Physician-assisted suicide in Oregon: what are the key factors?

Oregon's Death with Dignity Act has been operative since late 1997. The substantial national and international interest in Oregon's law makes it important to document any possible trends in the characteristics of persons who use the law. To do this, the present article examines previously reported data from various sources and places them within the context of the end-of-life decisions more generally. The Oregon data demonstrate that, regardless of the care received, a very small percentage of terminally ill Oregonians seem determined to request a lethal medication so that they may control the manner and timing of their death. College graduates and divorced persons are substantially more likely to use physician-assisted suicide to end their lives than are other persons. Control and autonomy appear to be the primary issues associated with taking legally prescribed medication to hasten one's death. A better understanding of the influence that a patient's marital status, education level, and desire for control may have on her or his ability to cope with, and make decisions related to, a terminal illness may allow health care professionals to better care for dying patients.     

Falls in people with learning disabilities: what are the risk factors and prevention strategies?

There is a high prevalence of falls and related injuries in adults with learning disabilities. This article highlights the latest evidence on the diverse risk factors for falls among this group. Research into effective falls management strategies is sparse, but there is some evidence to indicate that environmental management, strength and balance training, and careful management of medications may help to reduce falls. Nurses can play an important role by identifying those who are at most risk, implementing management strategies and educating others.     

Hemorrhage in pelvic fracture: who needs angiography?

Pelvic fractures are rare but potentially devastating injuries. An understanding of the bony and peripelvic anatomy along with common patterns and the classification of the injury are of critical importance in their management. These form the basis for a general treatment algorithm for pelvic fracture patients. Angiographic embolization is time-consuming and often delayed. Hemodynamic instability with unstable pelvic fracture is therefore best approached with a combination of pelvic emergency stabilization (C-clamp) and surgical hemostasis by pelvic tamponade. This is especially true for critically injured patients in extremis.     

Is ED disposition associated with intracerebral hemorrhage mortality?

Background

Early deterioration is common in intracerebral hemorrhage (ICH). Treatment at tertiary care centers has been associated with lower ICH mortality. Guidelines recommend aggressive care for 24 hours irrespective of the initial outlook. We examined the frequency of and factors associated with transfer to tertiary centers in ICH patients who initially presented at nontertiary emergency departments (EDs). We also compared observed with expected mortality in transferred and nontransferred patients using published short-term mortality predictors for ICH.

Methods

Adult patients who resided in a 5-county region and presented to nontertiary EDs with nontraumatic ICH in 2005 were identified. Intracerebral hemorrhage score and ICH Grading Scale (ICH-GS) were determined. Of 16 local hospitals, 2 were designated tertiary care centers. Logistic regression was used to assess factors associated with transfer.

Results

Of 205 ICH patients who presented to nontertiary EDs, 80 (39.0%) were transferred to a tertiary center. In multivariate regression, better baseline function (modified Rankin scale 0-2 versus 3-5; odds ratio, 0.42, 95% confidence interval, 0.21-0.85, P = .016) and black race (odds ratio, 2.28, 95% confidence interval 1.01-5.12, P = .046) were associated with transfer. A trend toward higher 30-day mortality was observed in nontransferred patients (32.5% versus 45.6%, P = .06). The ICH-GS overestimated mortality for all patients, while the ICH Score adequately predicted mortality.

Conclusions

We found no significant difference in mortality between transferred and nontransferred patients, but the trend toward higher mortality in nontransferred patients suggests that further evaluation of ED disposition decisions for ICH patients is warranted. Expected ICH mortality may be overestimated by published tools.     

ED patients with vertigo: can we identify clinical factors associated with acute stroke?

Background

Vertigo is a common emergency department (ED) complaint with benign and serious etiologies with overlapping features. Misdiagnosis of acute stroke may result in significant morbidity and mortality. Magnetic resonance imaging (MRI) is superior to computer tomography (CT) for diagnosis of acute stroke but is costly with limited availability.

Objective

The aim of this study was to identify clinical characteristics associated with a cerebrovascular cause for vertigo.

Methods

We performed a retrospective chart review on patients with an MRI for vertigo, with or without additional historical or physical examination findings, over 18 months. Study patients were seen in the ED for vertigo within 2 weeks of MRI. Data collected included medical history, physical findings, and imaging results. Fisher's exact test was used to identify factors associated with the primary outcome, an acute stroke.

Results

There were 325 eligible patients; 131 were ED patients. Patients were 57 (±18) years, and 53% were women. There were 12 ED patients with a new stroke (9.2%). Two variables were associated with acute stroke: a presenting complaint of gait instability (odds ratio, 9.3; 95% confidence interval, 2.6-33.9) or a subtle neurologic finding (odds ratio, 8.7; 95% confidence interval, 2.3-33.1). One patient with a new stroke had a prior stroke, 3 were age >65 years, and none had coronary artery disease or dysrhythmia. Among patients with acute stroke, 5 also had head CT, and none detected the stroke.

Conclusions

This study identified 2 variables associated with acute stroke that should be considered in the evaluation of ED patients with vertigo. Head CT was inadequate for diagnosing acute stroke in this patient population.     

Which factors are associated with a successful outcome in a weight management programme for obese children?

AIMS AND OBJECTIVE: To identify factors important in determining whether an obese child achieves significant reductions in Body Mass Index Standard Deviation Score (BMI SDS) within a UK, hospital-based paediatric obesity service aimed at lifestyle modification. DESIGN: Observational Study. SUBJECTS: 137 obese children (63 boys) who have attended our childhood obesity service within the last three and a half years at The Royal Hospital for Children, Bristol, UK. MEASUREMENTS: BMI SDS with a target reduction of - 0.5 or greater. RESULTS: 70% of children achieved reductions in BMI SDS with 18% achieving the target reduction. In those attending the clinic for a year or more the levels improved to 83% and 28% respectively. Age was found to be the most important predictor with younger children achieving larger reductions in BMI SDS. More boys than girls were likely to achieve target reductions in BMI SDS and those without a parental history of obesity were more likely to achieve greater reductions in BMI SDS. Socio-economic status did not appear to impact upon the child's level of success. CONCLUSIONS: In families of obese children, motivated to seek help by attending a hospital-based weight control clinic, improvements in BMI are possible by a simple approach of education and continued support. Improvement is greatest in younger children with maximal benefit being seen in boys without a parental history of obesity. We believe this emphasizes the importance of identifying significant obesity in primary school aged children, who seem most likely to benefit from simple lifestyle modification, while many older children may require additional intervention programmes to improve BMI.     

Chronic diseases: what are they? How are they inherited?

BACKGROUND: Chronic diseases (CD), miasms or reactional modes, remain one of the darkest concepts of homeopathy. They are supposed to be heritable and originate after suppression of other diseases. Besides this nothing is known about how they might produce the large number of diseases mentioned in homeopathic books. They have been described in a variety of terms, ranging from Kent and Gathak's spiritual or metaphysic conception; the biological-allergic by Paschero, and, Robert's materialist-nutritional point of view. Flores-Bejar et al have outlined an approach to CD from a cellular and bioenergetic point of view. RESULTS: Cellular pathology has led to an understanding of the basic repair mechanisms of every cell and tissue. These mechanisms exist in order to avoid necrosis or cell death. The main mechanisms are molecular repair, apoptosis and cell proliferation. Failure of these mechanisms leads to 'dysrepair'. Consequences of these 'dysrepair' mechanisms resemble the homeopathic reactional modes or miasms. These abnormal or 'dysrepair' mechanisms are probably the basis of miasms or reactional modes. A new interpretation of miasms is proposed: Psora corresponds to the dysmolecular reactional mode. Syphilis corresponds to dysapoptotic reactional mode. Sycosis corresponds to dysproliferative reactional mode.     

Dietary adherence and the associated factors among Indonesian patients with type 2 diabetes: what should we be concerned about?

Objective: To identify the level of dietary adherence for particular foods and determine which are challenging for patients with diabetes in Indonesia, as well as the associated factors. Methods: This study was conducted in a primary health care facility, using a cross-sectional design. Diabetic patients who had received dietary education, agreed to par ticipate, and adult age were invited. All patients with type 1, gestational, and other types of diabetes who did not join regular meetings of Pr...     

National service frameworks: what are they?

This article describes policy developments surrounding the creation of national service frameworks. The national service framework for mental health is used as an example to highlight the content of the framework and the way it has been received.