'Doctor, I don't want to know that'--exploring denial in patients with lung cancer]

Three patients with lung cancer, a man aged 68, a woman aged 69 and a man aged 52, denied the nature or the severity of their disease in three different ways: temporary denial to evade acute emotional shock, full-blown persistent denial, and unjustified optimism respectively. The psychological mechanism of denial may become operational in patients confronted with an overwhelming disease. A less pronounced denial of medical information provided by physicians can be recognised in many patients. It may also be noticed in how individuals or groups of people sharing the same unbearable reality face up to the facts. Denial may be helpful in (temporarily) circumventing a serious problem but when the disease is serious, it may interfere in relationships with partners, relatives and friends. Denial must be differentiated from organicity, e.g. anosognosia in cerebral damage, by patient ignorance, or by vague communication from the medical community. A direct and blunt confrontation of denial may result in adverse effects due to a defensive mechanism being aggravated. Slowly providing the patient with pieces of information whilst taking into account his or her reaction, may provide a clue for gradual conformation to the medical reality.     

Mortality from meningococcal disease during an epidemic in The Gambia, West Africa

Mortality from meningococcal disease was determined during an epidemic in a rural area of The Gambia with few medical resources, but where a system of registration of births and deaths had been established before the introduction of a primary health care programme. 33 deaths were recorded among 127 patients, a case mortality rate of 26%. 84% of deaths occurred within the first 24 h of illness and many patients died before they could reach any source of treatment. Previous studies, based on regional statistics or on hospital series, may have underestimated mortality from epidemic meningitis in Africa. Mortality from this infection will be reduced only if treatment can be made readily accessible to patients early in the course of their illness.     

A gender-specific hazard-based clinical and noninvasive coronary risk scoring system for patients with suspected coronary artery disease

OBJECTIVE: An outpatient-based scoring system was developed for at-risk patients with coronary artery disease based on data derived from the clinical history and noninvasive testing results for the prediction of an adverse event, the development of risk subsets, and the evaluation of the appropriateness of utilization patterns in an ambulatory care patient population. METHOD: This was a hospital-based cohort study. From a population of 3,795 consecutively tested patients, 872 with suspected coronary artery disease were enrolled from a midwestern university tertiary medical center from 1988 to 1989. RESULTS: Multivariable Cox modeling was used to develop scoring weights with scores ranging from -1.6 to 8.5 points. Significant multivariable disease predictors of cardiac death or myocardial infarction were use of nitroglycerin or insulin, ST-T wave changes, female gender, left ventricular hypertrophy, and a reversible thallium 201 defect. Receiver operating characteristics curves by use of the hazard score were comparable by gender. A probability threshold of .30 for cardiac death or myocardial infarction yielded a cut point of acceptable sensitivity and specificity for prompting medical management decisions. Below this threshold, the rate of follow-up diagnostic testing was 16.9% for women and 57.8% for men (p=.00001). Above this threshold, the rate of follow-up diagnostic testing was 40.6% for women and 64.3% for men (p= .04). CONCLUSION: Use of cardiac diagnostic services and cardiac event-free survival varies by gender in patients screened by noninvasive testing. For men at low risk of cardiac death or myocardial infarction, a statistically greater use of follow-up diagnostic testing was reported, thus reflecting more aggressive treatment and overuse of services for men as compared with women.     

临床重点疾病的不适当住院日研究

目的对新疆某三级甲等医院重点疾病的住院天数进行回顾性研究,发现诊疗流程中存在的不适当住院日,预测平均住院日的缩短空间。方法依照三级综合医院评审标准及实施细则,在重点疾病监测指标中选择某院2010—2012年3个内科疾病：高血压、急性心肌梗死、慢性阻塞性肺病：两个外科疾病：前列腺增生、颅脑损伤共200份病案资料的2496个住院日进行回顾性研究,并对可能影响的变量进行回归分析。结果2496个住院日中不适当住院日共217天,占到了8．7％,引起不适当住院日的三大主要因素分别是等待检查报告、出院不及时和等待手术,共产生177个不适当住院日,占到了不适当住院总天数的81．6％。结论高血压、急性心肌梗死、慢性阻塞性肺病、前列腺增生、颅脑损伤的平均住院日可以进一步缩短,其缩短幅度分别是1．3天、0．7天、1．0天、1．3天和1．1天。     

Maternal mortality due to heart disease]

A retrospective study on maternal mortality in pregnant women with cardiac disease over a period of eleven years (January 1979 to December 1989) was undertaken. The objective was an analysis of the main aspects of this association. Cardiac disease was diagnosed in 694 patients (4.2%) of a total of 16,423 admitted to the Obstetrics Department of the Escola Paulista de Medicina. As for etiology, rheumatic disease (52.3%); Chagas's disease (19.3%) and congenital disease (8.1%) were the most frequent causes. There were 51 maternal deaths, according to FIGO's definition (1967), corresponding to a maternal mortality rate of 428.2/100,000 livebirths during the same period. Twelve of these maternal deaths were due to cardiac disease (maternal mortality rate of 100.8/100,000 livebirths). The statistical analysis identified the following aspects associated with maternal mortality among patients with cardiac disease: primigravida, lack of adequate prenatal care, and cardiac surgery performed previously to and/or during pregnancy. Congestive heart failure with pulmonary edema (41.7%) and thromboembolism (25.0%) were the most frequent causes of maternal death among patients with cardiac disease. The NYHA functional classification was not a good parameter for pregnancy prognosis: eleven patients (91.7%) were considered as belonging to the favorable group before they became pregnant. Most maternal deaths occurred during the first 72 hours after delivery. Therefore, this period was considered most critical for maternal mortality in patients with cardiac disease. No relation-ship was found among the factors: maternal age, race, marital status, delivery and maternal mortality among patients with cardiac disease.(ABSTRACT TRUNCATED AT 250 WORDS)     

Population impact of stricter adherence to recommendations for pharmacological and lifestyle interventions over one year in patients with coronary heart disease

STUDY OBJECTIVE: To assess the potential number of lives saved associated with the full implementation of aspects of the National Service Framework (NSF) for coronary heart disease (CHD) in England using recently developed population impact measures. DESIGN: Modelling study. SETTING: Primary care. DATA SOURCES: Published data on prevalence of acute myocardial infarction and heart failure, baseline risk of mortality, the relative risk reduction associated with different interventions and the proportion treated, eligible for treatment and adhering to each intervention. MAIN RESULTS: Adopting the NSF recommendations for pharmacological interventions would prevent an extra 1027 (95% CI 418 to 1994) deaths in post-acute myocardial infarction (AMI) patients and an extra 37 899 (95% CI 25 690 to 52 503) deaths in heart failure patients in the first year after diagnosis. Lifestyle based interventions would prevent an extra 848 (95% CI 71 to 1 614) deaths in post-AMI patients and an extra 7249 (95% CI 995 to 16 696) deaths in heart failure patients. CONCLUSIONS: Moving from current to "best" practice as recommended in the NSF will have a much greater impact on one year mortality rates among heart failure patients compared with post-AMI patients. Meeting pharmacological based recommendations for heart failure patients will prevent more deaths than meeting lifestyle based recommendations. Population impact numbers can help communicate the impact on a population of the implementation of guidelines and, when created using local data, could help policy makers assess the local impact of implementing a range of health care targets.     

Use of health services after a myocardial infarction

Short-term and long-term use of physician consultations and rehospitalizations were studied in 383 myocardial infarction (MI) patients in relation to demographic, medical, and psychological factors. Short-term (i.e. within 6 months post-MI) utilization of physicians was only related to patients' health locus of control. In comparison, a higher number of physician consultations 3-5 years after the MI was independently related to female sex, more non-cardiac limitations before the MI, more complications during hospitalization, less cardiac lifestyle knowledge, and higher levels of anxiety and depression short time after the MI. Every second patient was readmitted to the hospital before the 3-5 years follow-up but only 14% suffered a non-fatal reinfarction. More rehospitalizations were independently related to a higher number of previous hospitalizations for heart disease, more pre-MI cardiac limitations, less cardiac lifestyle knowledge, and higher initial level of emotional distress. Discriminant analysis identified female sex and patients' initial expectations of reduced emotional control as the best predictor variables for a rehospitalization caused by chest pain without a new infarction, whereas a reinfarction was best discriminated by the number of previous hospitalizations for heart disease. We conclude that psychological factors influence health services utilization to a comparable extent as medical factors. These findings may indicate a greater need for long-term professional support in patients with less initial cognitive and emotional control.     

Long-term prognosis after peri-operative cardiac complications

The objective was to document the 5 year prognosis of patients who had cardiac complications after non-cardiac surgery. Design: 5-year follow-up of 218 patients originally enrolled in a prospective study to identify risks factors for perioperative complications. Setting: an academic medical center. Participants were hypertensives and diabetics who underwent elective surgery between 1982 and 1985. In the original study, patients were evaluated pre-operatively, monitored intra-operatively by an independent observer, and followed daily for 7 days post-operatively according to a standard surveillance protocol. Outcomes were judged by assessors blinded to the pre-operative status and intra-operative course. Patients were interviewed at 3 and 5 years post-operatively. Patients with post-operative cardiac complications had significantly higher rates of overall mortality, mortality attributable to cardiac causes (MI, CHF, arrest), and mortality attributable to other cardiovascular causes (stroke, renal failure) than patients without cardiac complications. For example, at 5 years 11% of those patients without post-operative cardiac complications had cardiac deaths, in contrast to 45% of those patients with post-operative cardiac complications. Proportional hazards analysis demonstrated that post-operative cardiac complications remained a significant predictor of cardiac (p < 0.001) and cardiovascular (p < 0.0001) mortality controlling for pre-operative cardiac disease, other non-cardiovascular comorbid diseases, age, sex, diabetes, and pre-operative renal insufficiency or stroke. Similarly, patients with post-operative non-fatal cardiac complications had higher rates of cardiac or cardiovascular events during the 5 year follow-up period. We conclude that post-operative cardiac complications have a significant adverse long-term prognostic impact comparable to the prognostic impact of myocardial infarction, ischemia or congestive failure in the non-operative setting. Understanding these events could be an important factor in identifying patients at high risk for subsequent peri-operative complications.     

Myocardial infarction patients in the acute care hospital: a conceptual framework for social work intervention

This paper describes a conceptual framework for identifying myocardial infarction patients in the acute care hospital who are at risk for medical and psychosocial complications that may impede recovery. Because of their precarious medical status, these patients present special issues for social work practice. Psychosocial factors affecting outcomes are reviewed and interventive strategies are outlined. The crucial role of adaptive denial in recovery is highlighted.     

Mortality in medicolegal deaths in Hyogo Prefecture (1986-88).

Only three medical examiner offices are undertaking inquests on medicolegal deaths and no coroner system exists in Japan. Medical practitioners are also entrusted to hold such inquests. Certificates filed by the medical examiners of Hyogo Prefecture were compared with those filed by medical practitioners. Medical examiners certified deaths as "heart failure" only when no pathological changes were found after an autopsy. Of 2,622 deaths caused by diseases, 1,707 were certified as "heart failure" by medical practitioners without performing an autopsy. The term "heart failure" seems likely to be misused for deaths of which causes are unknown. Although the age-adjusted mortality rate for "heart disease" in Japan (98.7 per 100,000 population) showed a higher rate than for "cerebrovascular disease" (84.2), it included 53.9 for "heart failure". The misuse of the term "heart failure" seems to have introduced serious bias into the recent mortality statistics of Japan. This inaccuracy is due to ignorance about the importance of mortality statistics and ICD. Improvement in the reliability of mortality statistics is necessary for disease prevention projects through clinical medicine and public health means.     

Predictors of sudden cardiac death among Hawaiian-Japanese men

A cohort of 7,591 middle-aged Hawaiian-Japanese men free at initial examination of evidence of coronary heart disease or stroke were followed starting in 1965. Between 1965 and 1983, 1,342 of these men died; 229 deaths occurred less than 24 hours after the onset of the terminal episode, of which 98 deaths occurred in less than one hour. In the category of deaths occurring less than one hour after onset, the risk characteristics of those whose deaths were attributed to coronary heart disease and those whose deaths were attributed to an unknown cause were similar. It is appropriate to combine them as "sudden cardiac death." In the category of deaths occurring one to 24 hours after onset, the risk characteristics of those whose deaths were attributed to coronary heart disease and those whose deaths were attributed to an unknown cause differed. It is not appropriate to assume coronary heart disease as the underlying cause of death in this unknown cause group. The predictors of sudden cardiac death were blood pressure, serum cholesterol, serum glucose, cigarette smoking, history of parental heart attack, and electrocardiographic evidence of left ventricular hypertrophy or strain. Inversely related to risk were alcohol intake and the number of years spent in Japan. No factor distinguished those at risk for sudden cardiac death from those at risk for other manifestations of coronary heart disease.     

A controlled trial of a rapid response system in an academic medical center

A medical emergency team composed of house staff and existing float-pool nurses was successfully implemented on the general medical floor of an academic medical center without increasing personnel. The intervention had little noticeable impact, although the number of cardiac arrests and deaths were low both before and after the intervention.     

Cost-Effectiveness of Treatments Reducing Coronary Heart Disease Mortality in Ireland, 2000 to 2010

Objective:  Coronary heart disease (CHD) is associated with a large burden of disease in Ireland and is responsible for more than 6000 deaths annually. This study examined the cost-effectiveness of specific CHD treatments in Ireland.
Methods:  Irish epidemiological data on patient numbers and median survival in specific groups, plus the uptake, effectiveness, and costs of specific interventions, all stratified by age and sex, were incorporated into a previously validated CHD mortality model, the IMPACT model. This model calculates the number of life-years gained (LYGs) by specific cardiology interventions to generate incremental cost-effectiveness ratios (ICERs) per LYG for each intervention.
Results:  In 2000, medical and surgical treatments together prevented or postponed approximately 1885 CHD deaths in patients aged 25 to 84 years, and thus generated approximately 14,505 extra life-years (minimum 7270, maximum 22,475). In general, all the cardiac interventions investigated were highly cost-effective in the Irish setting. Aspirin, beta-blockers, ACE inhibitors, spironolactone, and warfarin for specific conditions were the most cost-effective interventions (<€3000/LYG), followed by the statins for secondary prevention (<€6500/LYG). Revascularization for chronic angina and primary angioplasty for myocardial infarction, although still cost-effective, had the highest ICER (between €12,000 and €20,000/LYG).
Conclusions:  Using a comprehensive standardized methodology, cost-effectiveness ratios in this study clearly favored simple medical treatments for myocardial infarction, secondary prevention, angina, and heart failure.     

Underuse of invasive procedures among Medicaid patients with acute myocardial infarction.

OBJECTIVES: The purpose of this study was to determine whether underuse of cardiac procedures among Medicaid patients with acute myocardial infarction is explained by or is independent of fundamental differences in age, race, or sex distribution; income, coexistent illness; or location of care. METHODS: Administrative data from 226 hospitals in New York were examined for 11,579 individuals hospitalized with a primary diagnosis of acute myocardial infarction. Use of various cardiac procedures was compared among Medicaid patients and patients with other forms of insurance. RESULTS: Medicaid patients were older, were more frequently African American and female, and had lower median household incomes. They also had a higher prevalence of hypertension, diabetes, lung disease, renal disease, and peripheral vascular disease. After adjustment for these and other factors, Medicaid patients were less likely to undergo cardiac catheterization, percutaneous transluminal coronary angioplasty, and any revascularization procedure. CONCLUSIONS: Factors other than age, race, sex, income, coexistent illness, and location of care account for lower use of invasive procedures among Medicaid patients. The influence of Medicaid insurance on medical practice and process of care deserves investigation.     

Do routine clinic visits prevent de-stabilization in patients awaiting coronary revascularization?

We examined retrospectively the usefulness of routine clinic visits in preventing adverse cardiac events in 115 patients awaiting coronary surgery or angioplasty. Mean waiting time from angiography to revascularization was 126 days. A total of 126 visits were made by 80 patients. No deaths occurred, but one patient, despite three visits, suffered myocardial infarction at 316 days post-angiography. Eight patients required admission for unstable angina, five having been on the waiting list for less than 5 weeks. The mean number of clinic visits, number of diseased vessels and proportion on triple anti-ischaemic therapy were similar in the patients suffering such events and those remaining stable. In conclusion, the inherent unpredictability of coronary disease greatly limits the role of interim clinic visits in the prevention of adverse cardiac events in patients awaiting revascularization.     

Certification of death from ischaemic heart disease in Belfast

All death certificates over a one-year period (20 July 1981 to 19 July 1982) for residents of Belfast were examined in order to ascertain those due to ischaemic heart disease. Some 1654 were included for further investigation of which 1288 (78%) were coded by ICD Nos 410-414 (9th revision). Additional data were obtained from hospital records, ECGs, cardiac enzyme measurements, post mortems, general practitioners and from relatives of the deceased. Some 108 deaths coded by 410-414 and 223 deaths coded by other rubrics were eventually excluded. For people aged less than 70 years the net effect of excluding these deaths and including some coded under rubrics other than 410-414 was very small representing a change from 498 to 496 deaths (-0.4%). For people aged 70 years and above the net effect also was small, namely an increase from 790 to 827 (+4.4%). We conclude that the total number of deaths recorded as being due to IHD in Belfast was reasonably accurate. While 76% of deaths registered under ICD Nos 410-414 had been coded by ICD No 410 (acute myocardial infarction) only 19% of all deaths due to IHD could be classified as definite myocardial infarction using World Health Organization criteria.     

An audit of clinical nurse practitioner led thrombolysis to improve the treatment of acute myocardial infarction

BACKGROUND: The aim of the study was to audit the impact of cardiac nurse practitioner led thrombolysis as a method of reducing call to needle times for acute myocardial infarction (AMI) in a single district hospital. METHODS: This was a prospectively planned, observational study, comparing time delay between arrival at hospital and the administration of thrombolysis ('door to needle' time) in patients presenting with AMI in a district general hospital serving a population of 270000. The 6 months before and 6 months after initiation of the scheme were compared. RESULTS: There were 151 consecutive patients (undergoing 163 thrombolysis episodes). The median door to needle time fell from 60 min (range 42-110 min) to 30 min (range 20-61 min) (p<0.01). In those patients eligible for immediate thrombolysis the number of cases treated within 30 min of arrival rose from 10/58 (17 per cent) to 48/64 (75 per cent) (p<0.01). The proportion of cases where there was an initial delay as a result of non-diagnostic ECG or possible contra-indication to therapy remained constant, 20/78 (25 per cent) cases before and 21/85 (25 per cent) cases after initiation of the scheme. The number of cases of inappropriate thrombolysis fell from 73 per cent to 30 per cent. CONCLUSION: The provision of i.v. thrombolysis by cardiac nurse practitioners is safe and should be considered as a method for achieving acceptable door to needle times in the management of acute myocardial infarction.     

Seasonal variation of deaths from fatal myocardial infarction,primary cardiac arrest,sudden cardiac death,and refractory congestive heart failure in older persons living in New York City

OBJECTIVE: To investigate if there is seasonal variation in cardiac deaths in older persons living in a nursing home in New York City. DESIGN: In a prospective study, the major clinical cause of death of all persons aged 60 years and older residing in a nursing home in New York City during a 15-year period was investigated. The author carefully reviewed the major cause of death with the physicians taking care of all persons who died in the nursing home or after transfer to a general hospital. We investigated whether there was seasonal variation in deaths from either fatal myocardial infarction, primary cardiac arrest, sudden cardiac death, or refractory congestive heart failure. SETTING: A large nursing home in which 1265 older persons died of fatal myocardial infarction, primary cardiac arrest, sudden cardiac death, or refractory congestive heart failure during a 15-year period. PATIENTS: The 1265 persons who died from cardiac causes included 410 men and 855 women, mean age 83 +/- 8 years at the time of death. MEASUREMENTS AND MAIN RESULTS: During a 15-year period, 1265 older persons died of fatal myocardial infarction, primary cardiac arrest, sudden cardiac death, or refractory congestive heart failure. Cardiac deaths occurred from December through March in 497 of 1265 persons (39%), from April through July in 378 of 1265 persons (30%), and from August through November in 390 of 1265 persons (31%). The frequency of cardiac deaths was significantly greater between December and March (P < 0.001). The incidence of cardiac deaths between December and March was 1.29 times greater than the average of the incidence of cardiac deaths during the two other 4-month periods. CONCLUSION: The frequency of cardiac deaths in older persons living in a nursing home in New York City significantly increased 1.29 times during the period December through March compared with the average of the two other 4-month periods (P < 0.001).     

The relation between serum albumin levels and risk of coronary heart disease in the Multiple Risk Factor Intervention Trial.

The relation between serum albumin levels and subsequent incidence of myocardial infarction and coronary heart disease deaths was evaluated using stored serum from the Multiple Risk Factor Intervention Trial (MRFIT). There were 91 coronary heart disease deaths, 113 myocardial infarction patients, and 405 controls matched to cases within 5 years of age, treatment group, and clinic site. There was a highly significant inverse relation between serum albumin level and risk of coronary heart disease. Individuals with a baseline level of serum albumin greater than or equal to 4.7 g/dl had an odds ratio of 0.45 as compared with individuals with a baseline level of serum albumin less than 4.4 g/dl. The relation persisted after adjusting for other cardiovascular risk factors (blood pressure, smoking, and serum cholesterol). The association was stronger for coronary heart disease deaths than for surviving myocardial infarction patients, and for cigarette smokers as compared with cigarette nonsmokers. The deaths studied occurred in the time period at least 6 years after the sera had been obtained and up to 10.5 years of follow-up, and the myocardial infarctions studied occurred within the first 6.5 years of follow-up. There was no consistent relation between time and death due to coronary heart disease or myocardial infarction and albumin levels. Albumin levels are related to the acute phase reaction. Lower albumin levels may be a marker of persistent injury to arteries and progression of atherosclerosis and thrombosis. The consistent relation between albumin and coronary heart disease risk requires further evaluation.     

Silent myocardial infarction

INTRODUCTION: By autopsies of patients expired from different diseases not rarely chronic myocardial infarction is found, that was known before neither to patient nor to medical attendant (silent myocardial infarction) and is interpreted as incidental finding. AIM: Study of frequency, role in expectation of life, diagnosis and prognosis of silent myocardial infarction in relation to localisation. METHODS: Retrospective study and statistical analysis of 1568 autopsies performed during 10 years. RESULTS: Acute or chronic myocardial infarction was found in 470 cases (30%), acute infarction in 177 cases (37%), 90% of which was diagnosed in vivo and patients died of infarction and its direct complications. In 293 cases (63%) chronic myocardial infarction was found, 109 cases (37%) were known and 184 cases (63%) were silent myocardial necrosis, the ratio of female/male patients was nearly the same (90/94 persons). 97 patients (32%) with chronic myocardial infarction died of cardiac cause - mostly in cardiac failure -, 196 (68%) of extracardiac cause, most of them of stroke, predominantly the patients with inferior infarction. CONCLUSION: Considering the silent causes, the myocardial infarction is more frequent and has better prognosis, than it is known from epidemiological data without autopsies, because 42% of these patients dies of extracardiac diseases, and the continuity of life is not shorter, than by patients without myocardial infarction. Knowledge of silent infarction gives possibility to estimate the physical charge of patients, their treatment and to prevent recurrence.