中文版心理弹性量表（CD-RISC）观察鼻咽癌放疗患者心理弹性,采用自我感受负担（SPB）量表观察患者SPB情况,分析患者心理弹性的影响因素及其与SPB的关系。结果：鼻咽癌放疗患者CD-RISC乐观、坚韧、自强各维度评分及总分均低于国内常模（P<0.05）,SPB量表总分为（38.10±2.74）分,处于中等负担水平。Pearson相关性分析结果显示,鼻咽癌放疗患者心理弹性和SPB呈负相关（P<0.05）。鼻咽癌放疗患者心理弹性与接受放疗宣教情况、临床分期、家庭月收入、教育程度、年龄有关（P<0.05）。本研究表明,教育程度、临床分期、年龄及家庭月收入是鼻咽癌放疗患者心理弹性的影响因素（P<0.05）。结论：鼻咽癌放疗患者的心理弹性较差,且其SPB与心理弹性有一定的联系。患者心理弹性的影响因素包括年龄、家庭月收入、临床分期、教育程度,临床可结合以上因素制定针对性方案以改善患者心理弹性。     

Improving care: a study of orthopaedic outpatient referrals.

OBJECTIVE--To identify aspects of outpatient referral in which general practitioners'', consultants'', and patients'' satisfaction could be improved. DESIGN--Questionnaire survey of general practitioners, consultant orthopaedic surgeons, and patients referred to an orthopaedic clinic. SETTING--Orthopaedic clinic, Doncaster Royal Infirmary. SUBJECTS--628 consecutive patients booked into the orthopaedic clinic. MAIN OUTCOME MEASURES--Views of the general practitioners as recorded both when the referral letter was received and again after the patient had been seen, views of the consultants as recorded at the time of the clinic attendance, and views of the patients as recorded immediately after the clinic visit and some time later. RESULTS--Consultants rated 213 of 449 referrals (42.7%) as possibly or definitely inappropriate, though 373 of 451 patients (82.7%) reported that they were helped by seeing the consultant. Targets for possible improvement included information to general practitioners about available services, communication between general practitioners and consultants, and administrative arrangements in clinics. Long waiting times were a problem, and it seemed that these might be reduced if general practitioners could provide more advice on non-surgical management. Some general practitioners stated that they would value easier telephone access to consultants for management advice. It was considered that an alternative source of management advice on musculoskeletal problems might enable more effective use to be made of specialist orthopaedic resources. Conclusion--A survey of patients'' and doctors'' views of referrals may be used to identify aspects in which the delivery of care could be made more efficient. Developing agreed referral guidelines might help general practitioners to make more effective use of hospital services.     

The Clinical Utility of Informants' Appraisals on Prospective and Retrospective Memory in Patients with Early Alzheimer's Disease

Increasing studies suggest the importance of including prospective memory measures in clinical evaluation of dementia due to its sensitivity and functional relevance. The Prospective and Retrospective Memory Questionnaire (PRQM) is originally a self-rated memory inventory that offers a direct comparison between prospective and episodic memory. However, the informant''s report has been recognized as a more valid source of cognitive complaints. We thus aimed to examine the validity of the informant-rated form of the PRMQ in assessing memory function of the patients and in detecting individuals with early dementia. The informants of 140 neurological outpatients with memory complaints completed the Taiwan version of the PRMQ. Tests of prospective memory, short-term memory, and general cognitive ability were also administered to non-demented participants and patients with early stages of Alzheimer''s disease (AD). Results showed significant relationships between the PRMQ ratings and objective cognitive measures, and showed that higher ratings on the PRMQ were associated with increasing odds of greater dementia severity. Receiver operative characteristic (ROC) curves showed an adequate ability of the PRMQ to identify patients with dementia (93% sensitivity and 84% specificity). Hierarchical regression revealed that the PRMQ has additional explanatory power for dementia status after controlling for age, education and objective memory test results, and that the prospective memory subscale owns predictive value for dementia beyond the retrospective memory subscale. The present study demonstrated the external validity and diagnostic value of informants'' evaluation of their respective patients'' prospective and retrospective memory functioning, and highlighted the important role of prospective memory in early dementia detection. The proxy-version of the PRMQ is a useful tool that captures prospective and episodic memory problems in patients with early AD, in combination with standardized cognitive testing.     

Survey of "do not resuscitate" orders in a district general hospital.

OBJECTIVE--To evaluate the local use of written "Do not resuscitate" orders to designate inpatients unsuitable for cardiopulmonary resuscitation in the event of cardiac arrest. DESIGN--Point prevalence questionnaire survey of inpatients'' medical and nursing records. SETTING--10 acute medical and six acute surgical wards of a district general hospital. PARTICIPANTS--Questionnaires were filled in anonymously by nurses and doctors working on the wards surveyed. MAIN OUTCOME MEASURES--Responses to questionnaire items concerning details about each patient, written orders not to resuscitate in the medical case notes and nursing records, whether prognosis had been discussed with patients'' relatives, whether a "crash call" was perceived as appropriate for each patient, and whether the "crash team" would be called in the event of arrest. RESULTS--Information was obtained on 297 (93.7%) of 317 eligible patients. Prognosis had been discussed with the relatives of 32 of 88 patients perceived by doctors as unsuitable for resuscitation. Of these 88 patients, 24 had orders not to resuscitate in their medical notes, and only eight of these had similar orders in their nursing notes. CONCLUSIONS--In the absence of guidelines on decisions about resuscitation, orders not to resuscitate are rarely included in the notes of patients for whom cardiopulmonary resuscitation is thought to be inappropriate. Elective decisions not to resuscitate are not effectively communicated to nurses. There should be more discussion of patients'' suitability for resuscitation between doctors, nurses, patients, and patients'' relatives. Suitability for resuscitation should be reviewed on every consultant ward round.     

Palliative care: views of patients and their families.

OBJECTIVE--To investigate the current problems and needs of terminally ill cancer patients and their family members, and to discover their views of hospital, community, and support team services. DESIGN--Prospective study of patients and families by questionnaire interviews in the patients'' homes. SETTING--Inner London and north Kent (London suburbs). SUBJECTS--65 Patients, each with a member of their family or a career. MAIN OUTCOME MEASURES--Ratings of eight current problems and ratings and comments on three services-hospital doctors and nurses, general practitioners and district nurses, and the support team staff-obtained after a minimum of two weeks'' care from palliative care support teams. RESULTS--Effect of anxiety on the patient''s nearest career. and symptom control were rated as the most severe current problems by both patients and families; a few patients and families identified other severe problems. Families'' ratings of pain control, symptom control, and effect of anxiety on the patient were significantly worse than the patients'' ratings (p less than 0.05). Support teams received the most praise, being rated by 58 (89%) patients and 59 (91%) of family members as good as excellent. General practitioners and district nurses were rated good or excellent by 46 (71%) patients and 46 (71%) family members, but six (9%) in each group rated the service as poor or very bad, and ratings in the inner London district were significantly worse than those in the outer London district. Hospital doctors and nurses were rated good or excellent by 22 (34%) patients and 35 (54%) of family members, and 14 (22%) patients and 15 (23%) family members rated this service as poor or very bad. Negative comments referred to communication (especially at diagnosis), coordination of services, the attitude of the doctor, delays in diagnosis, and difficulties in getting doctors to visit at home. Family members were more satisfied with the services than were patients. CONCLUSIONS--Palliative care needs to include both the patient and family because the needs of the family may exceed those of the patient. Support teams and some hospital and community doctors and nurses met the perceived needs of dying patients and families, but better education and organisation of services are needed.     

Pharmacologic management of refractory depression.

OBJECTIVE: To review published clinical trials of the pharmacologic management of refractory depression. DATA SOURCES: MEDLINE was searched for relevant articles published from 1983 to 1990. The bibliographies of review articles were searched for additional references. Studies of nonpharmacologic treatments, such as electroconvulsive therapy, were not included. STUDY SELECTION: Eleven studies were found that did not contain obvious digressions from several methodologic assessment criteria (adapted from the McMaster guidelines for the evaluation of clinical trials). Further scrutiny by a nonblind reviewer resulted in the selection of four reports that were considered acceptable. An assessment by a second reviewer, blind as to author, results and journal name, confirmed this judgement. DATA EXTRACTION: Data describing response to the treatments were extracted by a single (nonblind) reviewer. Post-hoc power estimates and 95% confidence intervals were calculated whenever possible. DATA SYNTHESIS: The efficacy of augmenting an antidepressant regimen with lithium carbonate, triiodothyronine or reserpine was not supported by findings from the clinical trials reviewed. However, many trials with negative results lacked adequate statistical power to exclude the possibility of the drug''s efficacy. The use of a monoamine oxidase inhibitor was supported by the one study that met the review''s methodologic criteria. However, this study was not conducted under double-blind conditions. CONCLUSION: The generally recommended strategies for the pharmacologic treatment of refractory depression are not supported by methodologically sound studies.     

When and Why Placebo-Prescribing Is Acceptable and Unacceptable: A Focus Group Study of Patients' Views

Background

Surveys of doctors suggest that they use placebos and placebo effects clinically to help patients. However, patients'' views are not well-understood. We aimed to identify when and why placebo-prescribing in primary care might be acceptable and unacceptable to patients.

Methods

A purposive diverse sample of 58 English-speaking adults (18 men; aged 19–80 years) participated in 11 focus groups. Vignettes describing doctors prescribing placebos in primary care were used to initiate discussions. Data were analyzed inductively.

Results

Participants discussed diverse harms and benefits of placebo-prescribing for individual patients, carers, healthcare providers, and society. Two perspectives on placebo-prescribing were identified. First, the “consequentialist” perspective focused on the potential for beneficial outcomes of placebo-prescribing. Here, some participants thought placebos are beneficial and should be used clinically; they often invoked the power of the mind or mind-body interactions. Others saw placebos as ineffective and therefore a waste of time and money. Second, the “respecting autonomy” perspective emphasized the harms caused by the deceptive processes thought necessary for placebo-prescribing. Here, participants judged placebo-prescribing unacceptable because placebo-prescribers deceive patients, thus a doctor who prescribes placebos cannot be trusted and patients'' autonomy is compromised. They also saw placebo-responders as gullible, which deterred them from trying placebos themselves. Overall, the word “placebo” was often thought to imply “ineffective”; some participants suggested alternative carefully chosen language that could enable doctors to prescribe placebos without directly lying to patients.

Conclusions

Negative views of placebos derive from beliefs that placebos do not work and/or that they require deception by the doctor. Positive views are pragmatic in that if placebos work then any associated processes (e.g. mechanisms, deception) are deemed unimportant. Public education about placebos and their effects is warranted and research to identify optimal ways of harnessing placebo effects in clinical practice is needed.     

Do patients wish to be involved in decision making in the consultation? A cross sectional survey with video vignettes

ObjectiveTo determine patients'' preferences for a shared or directed style of consultation in the decision making part of the general practice consultation.DesignStructured interview, with video vignettes of acted consultations.Setting5 practices in Lothian, Scotland.Participants410 patients (adults and adults accompanying children) attending surgery appointments.ResultsPatients varied in their preference for involvement in decision making in the consultation. Under multiple regression analysis, patients'' preference was found to be independently predicted by the problem viewed (patients presented with physical problems preferred a directed approach), patients'' age (patients aged 61 or older were more likely to prefer the directed approach), social class (social classes I and II were more likely to prefer the shared approach), and smoking status (smokers more likely to prefer the shared approach). Those patients who were able to answer (or who thought their doctor''s style similar to those in the vignettes) were more likely to describe their own doctor''s style as similar to their preferred style. No major association in preference was found with sex, frequency of attendance, or perceived chronic ill health.ConclusionPatients may vary in their desire for involvement in decision making in consultations. Although this variation seems to depend on the presenting problem, age, social class, and smoking status, these associations are not absolute, with large minorities in each group. Doctors need the skills, knowledge of their patients, and the time to determine on which occasions, with which illnesses, and at which level their patients wish to be involved in decision making.     

Disseminated gonorrhea: diagnosis through contact tracing.

Over a 1-year period four patients were seen at the Jewish General Hospital with presumed disseminated gonococcemia. The patients'' histories, clinical findings and responses to therapy strongly supported this diagnosis; however, cultures from various sites were negative for Neisseria gonorrhoeae in all four patients. Sexual contacts of these patients were traced and appropriate cultures were found to be positive, demonstrating the importance of tracing sexual contacts to help confirm the diagnosis in such patients.     

Advance directives: the views of health care professionals.

OBJECTIVES: This study examined the views and experiences of 20 physicians and 20 nurses at a major Canadian teaching hospital regarding the use of advance directives in clinical care. DESIGN: The participants were purposively drawn from four clinical specialties: family and community medicine, oncology, intensive care and geriatrics. Detailed interviews were conducted in person. Content analysis was used to code the data, which were further analysed with both quantitative and qualitative techniques. MAIN RESULTS: Thirty-nine of the 40 participants favoured the use of advance directives in clinical care; physicians had somewhat less positive attitudes than nurses toward such directives. Advance directives were thought by participants to be helpful in resolving disagreements between patients and their families about treatment options; in making patients more comfortable, both physically and psychologically, during the process of dying; and in opening up communication and trust among patients, their families and health care professionals. Concerns about the use of advance directives focused on the lack of clarity in some patients'' instructions, the absence of legal status for directives, the possible interference with a practitioner''s clinical judgement, the adequacy and appropriateness of patients'' information about their circumstances, and the type of intervention (passive or active) requested by patients. CONCLUSIONS: New regulations and legislation are making the use of advance directives more widespread. Health care professionals should participate in the development and implementation of these directives. Continuing professional education is essential in this regard.     

Investigating mental health risk assessment in primary care and the potential role of a structured decision support tool,GRiST

Aim To explore current risk assessment processes in general practice and Improving Access to Psychological Therapies (IAPT) services, and to consider whether the Galatean Risk and Safety Tool (GRiST) can help support improved patient care.Background Much has been written about risk assessment practice in secondary mental health care, but little is known about how it is undertaken at the beginning of patients'' care pathways, within general practice and IAPT services.Methods Interviews with eight general practice and eight IAPT clinicians from two primary care trusts in the West Midlands, UK, and eight service users from the same region. Interviews explored current practice and participants'' views and experiences of mental health risk assessment. Two focus groups were also carried out, one with general practice and one with IAPT clinicians, to review interview findings and to elicit views about GRiST from a demonstration of its functionality. Data were analysed using thematic analysis.Findings Variable approaches to mental health risk assessment were observed. Clinicians were anxious that important risk information was being missed, and risk communication was undermined. Patients felt uninvolved in the process, and both clinicians and patients expressed anxiety about risk assessment skills. Clinicians were positive about the potential for GRiST to provide solutions to these problems.Conclusions A more structured and systematic approach to risk assessment in general practice and IAPT services is needed, to ensure important risk information is captured and communicated across the care pathway. GRiST has the functionality to support this aspect of practice.