A shared treatment decision-making approach between patients with chronic conditions and their clinicians: the case of diabetes

In this paper, we discuss the Charles et al. approach to shared treatment decision-making (STDM) as applied to patients with chronic conditions and their clinicians. We perceive differences between the type of treatment decisions (e.g. end-of-life care, surgical treatment of cancer) that generated existing approaches of shared decision-making for acute care conditions (including the Charles et al. model) and the treatment decisions that patients with chronic conditions need to make and revisit on an ongoing basis. For instance, treatment decisions in the chronic care setting are more likely to require a more active patient role in carrying out the decision and to offer a longer window of opportunity to make decisions and to revisit and reverse them without important loss than acute care decisions. The latter may require minimal patient participation to realize, are often urgent, and may be irreversible. Given these differences, we explore the applicability of the Charles et al. model of STDM in the chronic care context, especially chronic care that relies heavily on patient self-management (e.g. diabetes). To apply the Charles et al. model in this clinical context, we suggest the need to emphasize the patient-clinician relationship as one of partners in making difficult treatment choices and to add a new component to the shared decision-making approach: the need for an ongoing partnership between the clinical team (not just the clinician) and the patient. In the last section of the paper, we explore potential healthcare system barriers to STDM in chronic care delivery. Throughout the discussion we identify areas for further research.     

Physician‐related facilitators and barriers to patient involvement in treatment decision making in early stage breast cancer: perspectives of physicians and patients

Objective To identify patients’ and physicians’ perceptions of physician‐related verbal and nonverbal facilitators and barriers to patient involvement in treatment decision making (TDM) occurring during clinical encounters for women with early stage breast cancer (ESBC). Methods Eligible women were offered treatment options including surgery and adjuvant therapy. Eligible physicians provided care for women with ESBC in either a teaching hospital or an academic cancer centre. In Phase 1, women were interviewed 1–2 weeks after their initial consultation. In Phase 2, women and their physicians were interviewed separately while watching their own consultation on a digital video disk. All interviews were audiotaped, transcribed and analysed. Results Forty women with ESBC and six physicians participated. Patients and physicians identified thirteen categories of physician facilitators of women’s involvement. Of these, seven categories were frequently identified by women: conveyed a rationale for patient involvement in TDM; explained the risk of cancer recurrence; explained treatment options; enhanced patient understanding of information; gave time for TDM; offered a treatment recommendation; and made women feel comfortable. Physicians described similar information‐giving facilitators but less often mentioned other facilitators. Few physician barriers to women’s involvement in TDM were identified. Conclusions Women with ESBC and cancer physicians shared some views of how physicians involve patients in TDM, although there were important differences. Physicians may underestimate the importance that women’s place on understanding the rationale for their involvement in TDM and on feeling comfortable during the consultation.     

Perturbation of endothelial functions by ionizing irradiation: effects on prostaglandins, chemoattractants and mitogens

Numerous studies have shown that early radiation injury is characterized by vascular damage and that the initial site of damage appears to be the EC lining of the vessel wall. Chronic irreversible tissue reactions to radiation include thrombotic occlusion of capillaries, enhanced atherosclerosis in larger vessels, inflammatory changes, and late tissue fibrosis. These processes may be mediated by endothelial products released as a result of cellular injury. Using EC cultures, we show that ionizing irradiation affects one of the major vascular defense mechanisms against platelet activation, thrombosis, and atherosclerosis--the capacity to produce PGI2. Dose- and time-related damage to enzymes of the arachidonic acid cascade were demonstrated. Radiation damage is associated with oxidant stress and production of free radicals. The oxygen radical scavenger, vitamin C, was found to protect the capacity of irradiated ECs to produce PGI2. Radiation injury often induces an acute inflammatory response. We found that irradiated ECs release a chemotactic factor for neutrophils, which is a lipid product of the lipoxygenase pathway. Late radiation-induced tissue fibrosis and the capacity of radiation to enhance arteriosclerosis may involve participation of mitogens released from perturbed and damaged ECs. We show that conditioned medium of irradiated ECs contain larger amounts of newly synthesized mitogens capable of stimulating the proliferation of fibroblasts, SMCs, and ECs. Hence, it may be assumed that the mitogenic activity released by irradiated ECs includes both PDGF and FGF-like mitogens.     

Circulating megakaryocytes: Delivery of large numbers of intact,mature megakaryocytes to the lungs

Abstract: To determine the locus of platelet production, we sought to determine if sufficient megakaryocytes reach the lungs in a state that could produce platelets. Elutriation was used to isolate megakaryocytes from blood reaching and leaving the lungs of 20 patients undergoing routine cardiac catheterizations. A mean of 5.0 intact megakaryocytes/ml were found in pulmonary artery blood, compared to only 0.5 megakaryocytes/ml, with partial cytoplasmic content, in aortic samples. The megakaryocytes in central venous and aortic samples were all mature. The identity of these cells as megakaryocytes, their maturity and normal morphology were confirmed by standard and immunoelectron microscopy. Cardiac outputs were obtained for each patient at the time of blood sampling, allowing an extrapolation that 40 × 10⁶ intact, mature megakaryocytes were being delivered to the lungs every day in the average patient, compared to only 4.0 × 10⁶ partially spent megakaryocytes exiting the lungs daily. About 98% of megakaryocyte cytoplasm reaching the lungs did not exit as recognizable megakaryocytes or fragments. The number and state of the megakaryocytes apparently filtered in the lungs is consistent with the hypothesis that megakaryocytes may shed platelets within the pulmonary microvasculature, which may be the primary site of platelet production.     

Acute Bronchospasm During Epidural Anesthesia in Asthmatic Patients

Bronchospasm is a well-recognized complication of general anesthesia. There is therefore a preference for regional anesthesia in those surgical patients suffering from asthma. Regional anesthesia avoids the administration of general anesthetics and intubation of the trachea which may initiate acute bronchospasm (1). The literature describes only a few rare cases of acute bronchospastic attack during epidural or spinal anesthesia (2).

We describe herein two cases of acute bronchospasm during epidural anesthesia for lower limb surgery.     

Familial relapsing thrombotic micro-angiopathy in two siblings

Abstract Two siblings, a 12-year-old girl and a 7-year-old boy, had recurrent episodes of haemolyticuraemic syndrome/thrombotic thrombocytopenic purpura, manifested mainly by thrombocytopenia and micro-angiopathic haemolytic anaemia. During 11 years of follow up the girl responded only to steroids, whereas many other therapeutic modalities were ineffective. Following treatment with low dose danazol relapses became fewer and of diminished severity and completely subsided after 6 months. The boy started his illness with signs of haemolytic uraemic syndrome and later developed neurological manifestations. During a 6 year follow up he responded only to plasma exchange. Althouth chronic thrombocytopenia persisted during the past 3 years, the boy's clinical condition improved.Conclusion A family with two children with recurrent episodes of thrombotic thrombocytopenic purpura is described. In one child danazol could have had a beneficial effect.     

Intracranial hemorrhage in patients with hemophilia

Intracranial hemorrhage (ICH) is a life-threatening complication of hemophilia. Seven of the 288 hemophiliacs living in Israel suffered eight episodes of ICH during the years 1972 to 1982. All episodes occurred in hemophilia A patients, with a higher incidence among patients with factor VIII inhibitor. Diagnosis was confirmed by computed tomographic scan in seven of the eight episodes. Four of the 7 patients died despite adequate factor replacement and supportive therapy, probably due to a conservative and hesitant neurosurgical approach. The correction of factor VIII to hemostatic level alone is inadequate in the majority of cases, and there is sudden deterioration in the patient's condition and death. Operation is strongly recommended when no improvement is noted within a few hours.     

Use of low-dose neostigmine intravenously in the treatment of supraventricular tachycardia: an immediate bradycardic effect

Neostigmine was first used 50 years ago to treat sinus tachycardia and paroxysmal auricular tachycardia. Then there were reports of successful treatment by neostigmine of other forms of supraventricular tachycardias. However, reports of sudden death using neostigmine for reversal of neuromuscular blockade at the end of an operation, which were not properly treated with atropine abandoned the use of neostigmine as an antiarrhythmic drug. Low-dose neostigmine intravenously was used in the treatment of supraventricular tachycardia in three patients described herein. It gave an immediate bradycardic effect in all three patients. The use of a low-dose neostigmine intravenously for an immediate treatment of supraventricular tachycardia is a novel suggestion. It has to be further evaluated and compared to the conventional drugs used like digoxin, verapamil, propranolol or esmolol.