Effect of Resident Involvement on Trauma Patient Outcomes: A Single-Institution Review

OBJECTIVE

The purpose of this study was to examine the mortality difference and other outcome measures amongst trauma patients with residents involved in the initial management versus those that were managed by attending physicians only without resident involvement.

DESIGN

Retrospective review. Chi-square, Fisher's tests were used to analyze the outcomes, diagnostics, and interventions using the presence of residents in the initial care of patients as an independent variable. Linear and logistic regression were used to estimate adjusted outcomes.

SETTING

Riverside Community Hospital, Riverside California (State-designated level I trauma center) PARTICIPANTS: Data on all trauma patients ≥18 years old that were admitted between July 1, 2018 and June 30, 2020 was collected retrospectively (total 2644 trauma patients). Trauma patients that were transferred from outside facilities were excluded from the study.

RESULTS

There was no significant difference in mortality associated with resident involvement in both unadjusted and adjusted analysis. Patients treated by residents, however, had more comorbidities (higher CCI) and were more severely injured (higher ISS). On adjusted analysis, higher ISS was independently associated with resident presence. There was also a statistically significant increase in the use of diagnostic studies and therapeutic interventions in the resident-present group.

CONCLUSIONS

Involvement of residents in the initial management of our trauma patient population was associated with no difference in overall mortality or morbidity, despite higher injury severity in the resident treated patient group.

Bradyarrhythmia After Remdesivir Administration in SARS-CoV-2: A Review of Literature and Meta-Analysis of Observational Studies in Epidemiology

Background

The coronavirus disease 2019 (COVID-19) pandemic has required timely and informed decisions about treatment recommendations for clinical practice. One such drug used for the treatment of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is remdesivir (RDV), and several cardiac side effects have been reported including bradyarrhythmia (e.g., transient sinus bradycardia, symptomatic sinus bradycardia, complete atrioventricular (AV) block). The current study aimed to explore the association between RDV treatment for SARS-CoV-2 infection and the risk of bradyarrhythmia by presenting a review and meta-analysis of available published studies.

Methods

We presented a review of published literature and meta-analysis of observational studies (MOOSE). A narrative summary of RDV and bradyarrhythmia in COVID-19 infection and pooled analysis of observational studies that meet inclusion criteria was included. Studies included were published between January 2020 and December 2021 (identified through PubMed and ScienceDirect) and examined the association between treatment with RDV in SARS-CoV-2 infection and the risk of bradyarrhythmia.

Results

Three studies (two retrospective cohort studies and one prospective cohort study) met inclusion criteria for pooled meta-analysis of bradyarrhythmia and RDV therapy in COVID-19 patients. Treatment with RDV was associated with increased risk of sinus bradycardia when compared to controls (odds ratio 3.27 (95% confidence interval 1.90 - 5.63)). In the pooled analysis, the incidence of bradycardia in those that received RDV was 34.07% vs. 18.13% among controls. Thirteen case reports, three case series, and three disproportionality analyses were identified in review of the literature.

Conclusion

Data from real-world observational studies suggest that treating COVID-19 patients with RDV may predispose the development of bradyarrhythmia. The importance of this observation is of uncertain clinical significance as some observational studies have reported more favorable outcomes among patients who experience bradycardia after RDV therapy. The current study is limited by the small number of studies that could be meaningfully pooled and more well-designed cohort studies are needed to explore this association.

Management of Blunt Traumatic Abdominal Wall Hernias: An Analysis of the National Trauma Data Bank

BACKGROUND

Blunt traumatic abdominal wall hernias (TAWH) are uncommon injuries with variable presentation and unstandardized management. Few national systematic descriptive studies have been conducted about TAWH. We present a retrospective descriptive study utilizing the National Trauma Data Bank (NTDB) to better characterize risk factors associated with TAWH and management practices.

METHODS

The NTDB (years 2016-2019) was examined for adult blunt trauma patients who had TAWH. Data included demographics, trauma-specific variables, management strategies, and outcome measures. Descriptive statistics were performed by univariate analysis.

RESULTS

2 871 367 adult blunt trauma patients were identified in the NTDB dataset. 206 had abdominal wall hernias (<.01%). Compared with the overall blunt trauma cohort, patients with TAWH had higher body mass index (BMI) and Injury Severity Scores (ISS), were more likely to be male, and had a higher mortality rate. 44 patients (21%) underwent operative management during their initial admission. Surgically managed patients were younger, had higher ISS and BMI, and were more likely to have concomitant intra-abdominal injuries. The few patients who had laparoscopic surgery had significantly higher BMI. Patients managed operatively had longer hospital and ICU lengths of stay and increased incidence of medical complications.

CONCLUSIONS

TAWH is an uncommon complication of blunt abdominal trauma, associated with higher BMI, ISS, and increased mortality. Initial operative management was pursued in 21% of cases, more often in younger, more severely injured patients with other intra-abdominal injuries. Evidence-based guidelines, based on multicenter prospective studies with longer follow-up, should be developed for management of these unique injuries.

Non-ischemic Painful Intermittent Left Bundle Branch Block With Infra-Hisian Block Treated Successfully With Biventricular Pacemaker: A Case Report and Literature Review

Non-ischemic painful left bundle branch block (LBBB) is defined as chest pain that occurs simultaneously with the appearance of left bundle branch block and resolves with the disappearance of the left bundle branch block in patients without evidence of myocardial ischemia. The underlying mechanism of this rare clinical occurrence has not been fully understood, but it has been proposed that it results from ventricular dyssynchrony. In this case report, we present a 65-year-old male with non-ischemic chest pain who was found to have intermittent left bundle branch block (ILBBB) with infra-Hisian conduction delay, treated successfully with a biventricular pacemaker. After excluding the presence of angiographic coronary artery disease, an electrophysiology study was conducted to direct the management and investigate other causes of chest pain. The present study highlights the importance of obtaining electrophysiology studies in patients with painful left bundle branch block with no angiographic evidence of coronary artery disease to diagnose this uncommon syndrome.

Corrected QT Interval Prolongation, Elevated Troponin, and Mortality in Hospitalized COVID-19 Patients

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has risen to the level of a global pandemic. Growing evidence has proven the cardiac involvement in SARS-CoV-2 infection. This study aims to evaluate the ability of cardiovascular complications determined by elevated troponin and electrocardiogram findings (e.g., corrected QT interval (QTc)) in predicting the severity of SARS-CoV-2 infection among hospitalized patients.

Methods

This is a retrospective review of medical records of 800 patients, admitted to Richmond University Medical Center in Staten Island, NY, and tested positive for SARS-CoV-2 between March 1, 2020 and July 31, 2020. A total of 339 patients met the study inclusion and exclusion criteria and were included in statistical analysis.

Results

Elevated serum troponin levels on admission statistically correlated with mortality in SARS-CoV-2 patients. Prolonged QTc was shown to have an independent statistically significant association with mortality among patients hospitalized with SARS-CoV-2.

Conclusions

Growing concern for cardiovascular sequelae of coronavirus disease 2019 (COVID-19) has prompted many researchers to investigate the role of cardiovascular complications in mortality due to SARS-CoV-2. Obtaining a simple electrocardiogram for hospitalized patients with COVID-19 could provide an independent prognostic tool and prompt more coordinated treatment strategies to prevent mortality among patients hospitalized with COVID-19.

A Re-Evaluation of the Effect of Trauma Center Verification Level on the Early Risk of Death in Hemodynamically Unstable Patients

Background Studies show increased early and overall mortality at level II compared to level I trauma centers in hemodynamically unstable patients. We hypothesize there is no mortality difference between level I and level II centers applying more contemporary data. Study design Utilizing the 2017 Trauma Quality Program Participant Use File (TQP-PUF), we identified adult patients (age >14 years) who presented to an American College of Surgeons (ACS) verified level I or II center with hypotension (systolic blood pressure [SBP] < 90 mmHg). Logistic regression was performed to identify adjusted associations with mortality. Results A total of 7,264 patients met the inclusion criteria, of whom most were males (4,924 [67.8%]) with blunt trauma (5,924 [81.6%]) being predominated. Mean admission SBP was 73.2 (±13.0) mmHg. There were 1,097 (15.1%) deaths. Level I admissions (4,931 (67.9%]) were more likely male (3,389 [68.7%] vs. 1,535 [65.8]; p=0.012), non-white (3,119 [63.3%] vs. 1,664 [71.3%]; p<0.001), a victim of penetrating trauma (933 [18.9%] vs. 385 [16.5%]; p=0.015), and more severely injured (mean Injury Severity Score: 19.3 [±15] vs. 16.7 [±13.7]; p<0.001). Level II admissions (2,333 [32.1%]) were older (46.8 [±18.5] vs. 50.3 [±20.1] years; p<0.001) with more co-morbidities (mean Charlson Comorbidity Index: 1.43 [±2] vs. 1.77 [±2.2]; p<0.001). Adjusted mortality between level I and II admissions was similar (766 [15.5%] vs. 331 [14.2%]; p=0.918). Early hourly mortality also did not differ. Conclusion There is no overall or hourly mortality discrepancy between ACS-verified level I and II centers for patients presenting with hypotension. This potentially relates to the use of more contemporary data gathered after implementation of updated verification requirements.

The Effect of Trauma Center Verification Level on Outcomes in Traumatic Brain Injury Patients Undergoing Interfacility Transfer

BACKGROUND

Previous literature demonstrates increased mortality for traumatic brain injury (TBI) with transfer to a Level II versus Level I trauma center. Our objective was to determine the effect of the most recent American College of Surgeons-Committee on Trauma (ACS-COT) "Resources for the Optimal Care of the Injured Patient" resources manual ("The Orange Book") on outcomes after severe TBI after interfacility transfer to Level I versus Level II center.

METHODS

Utilizing the Trauma Quality Program Participant Use File of the American College of Surgeons admission year 2017, we identified patients with isolated TBI undergoing interfacility transfer to either Level I or Level II trauma center. Logistic regression was performed to determine independent associations with mortality.

RESULTS

There were 10,268 (71.6%) transferred to a Level I center and 4,025 (28.4%) were transferred to a Level II center. They were mostly male (61.4%) with a mean ± SD age of 61 ± 20.8 years. Mean Injury Severity Score was 16.3 ± 6.3 and most were injured in a single-level fall (51.5%). Patients transferred to a Level I center were less likely to be White (82.3% vs. 84.7%, 0.002) and more likely to have sustained penetrating trauma (2.7% vs. 1.6%, <0.001). The incidence of severe TBI (Glasgow Coma Scale [GCS] = 3-8) was similar (9.3% vs. 8.3%, 0.068). On logistic regression, severity of TBI predicted death; however, there was no difference in adjusted mortality outcome with admission to a Level II versus a Level I center (0.998 [0.836-1.192], 0.985).

CONCLUSIONS

There is no mortality discrepancy in patients with isolated TBI transferred to a Level II versus Level I center despite previous contrary evidence and thus no reason to bypass a Level II in favor of a Level I. This relative improvement potentially relates to the new requirements as defined in the latest version of the ACS-COT's resources manual.

The effect of trauma center verification level on traumatic brain injury outcome after implementation of the Orange Book

BACKGROUND

Previous literature demonstrates mortality discrepancies at Level II vs. Level I centers in patients with isolated Traumatic Brain Injury (TBI). Our hypothesis is that the implementation of the 2014 version of the resources manual ("the Orange Book") is associated with an elimination of this outcome disparity.

METHODS

Utilizing the Trauma Quality Program Participant Use File for 2017, we compared TBI outcomes at ACS Level I vs. Level II centers.

RESULTS

39,764 records met inclusion criteria where 25,382 (63.8%) were admitted to a Level I center. Level I patients were younger (56.4 vs.59.1 years, p < 0.001) and less likely to have been injured in a single level fall (39.5%vs.45.5%, p < 0.001). The incidence of severe TBI (11.3%vs.10.3%, p < 0.001) was more common. Adjusted mortality at a Level II vs. Level I center were similar [7.8% vs. 8.4%, 0.669].

CONCLUSIONS

Implementation of 2014 version of the ACS resources manual is associated with improved TBI associated mortality in ACS Level II centers relative to their Level I counterparts.

Human Polyclonal Antibodies Prevent Lethal Zika Virus Infection in Mice

Zika virus (ZIKV) is an emerging mosquito-borne flavivirus that represents a major threat to global health. ZIKV infections in adults are generally asymptomatic or present with mild symptoms. However, recent outbreaks of ZIKV have revealed that it can cause Congenital Zika Syndrome in neonates and Guillain-Barré syndrome in adults. Currently, no ZIKV-specific vaccines or antiviral treatments are available. In this study, we tested the efficacy of convalescent plasma IgG hyperimmune product (ZIKV-IG) isolated from individuals with high neutralizing anti-ZIKV titers as a therapeutic candidate against ZIKV infection using a model of ZIKV infection in Ifnar1^-/- mice. ZIKV-IG successfully protected mice from lethal ZIKV challenge. In particular, ZIKV-IG treatment at 24 hours after lethal ZIKV infection improved survival by reducing weight loss and tissue viral burden and improving clinical score. Additionally, ZIKV-IG eliminated ZIKV-induced tissue damage and inflammation in the brain and liver. These results indicate that ZIKV-IG is efficacious against ZIKV, suggesting this human polyclonal antibody is a viable candidate for further development as a treatment against human ZIKV infection.

Zika Virus Protease Cleavage of Host Protein Septin-2 Mediates Mitotic Defects in Neural Progenitors

Zika virus (ZIKV) targets neural progenitor cells in the brain, attenuates cell proliferation, and leads to cell death. Here, we describe a role for the ZIKV protease NS2B-NS3 heterodimer in mediating neurotoxicity through cleavage of a host protein required for neurogenesis. Similar to ZIKV infection, NS2B-NS3 expression led to cytokinesis defects and cell death in a protease activity-dependent fashion. Among binding partners, NS2B-NS3 cleaved Septin-2, a cytoskeletal factor involved in cytokinesis. Cleavage of Septin-2 occurred at residue 306 and forced expression of a non-cleavable Septin-2 restored cytokinesis, suggesting a direct mechanism of ZIKV-induced neural toxicity. VIDEO ABSTRACT.

Hispanic Caregiver Experiences Supporting Positive Postschool Outcomes for Young Adults With Disabilities

The rate of competitive employment, or employment in community settings for minimum wage or higher, of working-age individuals with disabilities trails behind individuals without disabilities in the United States. These statistics are even more alarming among Hispanic individuals who have disabilities. The purpose of this study was to explore the negative and positive experiences of Hispanic caregivers from a Midwestern state as they support their family members with disabilities to achieve positive postschool outcomes, including competitive employment. We conducted semistructured interviews with 13 caregivers of family members with disabilities aged 14-25 years. Three key themes emerged from our analysis: (a) negative experiences with school educators, (b) negative experiences with community-based service providers, and (c) positive experiences and strategies for overcoming barriers. Implications for practice and future research are discussed.

Synergism between the tyrosine kinase inhibitor sunitinib and Anti-TNF antibody protects against lethal dengue infection

Dengue virus (DENV) currently circulates in more than 100 countries and causes an estimated 390 million infections per year. While most cases manifest as a self-resolving fever, ∼1.5% of infections develop into a more severe dengue hemorrhagic fever/dengue shock syndrome (DHF/DSS), which causes ∼20,000 deaths annually. The underlying pathological feature of DHF/DSS, also known as Severe Dengue, is an acute increase in vascular permeability leading to hypovolemia and shock. Angiogenic factors and cytokines, such as vascular endothelial growth factor (VEGF) and tumor necrosis factor (TNF), have been implicated in the increased vascular permeability, suggesting a potential therapeutic strategy for Severe Dengue. Here, we employed a mouse model of antibody-dependent enhancement of DENV infection, which recapitulates the fatal capillary leakage and shock of human Severe Dengue, to investigate the effects of approved VEGF- and TNF-targeting drugs. DENV infection caused a significant increase in serum VEGF levels within 2 days and resulted in ∼80% mortality within 8 days of infection. Treatment of mice with sunitinib, a VEGF receptor tyrosine kinase inhibitor, once (day 2) or twice (days 1 and 2) post-infection reduced mortality by 50-80% compared with untreated mice. Notably, sunitinib treatment decreased serum TNF levels, white blood cell counts, and hematocrit levels relative to untreated mice, but had only marginal effects on tissue viral burden. Combination therapy with anti-TNF antibody and sunitinib significantly reduced vascular leakage and synergized to provide superior protection from lethal DENV infection compared with either agent alone. These data suggest that a two-pronged anti-angiogenic and anti-inflammatory approach may be useful for the rapid treatment of DHF/DSS.

An IRF-3-, IRF-5-, and IRF-7-Independent Pathway of Dengue Viral Resistance Utilizes IRF-1 to Stimulate Type I and II Interferon Responses

Interferon-regulatory factors (IRFs) are a family of transcription factors (TFs) that translate viral recognition into antiviral responses, including type I interferon (IFN) production. Dengue virus (DENV) and other clinically important flaviviruses are suppressed by type I IFN. While mice lacking the type I IFN receptor (Ifnar1^-/-) succumb to DENV infection, we found that mice deficient in three transcription factors controlling type I IFN production (Irf3^-/-Irf5^-/-Irf7^-/- triple knockout [TKO]) survive DENV challenge. DENV infection of TKO mice resulted in minimal type I IFN production but a robust type II IFN (IFN-γ) response. Using loss-of-function approaches for various molecules, we demonstrate that the IRF-3-, IRF-5-, IRF-7-independent pathway predominantly utilizes IFN-γ and, to a lesser degree, type I IFNs. This pathway signals via IRF-1 to stimulate interleukin-12 (IL-12) production and IFN-γ response. These results reveal a key antiviral role for IRF-1 by activating both type I and II IFN responses during DENV infection.

Author Correction: Blocking Zika virus vertical transmission

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Blocking Zika virus vertical transmission

The outbreak of the Zika virus (ZIKV) has been associated with increased incidence of congenital malformations. Although recent efforts have focused on vaccine development, treatments for infected individuals are needed urgently. Sofosbuvir (SOF), an FDA-approved nucleotide analog inhibitor of the Hepatitis C (HCV) RNA-dependent RNA polymerase (RdRp) was recently shown to be protective against ZIKV both in vitro and in vivo. Here, we show that SOF protected human neural progenitor cells (NPC) and 3D neurospheres from ZIKV infection-mediated cell death and importantly restored the antiviral immune response in NPCs. In vivo, SOF treatment post-infection (p.i.) decreased viral burden in an immunodeficient mouse model. Finally, we show for the first time that acute SOF treatment of pregnant dams p.i. was well-tolerated and prevented vertical transmission of the virus to the fetus. Taken together, our data confirmed SOF-mediated sparing of human neural cell types from ZIKV-mediated cell death in vitro and reduced viral burden in vivo in animal models of chronic infection and vertical transmission, strengthening the growing body of evidence for SOF anti-ZIKV activity.

Investigation of CD8+ T Cell Immunity in Zika Virus Infection Using Mouse Models

CD8+ T cells may play a dual role in both protection against and pathogenesis of Flaviviruses, including Zika virus (ZIKV). However, virtually nothing is currently known about the role CD8+ T cells play during ZIKV infection in humans and animal models. The goal of our study is to investigate the role of CD8+ T cells during primary ZIKV infection in mice. Using LysMCre+IFNARfl/fl C57BL/6 (H-2b) mice that lack type I IFN receptor in a subset of myeloid cells, we characterized a new mouse model susceptible to infection with both East African lineage (MR766) and Asian lineage (FSS13025) ZIKV strains. A screening of 244 ZIKV epitopes predicted to bind H-2b class I molecules, defined a specific map of 26 and 15 peptides for MR766 and FSS13025 ZIKV strains, respectively. Intracellular cytokine staining confirmed the identity of these epitopes and demonstrated induction of polyfunctional ZIKV-specific CD8+ T cells. Furthermore, adoptive transfer of ZIKV-immune CD8+ T cells reduced viral burdens, whereas depletion of CD8+ T cells led to higher tissue burdens and mortality was increased in ZIKV-infected CD8−/− mice compared to Wild-type. These results demonstrate that CD8+ T cells are important mediators of protection during primary ZIKV infection and provide a H-2b mouse model for investigating ZIKV-specific CD8+ T cell responses. Based on these findings, studies are in progress towards defining the role of resident memory CD8+ T cells in protection against ZIKV infection using our recently developed mouse models of ZIKV systemic infection and sexual transmission.

Identification of Zika virus epitopes reveals immunodominant and protective roles for dengue virus cross-reactive CD8+ T cells

CD8⁺ T cells play an important role in controlling Flavivirus infection, including Zika virus (ZIKV). Here, we have identified 25 HLA-B*0702-restricted epitopes and 1 HLA-A*0101-restricted epitope using interferon (IFN)-γ enzyme-linked immunospot (ELISPOT) and intracellular cytokine staining (ICS) in ZIKV-infected IFN-α/β receptor-deficient HLA transgenic mice. The cross-reactivity of ZIKV epitopes to dengue virus (DENV) was tested using IFN-γ-ELISPOT and IFN-γ-ICS on CD8⁺ T cells from DENV-infected mice, and five cross-reactive HLA-B*0702-binding peptides were identified by both assays. ZIKV/DENV cross-reactive CD8⁺ T cells in DENV-immune mice expanded post ZIKV challenge and dominated in the subsequent CD8⁺ T cell response. ZIKV challenge following immunization of mice with ZIKV-specific and ZIKV/DENV cross-reactive epitopes elicited CD8⁺ T cell responses that reduced infectious ZIKV levels, and CD8⁺ T cell depletions confirmed that CD8⁺ T cells mediated this protection. These results identify ZIKV-specific and ZIKV/DENV cross-reactive epitopes and demonstrate both an altered immunodominance pattern in the DENV-immune setting relative to naive, as well as a protective role for epitope-specific CD8⁺ T cells against ZIKV. These results have important implications for ZIKV vaccine development and provide a mouse model for evaluating anti-ZIKV CD8⁺ T cell responses of human relevance.

Mapping and Role of the CD8+ T Cell Response During Primary Zika Virus Infection in Mice

CD8+ T cells may play a dual role in protection against and pathogenesis of flaviviruses, including Zika virus (ZIKV). We evaluated the CD8+ T cell response in ZIKV-infected LysMCre+IFNARfl/fl C57BL/6 (H-2b) mice lacking the type I interferon receptor in a subset of myeloid cells. In total, 26 and 15 CD8+ T cell-reactive peptides for ZIKV African (MR766) and Asian (FSS13025) lineage strains, respectively, were identified and validated. CD8+ T cells from infected mice were polyfunctional and mediated cytotoxicity. Adoptive transfer of ZIKV-immune CD8+ T cells reduced viral burdens, whereas their depletion led to higher tissue burdens, and CD8-/- mice displayed higher mortality with ZIKV infection. Collectively, these results demonstrate that CD8+ T cells protect against ZIKV infection. Further, this study provides a T cell competent mouse model for investigating ZIKV-specific T cell responses.

Zika Virus Infects Neural Progenitors in the Adult Mouse Brain and Alters Proliferation

Zika virus (ZIKV)-related neuropathology is an important global health concern. Several studies have shown that ZIKV can infect neural stem cells in the developing brain, but infection in the adult brain has not been examined. Two areas in the adult mouse brain contain neural stem cells: the subventricular zone of the anterior forebrain and the subgranular zone of the hippocampus. Here, using 6-week-old mice triply deficient in interferon regulatory factor (IRF) as a model, we show that blood-borne ZIKV administration can lead to pronounced evidence of ZIKV infection in these adult neural stem cells, leading to cell death and reduced proliferation. Our data therefore suggest that adult as well as fetal neural stem cells are vulnerable to ZIKV neuropathology. Thus, although ZIKV is considered a transient infection in adult humans without marked long-term effects, there may in fact be consequences of exposure in the adult brain.

Cutaneous metastasis of colon cancer: case report and literature review

Cutaneous metastases arising from an internal malignancy are a rare phenomenon, occurring in 0.001% of all skin biopsies performed. Of these, 6.5% originate from the a primary colon cancer. Colon cancer, when metastatic to the skin, typically appears as a painless flesh-colored nodule or as a mass with occasional ulceration. We report a case of a large cutaneous metastasis to the suprascapular region as the initial presenting symptom of an underlying colon cancer.

Families and intensive care nurses: comparison of perceptions

This study compared family members' and nurses' perceptions on families' needs when a relative was hospitalized in an intensive care unit (ICU). Family members (N = 32) and nurses (N = 23) complete equivalent 44-item questionnaires. Both family members and nurses agreed that the greatest needs of families were anxious at admission (P less than 0.05). Families and nurses seemed satisfied in the Participation/Information and Emotional Support categories, but more disagreements were noted in these areas. More nurses perceived families as not wanting to participate in patient care (P less than 0.003), felt that families did not have enough time to visit (P less than 0.004), believed that families were comfortable expressing their feelings (P less than 0.02) but thought families were uncomfortable asking questions (P less than 0.01). It was concluded that families be prepared for the patient's condition and appearance, and for the hospital milieu in order to cope more effectively with excessive stress in time of crisis. Concordance in perceived needs of family members and care providers may lead to greater need satisfaction and it is advocated that both the patient and the family (rather than the patient alone) be the focus of treatment because of the relationship between social support and patient recovery.