Recurrences of Atrial Fibrillation Despite Durable Pulmonary Vein Isolation: The PARTY-PVI Study

BACKGROUND

Recurrences of atrial fibrillation (AF) after pulmonary vein isolation (PVI) are mainly due to pulmonary vein reconnection. However, a growing number of patients have AF recurrences despite durable PVI. The optimal ablative strategy for these patients is unknown. We analyzed the impact of current ablation strategies in a large multicenter study.

METHODS

Patients undergoing a redo ablation for AF and presenting durable PVI were included. The freedom from atrial arrhythmia after pulmonary vein-based, linear-based, electrogram-based, and trigger-based ablation strategies were compared.

RESULTS

Between 2010 and 2020, 367 patients (67% men, 63±10 years, 44% paroxysmal) underwent a redo ablation for AF recurrences despite durable PVI at 39 centers. After durable PVI was confirmed, linear-based ablation was performed in 219 (60%) patients, electrogram-based ablation in 168 (45%) patients, trigger-based ablation in 101 (27%) patients, and pulmonary vein-based ablation in 56 (15%) patients. Seven patients (2%) did not undergo any additional ablation during the redo procedure. After 22±19 months of follow-up, 122 (33%) and 159 (43%) patients had a recurrence of atrial arrhythmia at 12 and 24 months, respectively. No significant difference in arrhythmia-free survival was observed between the different ablation strategies. Left atrial dilatation was the only independent factor associated with arrhythmia-free survival (HR, 1.59 [95% CI, 1.13-2.23]; P=0.006).

CONCLUSIONS

In patients with recurrent AF despite durable PVI, no ablation strategy used alone or in combination during the redo procedure appears to be superior in improving arrhythmia-free survival. Left atrial size is a significant predictor of ablation outcome in this population.

Impact of ablation index settings on pulmonary vein reconnection

PURPOSE

Ablation index (AI) is a radiofrequency lesion quality marker. The AI value that allows effective and safe pulmonary vein isolation (PVI) is still debated. We evaluated the incidence of acute and late PV reconnection (PVR) with different AI settings and its predictors.

METHODS

The Ablation Index Registry is a multicenter study that included patients with paroxysmal/persistent atrial fibrillation (AF) who underwent first-time ablation. Each operator performed the ablation using his preferred ablation catheter (ThermoCool® SmartTouch or Surround Flow) and AI setting (380 posterior-500 anterior and 330 posterior-450 anterior). We divided the study population into two groups according to the AI setting used: group 1 (330-450) and group 2 (380-500). Incidence of acute PVR was validated within 30 min after PVI, whereas the incidence of late PVR was evaluated at repeat procedure.

RESULTS

Overall, 490 patients were divided into groups 1 (258) and 2 (232). There was no significant difference in the procedural time, fluoroscopy time, and rate of the first-pass PVI between the two study groups. Acute PVR was observed in 5.6% PVs. The rate of acute PVR was slightly higher in group 2 (64/943, 6.8%, PVs) than in group 1 (48/1045, 4.6% PVs, p = 0.04). Thirty patients (6%) underwent a repeat procedure and late PVR was observed in 57/116 (49%) PVs (number of reconnected PV per patient of 1.9 ± 1.6). A similar rate of late PVR was found in the two study groups. No predictors of acute and late PVR were found.

CONCLUSION

Ablation with a lower range of AI is highly effective and is not associated with a higher rate of acute and late PVR. No predictors of PV reconnection were found.

Prevalence of Lassa virus among rodents trapped in three South-South States of Nigeria

BACKGROUND & OBJECTIVES

Lassa fever has been endemic in Nigeria since 1969. The rodent Mastomys natalensis has been widely claimed to be the reservoir host of the Lassa virus. This study was designed to investigate the dis- tribution of species of rodents in three states (Edo, Delta and Bayelsa) of Nigeria and to determine the prevalence of Lassa virus amongst trapped rodents in the selected states.

METHODS

Rodents were trapped during November 2015 to October 2016 from the three states in South-South re- gion of Nigeria. Total RNA was extracted from the blood collected from the trapped rodents. Reverse transcription polymerase chain reaction (RT-PCR) was used to confirm the presence of Lassa virus in the rodents.

RESULTS

The results revealed that six species of rodents were predominantly present in these geographical locations. Mus musculus (39.4%) had the highest prevalence, closely followed by Rattus rattus (36.1%), R. fuscipus (20.3%), M. natalensis (2%), Myosoricinae soricidae (1.2%) and R. norvegicus (1%). The overall positivity (carrier rate) of Lassa virus was 1.6% amongst the 1500 rodents caught in the three states. In Edo and Delta States, the RT-PCR results showed presence of Lassa virus in R. rattus, M. musculus and M. natalensis. On the other hand, only M. na- talensis was detected with the virus, amongst the species of rodents caught in Bayelsa State. M. natalensis recorded the highest Lassa virus among rodents trapped in Edo (87%), Delta (50%) and Bayelsa (11%) States respectively.

INTERPRETATION & CONCLUSION

The rather low Lassa virus positive among rodents in Bayelsa State of Nigeria may explain the absence of reports of outbreak of Lassa fever over the past 48 yr in the state. The results also confirmed that apart from Mastomys natalensis, other rodents such as Rattus rattus and Mus musculus may also serve as res- ervoirs for Lassa virus. From the findings of this cross-sectional study, it was concluded that a more comprehensive study on rodents as reservoir host, need to be undertaken across the entire states of Nigeria, for better understanding of the epidemiology and endemicity of Lassa fever.

Social and Financial Outcomes of Living Liver Donation: A Prospective Investigation Within the Adult-to-Adult Living Donor Liver Transplantation Cohort Study 2 (A2ALL-2)

Because results from single-center (mostly kidney) donor studies demonstrate interpersonal relationship and financial strains for some donors, we conducted a liver donor study involving nine centers within the Adult-to-Adult Living Donor Liver Transplantation Cohort Study 2 (A2ALL-2) consortium. Among other initiatives, A2ALL-2 examined the nature of these outcomes following donation. Using validated measures, donors were prospectively surveyed before donation and at 3, 6, 12, and 24 mo after donation. Repeated-measures regression models were used to examine social relationship and financial outcomes over time and to identify relevant predictors. Of 297 eligible donors, 271 (91%) consented and were interviewed at least once. Relationship changes were positive overall across postdonation time points, with nearly one-third reporting improved donor family and spousal or partner relationships and >50% reporting improved recipient relationships. The majority of donors, however, reported cumulative out-of-pocket medical and nonmedical expenses, which were judged burdensome by 44% of donors. Lower income predicted burdensome donation costs. Those who anticipated financial concerns and who held nonprofessional positions before donation were more likely to experience adverse financial outcomes. These data support the need for initiatives to reduce financial burden.

Canadian Society of Transplantation Members' Views on Anonymity in Organ Donation and Transplantation

BACKGROUND

Anonymity has been central to medical, psychosocial, and societal practices in organ donation and transplantation. The purpose of this investigation was to explore transplant professionals' views on anonymity in the context of organ transplantation.

METHODS

The study consisted of an electronic 18-item survey distributed to the Canadian Society of Transplantation membership, asking about anonymity vs open communication/contact between organ recipients and donor families.

RESULTS

Of the 541 members surveyed, 106 replied. Among respondents, 71% felt that organ recipients and donor families should only communicate anonymously, yet 47% felt that identifying information could be included in correspondence between consenting recipients and donor families. When asked whether organ recipients and donor families should be allowed to meet, 53% of respondents agreed, 27% disagreed, and 20% neither agreed nor disagreed. With social media facilitating communication and eliminating the ability to maintain donor/recipient anonymity, 38% of respondents felt that a reexamination of current policies and practices pertaining to anonymity was necessary.

CONCLUSION

In conclusion, there was no dominant position on the issue of anonymity/communication between donor families and transplant recipients. Further research and discussion concerning the views of healthcare professionals, organ recipients, and donor families on the mandate of anonymity is needed and may influence future policy.

Adult living liver donors have excellent long-term medical outcomes: the University of Toronto liver transplant experience

Right lobe living donor liver transplantation is an effective treatment for selected individuals with end-stage liver disease. Although 1 year donor morbidity and mortality have been reported, little is known about outcomes beyond 1 year. Our objective was to analyze the outcomes of the first 202 consecutive donors performed at our center with a minimum follow-up of 12 months (range 12-96 months). All physical complications were prospectively recorded and categorized according to the modified Clavien classification system. Donors were seen by a dedicated family physician at 2 weeks, 1, 3 and 12 months postoperatively and yearly thereafter. The cohort included 108 males and 94 females (mean age 37.3 +/- 11.5 years). Donor survival was 100%. A total of 39.6% of donors experienced a medical complication during the first year after surgery (21 Grade 1, 27 Grade 2, 32 Grade 3). After 1 year, three donors experienced a medical complication (1 Grade 1, 1 Grade 2, 1 Grade 3). All donors returned to predonation employment or studies although four donors (2%) experienced a psychiatric complication. This prospective study suggests that living liver donation can be performed safely without any serious late medical complications and suggests that long-term follow-up may contribute to favorable donor outcomes.

Troubling dimensions of heart transplantation

Heart transplantation is now the accepted therapy for end-stage heart failure that is resistant to medical treatment. Families of deceased donors routinely are urged to view the heart as a "gift of life" that will enable the donor to live on by extending and sustaining the life of a stranger. In contrast, heart recipients are encouraged to view the organ mechanistically-as a new pump that was rendered a spare, reusable part when a generous stranger died. Psychosocial and psychoanalytic research, anecdotal evidence and first-person accounts indicate that after transplant, many recipients experience unexpected changes or distress that cannot be understood adequately using biomedical explanatory models alone. In this paper it is argued that phenomenological philosophy offers a promising way to frame an ongoing empirical study that asks recipients to reflect on what it is like to incorporate the heart of another person. Merleau-Ponty and others have posited that any change to the body inevitably transforms the self. Hence, it is argued in this paper that replacing failing hearts with functioning hearts from deceased persons must be considered much more than a complex technical procedure. Acknowledging the disturbances to embodiment and personal identity associated with transplantation may explain adverse outcomes that heretofore have been inexplicable. Ultimately, a phenomenological understanding could lead to improvements in the consent process, preoperative teaching and follow-up care.

Adult right-lobe living liver donors: quality of life, attitudes and predictors of donor outcomes

To refine selection criteria for adult living liver donors and improve donor quality of care, risk factors for poor postdonation health-related quality of life (HRQOL) must be identified. This cross-sectional study examined donors who underwent a right hepatectomy at the University of Toronto between 2000 and 2007 (n = 143), and investigated predictors of (1) physical and mental health postdonation, as well as (2) willingness to participate in the donor process again. Participants completed a standardized HRQOL measure (SF-36) and measures of the pre- and postdonation process. Donor scores on the SF-36 physical and mental health indices were equivalent to, or greater than, population norms. Greater predonation concerns, a psychiatric diagnosis and a graduate degree were associated with lower mental health postdonation whereas older donors reported better mental health. The majority of donors (80%) stated they would donate again but those who perceived that their recipient engaged in risky health behaviors were more hesitant. Prospective donors with risk factors for lower postdonation satisfaction and mental health may require more extensive predonation counseling and postdonation psychosocial follow-up. Risk factors identified in this study should be prospectively evaluated in future research.

Living anonymous liver donation: case report and ethical justification

Most living organ donations are from genetically or emotionally related donors. Although some transplant centers are willing to accept donations from living anonymous kidney donors (LAKDs), very few centers will accept donations from living anonymous liver donors (LALDs). The difference in acceptance rates is primarily due to the greater risk in liver donation, which is estimated to be 10-fold that of the risk in kidney donation. We present a case of donation from a LALD, the first reported in Canada. There are currently no established standards for LALDs. Our criteria for the ethical acceptability of LALDs require such donors to be physically healthy, mentally competent, altruistic, highly motivated, well-informed and able to give voluntary consent to donation. Another major ethical criterion is that the likely psychological benefit to the LALD balances the physical risks. Our case demonstrates that transplants from LALDs are medically successful and ethically justified under certain conditions.

[Bi-directional ventricular tachycardia and pheochromocytoma: a case report]

We present the case of a 48 year old woman who was admitted to our university hospital in cardiogenic shock with bi-directional ventricular tachycardia degenerating into polymorphic venricular tachycardia which resolved spontaneously. Investigation revealed healthy coronary arteries but severe left ventricular dysfunction due to akinesia involving the entire base. There was a rapid improvement within several days. The diagnosis of bilateral phaeochromocytoma was made on the biochemistry and CT scan of the adrenals.

[Septal alcoholisation of hypertrophic obstructive cardiomyopathy in childhood]

The authors report a case of septal alcoholisation in a 6 year old child with hypertrophic obstructive cardiomyopathy responsible for congestive cardiac failure despite optimal betablocker therapy. The indication was retained in a context of mucoviscidosis complicated by multiresistant bacterial infection. At catheterisation, the dominant septal artery was identified and an alcoholisation was performed by the classic technique described in adults. The immediate result was satisfactory with regression of the signs of cardiac failure and reduction of 70 mmHg of the maximal instantaneous pressure gradient (from 160 to 90 mmHg). However, 10 months later, the signs of right heart failure reappeared with a partial increase in the maximal instantaneous pressure gradient (100 mmHg) leading to surgical myectomy while the patient's condition had considerably improved from the pulmonary point of view. Septal alcoholisation would appear to be a therapeutic alternative in children especially in cases with a temporary or permanent contraindication to conventional surgery.

Structure of lifestyle disruptions in chronic disease: a confirmatory factor analysis of the Illness Intrusiveness Ratings Scale

BACKGROUND

The Illness Intrusiveness Ratings Scale (IIRS) measures the extent to which disease or its treatment or both interfere with activities in important life domains. Before comparing IIRS scores within or across groups it is crucial to determine whether a common underlying factor structure exists across patient populations.

OBJECTIVE

To investigate the factor structure underlying the IIRS and evaluate its stability across diagnoses.

METHODS

IIRS responses from 5,671 respondents were pooled from 15 separate studies concerning quality of life in eight patient groups: rheumatoid arthritis; osteoarthritis; systemic lupus erythematosus; multiple sclerosis; end-stage renal disease (maintenance dialysis); renal transplantation; heart, liver, and lung transplantation; and insomnia. Data were gathered by different methods (eg, interview, self-administered, mail survey) and in diverse contexts (eg, individual vs. group).

RESULTS

Exploratory maximum-likelihood factor analysis identified three underlying factors in a randomly selected subset of respondents (n = 400), corresponding to "Relationships and Personal Development," "Intimacy," and "Instrumental" life domains. Confirmatory factor analysis corroborated the stability of this structure in an independent subsample (n = 2100). Complementary goodness-of-fit indices confirmed the consistency of the three-factor solution, corroborating that IIRS scores are uniquely defined across patient populations. Coefficient alpha was high for total and subscale scores.

CONCLUSIONS

IIRS scores can be compared meaningfully within and across patient groups. Both total and subscale scores can be used depending on research objectives.

Evaluation of a mentorship program for heart transplant patients

The Heart Transplant Mentor Programme (HTMP) was initiated to augment patient care by providing patients and families with information and support from a peer perspective. We assessed program effectiveness with a pilot study of semi-structured interviews of 63% (10/16) of the mentored patients and an open-ended inquiry that rated the program on a 5-point scale (1, poor, to 5, excellent) and that selected descriptors of the program. Qualitative and quantitative analyses indicated that participants found the information and support provided by their mentors positive (3.8 and 4.0, respectively), discussion focused on medical rather than psychosocial topics, pre-transplant dissatisfaction with the program was caused by late or little mentor contact, and post-transplant dissatisfaction was attributed to difference in clinical course between mentor and patient. Although findings indicate that HTMP augments patient care, recommendations to increase patient satisfaction include earlier introduction of a mentor and individualizing mentors according to demographics and clinical course.

Psychological factors and depressive symptoms in ischemic heart disease

The aim of this study was to determine whether learned helplessness, cognitive distortions, self-efficacy, and dispositional optimism assessed at Time 1 (T1; questionnaires mailed at 1 month postdischarge) would predict depressive symptoms at Time 2 (T2; questionnaires mailed at 1-year follow-up) in a sample of 86 patients hospitalized with ischemic heart disease. Multiple regression results indicated that optimism and cognitive distortions at T1 were significantly associated with T1 depressive symptoms after controlling for confounding variables. When the T1 psychological factors were analyzed with T2 depressive symptoms, only optimism continued to predict depressive symptoms after controlling for confounds and T1 depressive symptoms. The global expectancies that optimism assessed appeared to be more stable over time than the statelike beliefs of cognitive distortions and may have accounted for why optimism predicted T2 depressive symptoms.

Psychological factors and depressive symptoms in ischemic heart disease

The aim of this study was to determine whether learned helplessness, cognitive distortions, self-efficacy, and dispositional optimism assessed at Time 1 (T1; questionnaires mailed at 1 month postdischarge) would predict depressive symptoms at Time 2 (T2; questionnaires mailed at 1-year follow-up) in a sample of 86 patients hospitalized with ischemic heart disease. Multiple regression results indicated that optimism and cognitive distortions at T1 were significantly associated with T1 depressive symptoms after controlling for confounding variables. When the T1 psychological factors were analyzed with T2 depressive symptoms, only optimism continued to predict depressive symptoms after controlling for confounds and T1 depressive symptoms. The global expectancies that optimism assessed appeared to be more stable over time than the statelike beliefs of cognitive distortions and may have accounted for why optimism predicted T2 depressive symptoms.

Fatigue in primary biliary cirrhosis

BACKGROUND

Fatigue is a frequent and debilitating symptom in patients with primary biliary cirrhosis (PBC).

AIMS

To study fatigue in relation to sleep, depression, and liver disease severity.

METHODS

Patients with PBC completed validated self report questionnaires measuring fatigue, sleep quality, depression, and functional capacity. Verbally reported fatigue and observer rated measure of depression and ursodeoxycholic acid (UDCA) use were recorded. Liver biochemistry and tests to rule out metabolic causes of fatigue were performed.

RESULTS

Mean age of the 88 patients enrolled was 57 years; 86% were female and mean duration of disease was 6.6 years. Median bilirubin was 13 micromol/l (mean 18.6). Verbally reported fatigue (for more than six months) was present in 60 patients (68%). The self rated Fatigue Severity Score (FSS) correlated well with verbally reported fatigue (p=0.0001). The FSS did not correlate with age, duration of disease, serum bilirubin, Mayo Risk Score, or UDCA use, but correlation was seen with sleep quality. Fatigued patients had more sleep problems and higher depression scores than non-fatigued patients. Self rated depression was present in 28% (17/60) of fatigued compared with 4% (1/28) of non-fatigued patients.

CONCLUSIONS

Long term fatigue affected 68% of the patients with PBC but it was not related to the severity of their liver disease. Poor sleep quality and depression were commonly associated with fatigue.

Group therapy and organ transplantation

Group therapy for organ transplantation patients is in its infancy but has a promising future. Overextended transplantation service providers are interested in its potential for cost-efficient and effective forms of psychosocial intervention. This article summarizes the biomedical and psychosocial aspects of solid organ transplantation, one institution's group therapy program, common group themes, and specific demands on the group therapist working with this population.

Predictors of quality of life and adjustment after lung transplantation

STUDY OBJECTIVE

Few studies have examined predictors of quality of life and adjustment after lung transplantation. This study determined whether pretransplant psychological measures predicted physical health, quality of life, and overall adjustment posttransplant. Cross-sectional analyses also examined differences in adjustment and quality of life for lung transplant candidates and recipients.

DESIGN AND PARTICIPANTS

Seventeen transplant candidates and 60 transplant recipients completed questionnaires measuring adjustment and quality of life. In addition, we examined archival data on 107 transplant candidates who had received pretransplant psychological assessments, and posttransplant physical health status data were collected on these patients. Of the 107 patients who provided a pretransplant psychological assessment, 32 completed the questionnaires measuring posttransplant adjustment and quality of life.

SETTING

University medical center transplant service.

RESULTS

Cross-sectional analyses indicated significantly better adjustment and quality of life posttransplant. Pretransplant psychological variables were not associated with measures of posttransplant physical health. Hierarchical multiple regression analyses found that pretransplant anxiety and psychopathology predicted posttransplant adjustment (beta's ranging from 0.32 to 0.68) and greater pretransplant anxiety also predicted worse posttransplant quality of life (beta's ranging from 0.29 to 0.62). Subjective sleep disturbances were associated with poorer adjustment and quality of life (beta's ranging from 0.36 to 0.75), and were found to mediate the relationship between presurgical anxiety and posttransplant adjustment and quality of life.

CONCLUSIONS

This study found that psychological status pretransplant predicted adjustment and quality of life posttransplant. Moreover, increased anxiety levels pretransplant predicted subsequent subjective sleep disturbances, which were, in turn, associated with poorer adjustment and quality of life. The benefits of pretransplant stress management interventions are discussed.

What makes women tired? A community sample

We aimed to determine the major health concerns or problems of women and their personal attributions for the causes of their primary health concerns. We used a survey of women from the Toronto area attending a women's health symposium. Completed questionnaires were returned by 153 (85%) of 180 women attendees. Persistent fatigue was the primary and most commonly cited health concern. Fatigue was ranked first by 42 (27.5%) women and among the top 10 concerns by 123 (80.4%) women. Women attributed their fatigue to a combination of home and outside work (63.4%), poor sleep (38.2%), lack of time for self (34.1%), lack of exercise (32.5%), financial worries (28.5%), relationship problems (22.0%), emotional causes (17.9%), care of ill family members (13.8%), lack of social or individual support (9.8%), poor physical health (8.9%), work in home or child care (3.3%), or gender bias/harassment (2.4%). Our subjects, women from the community, overwhelmingly endorsed social determinants as the cause of their persistent fatigue. Although depression and anxiety form the most robust associations with persistent fatigue in primary care and community studies, women in this sample ranked these factors in seventh place in their attributions. Similarly, although physicians often assume physical causes for fatigue, women rank physical health low in their own attributions. Given the high prevalence of fatigue in women and its impact on quality of life, more attention needs to be given to the social, systemic, and personal factors that women feel contribute to their fatigue to develop more effective interventions.

Quality of life following transplantation of the heart, liver, and lungs

The purpose of this study was to describe the quality of life of patients who have received a transplant of the heart, liver, and lungs. We wished to document how the different patient groups fared in relation to each other with respect to physical, psychological, and social functioning, as well as in relation to published normative data. We also wished to identify factors that contribute to better functioning. We sent out a questionnaire by mail and received responses from 55 heart, 149 liver, and 59 lung transplant recipients (82% response rate). Measures included the SF-36, Mental Health Inventory, the State Anxiety Inventory, the UCLA Loneliness Scale-Revised, a quality of life measure that rated degree of improvement since transplantation, a measure of degree of difficulty in following medical and lifestyle regimens, sleep disturbance, and the Illness Intrusiveness Rating Scale. Results indicated that lung transplant patients reported better functioning than heart or liver transplant patients in all three domains of physical, psychological, and social functioning. Lung patients' level of functioning was equivalent to or better than published norms for the SF-36. Heart and liver recipients reported equivalent functioning to published norms in some domains, but reported impairment in the areas of physical and social functioning. Heart patients especially reported greater intrusiveness of their illness on their daily lives and indicated more difficulty complying with their lifestyle regimen. In all three groups, a large majority of patients reported feeling that life had improved since transplant with respect to health, energy level, activity level, and overall quality of life. Fewer patients reported improvements in the areas of sex life, marriage, family relationships, and social relationships. Where there were differences among the three patient groups, again it was the lung patients who reported more improvement in life since transplantation. Patients with better physical functioning tended to have more energy and pep, to be younger, to see themselves as being in better health, to feel less intrusion on their lives of their illness, and to be employed. Those with better psychological functioning tended to report less sleep disturbance, less loneliness, better social functioning, more vitality, and to be older. Better social functioning was associated with better mental health, less illness intrusiveness, and less role impairment as a result of physical or emotional factors. Relatively few patients-roughly a quarter of the total sample-reported that they were working either full or part time. We conclude that transplantation results in improved quality of life overall, but that problems persist for some patients in their physical and social functioning. Interventions aimed at improving rehabilitation in specific targeted areas may enable patients to resume a more fulfilling lifestyle posttransplant.

Psychiatric consultation for competency to refuse medical treatment. A retrospective study of patient characteristics and outcome

Forty-one psychiatric consultations on medical-surgical inpatients for competency to refuse medical treatment were studied retrospectively. The competent (n = 16) and incompetent (n = 25) patients were compared in terms of demographic data, diagnoses, clinical variables, details about treatment refusal, and outcome following competency assessment. The incompetent patients tended to be men, the focus of more urgent requests, and to have refused operations. The incompetent patients tended to have organic brain syndromes; the competent patients had personality disorders, adjustment disorders, or no psychiatric diagnosis. Ultimate acceptance of treatment initially refused was common in both groups; differential psychiatric interventions were recommended. The process of psychiatric consultation appeared to facilitate acceptance of treatment initially refused.

Consultation-liaison psychiatry as a subspecialty. A Canadian survey

In Canada, in recent years, there has been increased interest in the issue of subspecialization in psychiatry. One hundred and forty-four members of the Section on Psychosomatic Medicine of the Canadian Psychiatric Association responded to a survey about their opinions on teaching, training, continuing education, and designation of consultation-liaison (C-L) psychiatry as a subspecialty. Fifty-five percent of respondents agreed that C-L psychiatry should receive designation as a psychiatric subspecialty, 35% were opposed, and 10% did not give an opinion. The results also indicated that formal teaching in C-L psychiatry has increased, particularly over the past 20 years; that training in C-L psychiatry is believed by many to have been inadequate, regardless of when the training took place; and recent graduates were more likely than psychiatrists graduating more than 10 years ago to agree that C-L psychiatry should be designated as a subspecialty. Psychiatrists who devote more of their time to the care of patients with combined medical and psychiatric illness were also more likely to favor subspecialty designation. Factors unique to Canada that may influence attitudes toward psychiatric subspecialization include the number and geographic distribution of psychiatrists, their educational background, and governmental funding priorities.

High-risk indicators for family involvement in social work in health care: a review of the literature

Shifts in health concerns, fiscal restraints, technological advances, and demands for accountability have created severe tensions within health care settings. New demands point to the need for a redefinition of services. High-risk screening appears to be a clear method of delineating service need. A review of the empirical literature highlights individual, family, and illness variables that alone and together may improve identification of patients and families in need of social work services. The development of screening mechanisms may be a useful vehicle for improved psychosocial care and for the planning of social work services.

Critical care nurses' attitudes toward, concerns about, and knowledge of the acquired immunodeficiency syndrome

Two samples of critical care nurses (from a secular teaching hospital and a religious-affiliated community hospital, respectively) were compared on their attitudes, concerns, and knowledge regarding the acquired immunodeficiency syndrome (AIDS). Nurses from the teaching hospital had significantly (p = 0.003) more favorable attitudes toward patients with AIDS than did the community hospital nurses. Modal response in each group for perceived risk of acquiring AIDS from patients was 1 chance in 10,000. If given a choice, a sizable percentage in both the teaching (45%) and the community hospital (65%) groups would refuse to care for patients with AIDS. Those indicating preference for refusing showed significantly higher levels of concern and significantly less favorable attitudes than the others. Knowledge about AIDS was high, with means in each group exceeding 14 out of 16 possible points. Implications for nursing practice are discussed.

Chemical Composition of Lunar Material

Chemical and emission spectrographic analyses of three Apollo 11 samples, 10017-29, 10020-30, and 10084-132, are given. Major and minor constituents were determined both by conventional rock analysis methods and by a new composite scheme utilizing a lithium fluoborate method for dissolution of the samples and atomic absorption spectroscopy and colorimetry. Trace constituents were determined by optical emission spectroscopy involving a d-c arc, air-jet controlled.