Preconditions for and consequences of self-determination: the psychiatric patient's point of view

In the context of an interview study concerned with self-determination in psychiatric patients, this paper describes the preconditions for and consequences of self-determination from the point of view of psychiatric patients themselves. The data were collected in semi-structured interviews with long-term psychiatric patients ( n =72) and analysed using the method of content analysis. Responses on the preconditions for self-determination were grouped into three categories: firstly, there were those who said that reference to self-determination in the case of psychiatric patients is nonsense; secondly, there were those who said that self-determination requires no preconditions; and thirdly, there were those who said that there are certain preconditions, such as the ability to think and make decisions, activity, obedience, and illness. Both positive and negative consequences were identified in situations where self-determination is maintained, but only negative consequences in situations where self-determination is lost. On the basis of these tentative results, self-determination seemed to be relevant in psychiatric nursing. We are continuing to develop and test an instrument for the evaluation of the opportunity for self-determination in clinical practice.     

Retinopathy of prematurity in infants less than 29 weeks' gestation at birth

From January 1986 to December 1991 we examined the eyes of 206 infants born at Westmead Hospital, Neonatal Intensive Care Unit who were less than 29 weeks' gestation at birth to determine the incidence of retinopathy of prematurity. Eighty-five infants (41.3%) had no retinopathy of prematurity (ROP) in either eye, 82 infants had stages 1 or 2 ROP (39.8%), 29 had stage 3 ROP (14.1%) and 11 had stage 4 ROP (5.3%). Of these, cryotherapy was performed in 18; six now have bilateral retinal detachment and are blind The more severe stages of ROP were significantly associated with an increase in the number of days of oxygen supplementation, an increase in the number of days of mechanical ventilation and the presence of patent ductus arteriosus. Infants receiving steroids for mechanical ventilator dependence had a significantly greater chance of requiring cryotherapy (11 or 22 receiving steroids versus seven of 43 without steroids; P < 0.01).     

Evaluation of Tissue-Engineered Skin (Human Skin Substitute) and Secondary Intention Healing in the Treatment of Full Thickness Wounds after Mohs Micrographic or Excisional Surgery

BACKGROUND: Human Skin Substitute (Apligraf, Organogenesis, Inc., Canton, MA) is a bi-layered tissue-engineered living biological dressing developed from neonatal foreskin. It consists of a bovine collagen matrix containing human fibroblasts with an overlying sheet of stratified human epithelium containing living human keratinocytes. Human Skin Substitute (HSS) appears to be immunologically inert, and has shown usefulness in the treatment of chronic and acute wounds. OBJECTIVE: Primary objectives were to evaluate the safety and efficacy of HSS in the treatment of full-thickness wounds in a prospective case series. Secondary objectives were to determine the rate of complete wound reepithelialization, incidence of complete wound healing, pain at wound site, overall cosmetic outcome, and patient satisfaction. METHODS: Fourteen patients were enrolled in the study, of which 12 were evaluable. HSS was applied in a blinded fashion to 6 of the patients immediately following Mohs or excisional surgery for skin cancer. The remaining 6 patients were allowed to heal by secondary intention. Both groups were evaluated at weekly appointments until complete reepithelialization occurred. During each evaluation, wound quality was assessed through the Vancouver Burn Scar Assessment Scale by the investigator and an independent blinded dermatologist. The investigator, blinded observer, and patient further evaluated the cosmetic outcome of the wound through the use of a Visual Analog Scale over a 6-month period. RESULTS: HSS patients and secondary intention patients were equivalent in comorbid factors such as pain, erythema, edema, exudate, infection, or hematoma between the groups. The incidence of complete wound healing at 6 months was 100% for both groups. Both groups also appeared to heal at similar rates, as defined by the complete reepithelialization of the wound. HSS patients ultimately resulted in more pliable and less vascular wounds as defined by the Vancouver Burn Scar Assessment Scale. Patient satisfaction with cosmetic outcome in both groups was positive at 6 months. CONCLUSIONS: HSS appears to be a safe, well-tolerated biological dressing with equivalent comorbid factors to secondary intention healing. HSS, however, seems to produce a more pliable and less vascular scar than those developed through healing by secondary intention. HSS also appears to produce more satisfactory cosmetic results when compared to secondary intention healing.     

Tyramine-Induced cardiac arrhythmias

Five out of 12 physically healthy patients with depression undergoing a tyramine pressor test developed cardiac arrhythmias. These arrhythmias occurred in drug-free patients in three out of 12 infusions following as little as 0.03 mg/kg of tyramine and after moclobemide, a reversible inhibitor of monoamine oxidase-A, in four out of 14 tyramine infusions with as little as 0.04 mg/kg of tyramine. The arrhythmias seen were independent of patient's age and occurred both before and after 30 mmHg elevations in systolic blood pressure. Electrocardiographic abnormalities and arrhythmias seen were a loss of p waves, sinus tachycardia, frequent atrial ectopic beats, atrial premature beats, Wenckebach phenomenon, junctional rhythm, ventricular ectopics, varying QRS configurations, and ventricular bigeminy. Tyramine, both oral and intravenous, caused similar reproducible changes in dogs, though not in rats, mice or guinea pigs. Practical implications are that tyramine pressor testing in humans should be performed cautiously and only with adequate cardiac monitoring and resuscitation facilities at hand. These findings suggest that a normal dietary component can induce serious cardiac arrhythmias, and that a low-tyramine diet may be of value for patients who are susceptible to cardiac arrhythmias.     

Health Behavior Correlates of Depression in a Sample of High School Students

Frequency of symptoms of depression and selected health-related practices and events were measured in a sample of 219 high school students. Students reported numerous symptoms of depression. Relative proportions of boys and girls reporting symptoms of depression were not significantly different. However, girls reported experiencing more severe depression than their male counterparts. Depression correlated significantly with several of the 22 health practices and states of affect examined. Both the determinants and manifestations of depression in adolescent cohorts require in-depth investigation. Possible implications for school health personnel are discussed.     

The life situation of a long-term psychiatric patient: some restrictions in, and possibilities of, open care

This paper describes and analyses, from a sociocultural viewpoint, the ways of life of discharged long-term psychiatric patients in northern Finland The paper focuses on subjectivity control of life and fundamental experiences in life The data consist of interviews with 25 outpatients who have moved to live in residential homes, rehabilitation centres or their own homes after receiving preparatory training in the psychiatric hospital The findings suggest that the way of life of the outpatients did not significantly differ from that of other people belonging to the same generation of Finns With respect to control of life, a conspicuous feature was the strong tendency to let themselves be led by others, and to self-sacrifice for the good of others For the patients, independence was the best aspect of open care Fear for being branded as a psychiatric case or as a former mental patient threatened the patients'external control of life The central element of control of life of the Finns is work The outpatients thought work a matter of honour and they did not find their present, inactive way of life satisfactory     

Practice guidelines: the radiology perspective

Clinical practice guidelines have emerged as a reality for medical practitioners over the past 20 years. Although virtually all groups interested in the development of practice guidelines hope for improvements in patient care, secondary expectations vary widely among those using them. Their use in daily practice by physicians has met with resistance from barriers including concerns of “cookbook” medicine, a loss of autonomy, and increased professional liability. The recent experience of the ACR in addressing these challenges illustrates that physicians are receptive to steps perceived to mitigate the risks accompanying the use of guidelines as well as to efforts to increase their understanding of implementing guidelines in clinical practice. The experiences of other medical societies and an inventory of future trends reveal additional challenges associated with the use of practice guidelines, as third parties look to guidelines as points of reference for gauging the performance of health care providers.     

Factors Affecting Cardiac Catheterization Rates in Elders with Acute Coronary Syndromes

Background: Elder patients with acute coronary syndromes (ACS) are less likely to receive cardiac catheterization. The reasons for this are unclear.
Objectives: To assess whether elder patients who had a documented history of dementia, lived in extended care facilities, or had do not intubate–do not resuscitate (DNR-DNI) advance directives were less likely to receive cardiac catheterization, despite having ACS with high-risk features.
Methods: This was a medical record review conducted at an urban teaching hospital. DNR-DNI status before hospitalization, extended care facility (nursing home or assisted living) residence, and a previous diagnosis of dementia were obtained from the medical record. Patients 65 years and older who presented to the emergency department with acute myocardial infarction or with unstable angina with ST segment deviation were included. Univariate and multivariate logistic regression were performed, and odds ratios (ORs) were reported with their 95% confidence intervals (CIs).
Results: Of the 201 eligible patients, 66 (32.8%) patients did not undergo cardiac catheterization. In the univariate analysis, patients who had dementia, resided in extended care facilities, or were DNR-DNI were less likely to receive cardiac catheterization. Only extended care facility residence (OR, 0.18; 95% CI = 0.04 to 0.83) and DNR-DNI status (OR, 0.19; 95% CI = 0.04 to 0.92) remained significantly associated with decreased cardiac catheterization in the multivariate analysis.
Conclusions: Elder patients with ACS residing in extended care facilities or who are DNR-DNI are less likely to receive cardiac catheterization. Future studies concerning the quality of ACS care for elders should take these variables into account.