Educating anesthesia residents to obtain and document informed consent for epidural labor analgesia: does simulation play a role?

BACKGROUND

Informed consent is required before placing an epidural. At our hospital, teaching of residents about this is done informally at the bedside. This study aimed to assess the ability of anesthesia residents to acquire and retain knowledge required when seeking informed consent for epidural labor analgesia. It assessed how well this knowledge was translated to clinical ability, by assessing the verbal consent process during an interaction with a standardized patient.

METHODS

Twenty anesthesia residents were randomized to a 'didactic group' or a 'simulation group'. Each resident was presented with a written scenario and asked to document the informed consent process, as they normally would do (pre-test). The didactic group then had a presentation about informed consent, while the simulation group members interviewed a simulated patient, the scenarios focusing on different aspects of consent. All residents then read a scenario and documented their informed consent process (post-test). Six weeks later all residents interviewed a standardized patient in labor and documented the consent from this interaction (six-week test).

RESULTS

There was no significant difference in the baseline performance of the two groups. Both groups showed significant improvement in their written consent documentation at the immediate time point, the improvement in the didactic group being greater. The didactic group performed better at both the immediate time point and the six-week time point.

CONCLUSIONS

In this small study, a didactic teaching method proved better than simulation-based teaching in helping residents to gain knowledge needed to obtain informed consent for epidural labor analgesia.

Maintenance of clinical benefit in Crohn's disease patients after discontinuation of infliximab: long-term follow-up of a single centre cohort

BACKGROUND

Tumour necrosis factor-blockade with infliximab has advanced the treatment of Crohn's disease. While infliximab is efficacious, it remains to be determined whether patients who enter clinical remission with an anti-tumour necrosis factor therapy can have their treatment stopped and retain the state of remission.

AIM

To assess in patients with Crohn's disease who obtained infliximab-induced remission, the proportion who relapsed after infliximab discontinuation.

METHODS

This longitudinal cohort study examined patients from a University-based IBD referral centre. Forty eight patients with Crohn's disease in full clinical remission and who then discontinued infliximab were followed up for up to 7 years. Crohn's disease relapse was defined as an intervention with Crohn's disease medication or surgery.

RESULTS

Kaplan-Meier analysis of the proportion of patients with sustained clinical benefit demonstrated that 50% relapsed within 477 days after infliximab discontinuance. In contrast, 35% of patients remained well, and without clinical relapse, up to the end of the nearly 7-year follow-up.

CONCLUSIONS

In patients with Crohn's disease with an infliximab-induced remission, stopping infliximab results in a predictable relapse in a majority of patients. Nevertheless, a small percentage of patients sustain a long-term remission.

Current opinion regarding indications for emergency department thoracotomy

BACKGROUND

Emergency department thoracotomy (EDT) is a dramatic but rarely lifesaving intervention. Clinical variability regarding indications for EDT has yet to be quantified. Members of the Eastern and American Associations for the Surgery of Trauma were questioned by mail to evaluate which clinical and demographic factors influence the decision to perform EDT and whether physicians perform EDT in accordance with current practice guidelines.

METHODS

A single mailing of an anonymous survey was sent to 1,124 surgeons to collect institutional and physician demographics as well as indications for EDT on the basis of variable mechanisms of trauma, duration of arrest, and signs of life (SOL). Statistical analysis included the Pearson and linear-by-linear association chi(2) tests, independent samples t test, and univariate and multivariate analyses of variance; p values of < 0.05 were considered significant.

RESULTS

Completed surveys were received from 358 respondents. After 54 surveys were excluded that were incomplete, late, or from noneligible respondents, 304 surveys were analyzed. There were no significant differences in EDT indications among institutions of differing caseload volume, exposure to penetrating trauma, trauma level designation, American College of Surgeons verification status, or residency program affiliation. In addition, neither the respondent's position nor whether attendings versus residents performed the majority of EDTs influenced clinical decision-making. Performance criteria for EDT were liberal in comparison with established guidelines, especially for blunt trauma. The presence or recent loss of SOL influenced responses, but respondents varied greatly in their definition of SOL.

CONCLUSION

A lack of agreement exists regarding the indications for EDT in multiple clinical scenarios as well as in defining SOL. Indications for EDT were liberal, especially for blunt trauma-related indications, and were determined by clinical parameters, not by physician or institutional factors. Our results suggest that clinical practice is at variance with Advanced Trauma Life Support guidelines. We recommend that practice guidelines for EDT be established on the basis of a consensus definition of SOL to allow for a more uniform and selective approach to EDT.

Fluorescence recovery after photobleaching reveals that LPS rapidly transfers from CD14 to hsp70 and hsp90 on the cell membrane

Although CD14 has been implicated in the immune recognition of bacterial lipopolysaccharide (LPS) from Gram-negative bacteria and also peptidoglycan (PGN) and lipoteichoic acid (LTA) from the outer cell wall of Gram-positive bacteria, accumulating evidence has suggested the possible existence of other functional receptor(s). In this study, we have used fluorescence recovery after photobleaching (FRAP) in order to get the first dynamic picture of the innate recognition of bacteria. We have found that the diffusion coefficient of CD14 remains unaffected after LPS ligation and that the diffusion coefficients of FITC-LPS and FITC-LTA bound to cells differ from that of CD14. Furthermore, FITC-LPS/LTA rapidly become immobile when bound to cells, suggesting that FITC-LPS/LTA must briefly associate with CD14 in the initial attachment process and rapidly move on to an immobile receptor or to a complex of receptors. Further FRAP experiments revealed that heat shock protein 70 (hsp70) and hsp90 are immobile in cell membranes, and antibodies against them were found to block the transfer of LPS to the immobile receptor and to inhibit interleukin 6 production upon LPS stimulation. These experiments indicated that LPS transfers from CD14 to hsp70 and hsp90, which may be part of an LPS/LTA multimeric receptor complex. Thus, hsps are implicated as mediators of the innate activation by bacteria.

Fat embolism syndrome after cementless total hip arthroplasty

There are few reports in the literature of fat embolism syndrome after cementless total hip arthroplasty (THA). Most reported cases have occurred after fracture or cemented THA. We report a case of a healthy 51-year-old woman who underwent THA for osteoarthritis under spinal anesthesia. A press-fit cup and extensively porous-coated diaphyseal locking stem were used and inserted without cement. In the recovery room, the patient became hypoxemic and hypotensive and developed cortical blindness. The next day, a petechial rash was evident. Gurd's criteria for fat embolism syndrome were fulfilled. Her symptoms resolved over a 2-week period. Patients undergoing cementless THA are at risk for fat embolism syndrome, and this must be considered in the differential diagnosis for postoperative hypoxemia and neurologic deficits.

Ambient pollution and heart rate variability

BACKGROUND

We investigated associations between ambient pollution levels and cardiovascular function in a repeated measures study including 163 observations on twenty-one 53- to 87-year-old active Boston residents observed up to 12 times from June to September 1997. Particles with aerodynamic diameter </=2.5 microm (PM(2.5)) were measured continuously using a tapered element oscillating microbalance.

METHODS AND RESULTS

The protocol involved 25 minutes per week of continuous Holter ECG monitoring, including 5 minutes of rest, 5 minutes of standing, 5 minutes of exercise outdoors, 5 minutes of recovery, and 20 cycles of slow breathing. Heart rate variability (HRV) was assessed through time domain variables: the standard deviation of normal RR intervals (SDNN) and the square root of the mean of the squared differences between adjacent normal RR intervals (r-MSSD). Mean 4-hour PM(2.5) levels ranged from 3 to 49 microg/m(3); 1-hour ozone levels ranged from 1 to 77 ppb. In multivariate analyses, significantly less HRV (SDNN and r-MSSD) was associated with elevated PM(2.5). During slow breathing, a reduction in r-MSSD of 6.1 ms was associated with an interquartile (14.3 microg/m(3)) increase in PM(2.5) during the hour of and the 3 hours previous to the Holter session (P=0.006). During slow breathing, a multiple pollution model was associated with a reduction in r-MSSD of 5.4 ms (P=0.02) and 5.5 ms (P=0.03) for interquartile changes in PM(2.5) and ozone, respectively, resulting in a combined effect equivalent to a 33% reduction in the mean r-MSSD.

CONCLUSIONS

Particle and ozone exposure may decrease vagal tone, resulting in reduced HRV.

Anticipatory strategy training: implications for the postlingually hearing-impaired adult

The present study was designed to determine if speech recognition performance will improve after subjects prepare for an unfamiliar communication situation as opposed to a familiar one. Forty-five normal-hearing subjects were divided into three groups: one trained using a well-known fairytale, one trained using an obscure fable, and one without training. Post-training, all groups performed similarly when tested on the familiar tale. When test material involved the unfamiliar fable, only the group trained on that material obtained significantly better scores than the other groups. Results support teaching clients that increasing their knowledge of upcoming unfamiliar events can improve subsequent speech recognition.

The long-term effect of early telephone intervention on hearing aid success

The purpose of the study was to determine if subjects who were contacted by telephone periodically during the first 3 months following hearing-aid dispensing would report greater satisfaction, more frequent hearing aid use, and fewer complaints at one year postdispensing than subjects who were not contacted frequently. Subjects were 55 hearing-impaired adults who purchased aids, 27 of whom were contacted periodically by phone. Results revealed that frequent telephone contact in the period soon after dispensing does not appear to be an effective mass management tool in this population, although its value cannot be ruled out for some types of clients.

The effect of telephone intervention on success with amplification

The purpose of this study was to determine whether periodic clinician-initiated telephone contact would reduce the number of unresolved complaints and increase satisfaction, use, and perceived benefit at 4 mo postfitting. Thirty subjects were contacted at 6, 9, and 12 wk postfitting to address questions and to encourage them to return to the clinic to resolve hearing aid-related problems. A control group of 30 subjects was encouraged to contact the center if problems arose at the time of dispensing only. All subjects were interviewed at 4 mo following receipt of the aids, and were sent the Hearing Handicap Inventory for the Elderly at the same time as well as at the time of dispensing. Results revealed a significant reduction in perceived handicap in general, but no significant difference between groups on measures of satisfaction, use, or benefit. There was no significant difference between groups in the number of unresolved complaints at the time of the interview; however, a trend toward fewer complaints in the experimental group was noted. A significantly greater number of complaints were raised for the first time in the control group than in the experimental group at the time of the interview, indicating that more problems remained unaddressed in the absence of clinician-initiated intervention. Therefore, the continued investigation of aggressive, and efficient, postfitting management schemes is warranted.

Glucose and amino acid transport and metabolism in flat duodenal sheets of dairy cattle at three stages of lactation

The apparent duodenal transport and metabolism of amino acids and glucose in early-, mid-, late- and non-lactating dairy cows was investigated. Km values for glucose were not affected by stage of lactation. The capacity (Iscmax) of duodenal sheets to transport glucose was greater in lactating than in non-lactating cows. Lactating cows had a greater transport capability for amino acids than non-lactating cows. Duodenal sheets of early-lactation cows metabolized a greater percentage of absorbed glucose carbon to carbon dioxide than cows in mid-, late- and non-lactating cows.

A randomised trial of selective or routine on-table cholangiography

To assess the value of pre- and peroperative indicators of common bile duct (CBD) stones, 167 patients undergoing cholecystectomy were randomised to receive either routine (R) or selective (S) on-table cholangiography (OTC). In all, 81/84 patients in the R group and 22/78 in the S group had OTCs (P < 0.0001). In the R group 11/81 were positive (one false-positive) and in the S group 7/22 were positive (P < 0.05). CBD stones were present in 10/81 in the R group and 7/78 in the S group (P = NS). In the R group 8/10 and in the S group 5/7 had CBD stones diagnosed preoperatively by ultrasound scanning (USS), giving USS a positive predictive value (PPV) of 100% and a sensitivity of 71.4% in the S group. A raised preoperative alkaline phosphatase (ALP) was found in 1/10 in the R group and 1/7 in the S group (PPV = 33.3%, sensitivity = 14.3%). In the R group 1/10 and in the S group 1/7 (PPV = 25%, sensitivity = 14.3%) were found to have a dilated CBD during operation suggesting CBD stones. There have been no cases of symptomatic unsuspected retained CBD stones during follow-up to date. Our study has demonstrated that selective use of OTCs can be safely employed in open cholecystectomies. Over 85% (6/7 in the S group and 15/17 overall) of CBD stones can be diagnosed preoperatively by USS and liver function tests, with USS having the greatest PPV and sensitivity.

Vascular (humoral) rejection in human cardiac allograft biopsies: relation to circulating anti-HLA antibodies

Vascular or humoral rejection (as defined by linear deposits of immunoglobulin and complement in myocardial capillaries) and the presence of circulating lymphocytotoxic anti-HLA antibodies are each associated with reduced long-term graft or patient survival. The relationship between these two factors has not been determined. We used immunofluorescent techniques to study 46 cardiac biopsy specimens in 16 patients from 15 to 412 days after transplantation. Biopsy specimens were selected from the first 2 months, and at approximately 6 and 12 months after transplantation and did not include episodes of acute cellular rejection. Each specimen studied was compared to a serum sample drawn an average of 1.8 days (range, 0 to 9 days) from the time of biopsy to assay for circulating anti-HLA antibodies. Of the specimens obtained at or near a positive anti-HLA antibody test, 90% (27 of 30) were found to have linear deposits of immunoglobulin (not necessarily with complement) versus 75% (12 of 16) of specimens obtained at the time of a negative test. Twenty-one cases of vascular rejection were documented. Both immunoglobulin M and immunoglobulin G were deposited along with complement in 13 instances; immunoglobulin M and complement were deposited in eight cases; no case had only immunoglobulin G and complement. The presence of circulating anti-HLA antibody in the serum was associated with 14 of the 21 cases of vascular rejection. Linear deposits of immunoglobulin in the capillaries of myocardium were frequently observed when anti-HLA antibodies were present in the serum.(ABSTRACT TRUNCATED AT 250 WORDS)

The use of extracorporeal shock wave lithotripsy in patients with aortic aneurysms

Extracorporeal shock wave lithotripsy (ESWL*) has revolutionized management of most patients with urolithiasis. The effect of ESWL on patients with an aortic aneurysm is unknown and its safety is questioned by the absence of any case reports in the urological literature. A 68-year-old man with an abdominal aortic aneurysm underwent successful ESWL using the Medstone STS 1050 lithotriptor for right renal calculi. Continuous monitoring of the aneurysm was done using real-time ultrasound during the ESWL treatment. Careful preoperative evaluation in conjunction with appropriate intraoperative and postoperative monitoring makes ESWL management of patients with associated aortic aneurysm possible.

Adherence of bacteria to human foreskins

The mucosal surface of the human foreskin from newborns shows a propensity to be colonized by pathogenic bacteria. Bacteria with P fimbriae and type 1 fimbriae adhere. However, hydrophobic interaction as well as electrostatic charge appear to be as important in this adherence as are fimbriae. Since bacterial adherence has been shown to precede urinary tract infection in female patients it is assumed that this adherence to the foreskin in male patients also may be necessary before initiation of the disease. The high incidence of urinary tract infection in uncircumcised male patients combined with these findings of adherence of pathogenic bacteria to the mucosal surface of the foreskin, thus, would seem to be related. Prevention of urinary tract infection and acute pyelonephritis in male neonates then may require either circumcision or the prevention of bacterial adherence to the human foreskin.

Measurement of the rotational behaviour of virus particles during adsorption to the host cell surface

The rotational diffusion of bacteriophage epsilon 15 was measured before and after virus adsorption to outer membrane vesicles of the host Salmonella anatum. The virus capsid was labeled with eosin isothiocyanate, and the decay of transient dichroism following dye excitation by pulses of plane-polarized light was measured. From the data, the rotational diffusion constant of the unadsorbed virion and its hydrodynamic diameter were estimated and found to be consistent with electron microscopic measurements of the capsid dimensions. Addition of outer membrane vesicles of S. anatum to the virus suspension revealed the immobilization of the virus particles on the membrane surface.

Informed consent for investigational chemotherapy: patients' and physicians' perceptions

One hundred forty-four patients and 68 physicians at three cancer centers were studied for their perceptions of the consent procedure, in which they participated one to three weeks earlier, for chemotherapy by one of 65 investigational protocols. Patients recalled the procedure positively and relied heavily on physician's advice. They felt most physicians wanted them to accept; 29% felt their participation in the decision was not encouraged. Primary reasons for accepting were trust in the physician, belief the treatment would help, and fear the disease (viewed as highly serious) would get worse without it. Nearly a fourth did not recall the information given that treatment was investigational. The consent form played no role in decision-making for 69%. Physicians believed therapeutic benefits would exceed potential problems for most patients; they viewed 41% of the patients as less than eager for details of treatment, a third as avoiding the seriousness of the discussion, and a third as passive in decision-making. The perceptual set of both parties places inadvertent constraint on patients' autonomy in decision making.

Independent living: a successful concept

The Independent Living Program at the Little Rock Veterans Administration Medical Center is providing an invaluable service to disabled veterans. Since activation 2 1/2 years ago, it was proven to be a strong, viable program which fills a previous gap in the discharge plans of the medically stable but physically disabled veteran. Without a successful transition into the community, many are susceptible to failure, which then results in hospital readmission or nursing home placement. These veterans, having suffered a severe disability, cannot be expected to return to the mainstream of life solely on the basis of having received medical treatment and therapy. The utilization of available resources and expertise of professionals, combined with the constructive input and determination of the veteran will significantly enhance the potential of a smooth transition into the community. The veteran's satisfaction and pleasure of living independently, despite his disability, is immeasurable. Independent living should be the ultimate goal for health care providers of the disabled.

The Effects of Officiating Football on Heart Rates

Many people with sedentary jobs exercise strenuously on weekends. This report on a college football official shows what hidden dangers may lie in such sporadic activity.