Whose information is it anyway? Informing a 12-year-old patient of her terminal prognosis

OBJECTIVE: To examine students' attitudes and potential behaviour towards informing a 12-year-old patient of her terminal prognosis in a situation in which her parents do not wish her to be told, as they pass through a modern medical curriculum. DESIGN: A cohort study of students entering Glasgow University's new medical curriculum in October 1996. METHODS: Students' responses obtained before year 1 and at the end of years 1, 3, and 5 to the "childhood leukaemia" vignette of the Ethics in Health Care Survey Instrument (EHCI) were examined quantitatively and qualitatively. Analysis of the students' multichoice answers enabled measurement of the movement towards professional consensus opinion. An analysis of their written justifications for their answers helped to determine whether their reasoning was consistent with professional consensus and enabled measurement of changes in knowledge content and recognition of the values inherent in the vignette. Themes on the students' reasoning behind their decision to tell the patient or not were also identified. RESULTS: Unlike other vignettes of the EHCI in which autonomy was a main theme, few students chose the consensus answer before year 1 and there was no significant movement towards consensus at any point during the course. In defence of their decision to withhold information, the students expressed strong paternalistic opinions. The patient's age was seen as a barrier to respecting her autonomy. CONCLUSIONS: It is important to identify students' perceptions on entry to medical school. Transformative learning theory may provide the basis for an approach to foster doctors who consider the rights of young people. Small-group teaching is most conducive to this approach. The importance of positive role modelling is also emphasised.     

Do Intraoperative Total Serum and Ionized Calcium Levels, Like Intraoperative Intact PTH Levels, Correlate with Cure of Hyperparathyroidism?

Intraoperative parathyroid hormone (ioPTH) monitoring is useful in the operative management of hyperparathyroidism. Measurement of intraoperative total serum calcium (TSC) and ionized calcium (ICa) levels may be less expensive and more readily available methods of intraoperative guidance during neck dissection than ioPTH levels, the gold standard. We compared the accuracy of monitoring intraoperative TSC and ICa to that of ioPTH for predicting surgical cure during parathyroidectomy. Over a 10-month period, 47 parathyroidectomies were performed, during which ioPTH, TSC, and ICa were measured. Samples were obtained at the start of the operation and 5 and 10 minutes after gland removal. Data were compared and trends analyzed with respect to removal of abnormal parathyroid tissue as confirmed by pathology. The Wilcoxon signed rank test was used to determine if decreases in TSC and ICa were significant. The mean baseline ioPTH level (253 ± 247 pg/ml) dropped by 70% at 5 minutes after removal of the abnormal glands (68 ± 85 pg/ml) and by 83% at 10 minutes (32 ± 25 pg/ml). The mean baseline TSC level (10.1 ± 0.9 mg/dl) dropped by 4% at 5 minutes after removal of the abnormal glands (9.7 ± 0.8 mg/dl) and remained at 4% at 10 minutes (9.6 ± 0.7 mg/dl). The mean baseline ICa level (1.4 ± 0.1 mmol/dl) also dropped by 4% at 5 minutes after removal of the abnormal glands (1.3 ± 0.1 mmol/dl) and remained at 4% at 10 minutes (1.3 ± 0.1 mg/dl). ioPTH dropped by ≥ 50% in 39 patients (83%) at 5 minutes and in 46 patients (98%) at 10 minutes after gland resection. TSC decreased below baseline at 5 minutes and remained below baseline at 10 minutes in only 37 patients (79%). In the remaining 21% of patients, TSC decreased inconsistently, if at all, with respect to baseline at both the 5- and 10-minute time points. ICa decreased below baseline at 5 minutes and remained below baseline at 10 minutes in only 35 patients (77%). In the remaining 23% of patients, ICa, like TSC, changed inconsistently at 5 and 10 minutes after parathyroidectomy with respect to baseline levels. Decreases in TSC and ICa during parathyroidectomy, if present, are thus minimal. Unlike ioPTH levels, TSC and ICa levels do not consistently decrease at 5 and 10 minutes after gland resection. Although inexpensive and readily available, monitoring the intraoperative TSC and ICa is not clinically reliable for confirming removal of hyperfunctioning parathyroid glands.This work was presented at the International Association of Endocrine Surgeons Conference, Uppsala, Sweden, June 2004     

Control of lead and trail limbs during obstacle crossing following stroke

BACKGROUND AND PURPOSE: Obstacle crossing is compromised following stroke. The purpose of this study was to quantify modifications during obstacle clearance following stroke. SUBJECTS: Twelve subjects with stroke and 12 subjects without stroke participated in the study. METHODS: Kinematic variables were measured while participants crossed a 4-cm-high obstacle. Subjects with stroke walked at a self-selected speed; subjects without stroke walked at a comparable speed and at a self-selected speed. RESULTS: Several modifications were observed following stroke with both groups walking at self-selected speeds. The affected lead limb was positioned closer to the obstacle before crossing. Affected trail-limb clearance over the obstacle was reduced. Both affected and unaffected lead and trail limbs landed closer to the obstacle after clearance. Swing time was increased in the affected lead limb after obstacle clearance. Fewer modifications were detected at matched walking speed; the trail limb still landed closer to the obstacle. DISCUSSION AND CONCLUSION: Modifications during obstacle crossing following stroke may be partly related to walking speed. The findings raise issues of safety because people with stroke demonstrated reduced clearance of a 4-cm obstacle and limb placement closer to the obstacle after clearance.     

A novel role for tachykinin neurokinin-3 receptors in regulation of human bronchial Ganglia neurons

The neuropeptide tachykinins and their receptors have been implicated in the pathogenesis of lung disease, although the role of the tachykinin neurokinin-3 receptor has not been elucidated. Using confocal microscopy, we identified tachykinin neurokinin-3 receptors on human bronchial parasympathetic ganglion neurons. Electrophysiologic recordings demonstrated that activation of sensory nerve fibers, either by antidromic stimulation or capsaicin, depolarized these neurons. This response was mimicked by exogenously applied tachykinin neurokinin-3 receptor-selective agonist, senktide analogue, but not significantly by tachykinin neurokinin-1 or neurokinin-2 receptor-selective agonists. Responses to endogenous tachykinins or exogenous selective tachykinin neurokinin-3 receptor activation with senktide analogue were inhibited by the selective tachykinin neurokinin-3 receptor antagonists, SB 223412 or SB 235375. We provide the first evidence that tachykinin neurokinin-3 receptors regulate human bronchial parasympathetic ganglion neurotransmission by activation of a peripheral reflex. This pathway may play a significant role in controlling bronchomotor tone and air flow to the lung.     

Moderate chronic pain, weight and dietary intake in African-American adult patients with sickle cell disease

In this exploratory study, we evaluated weight status and dietary intake patterns during painful episodes in adult patients with SCD. Specifically, we explored the relation between pain severity and body mass index (BMI), and we tested the hypothesis that dietary intake would be reduced and dietary content altered during periods of increased pain. We conducted an analysis of survey data from 62 patients involved in a longitudinal evaluation of the relationship of medical and psychosocial factors to pain. Nearly half of patients with SCD were overweight, and 20% were obese. BMI was positively related to interference associated with pain. Although BMI was not statistically associated with reported pain severity, >40% of patients reported that they perceived their pain to be affected by their weight. Less than 20% of patients reported that they perceived that their weight affected their pain. Regarding dietary patterns, the majority of patients reported eating less during episodes of pain and significantly decreasing their intake of fats and proteins. We conclude that there is a need to better understand the relation among weight, dietary patterns and pain in patients with SCD in order to provide patients with accurate education and effective treatment recommendations for managing their disease and reducing current and future risks of lifestyle and disease-related morbidities.     

Can students' reasons for choosing set answers to ethical vignettes be reliably rated? Development and testing of a method

Although ethics is an important part of modern curricula, measures of students' ethical disposition have not been easy to develop. A potential method is to assess students' written justifications for selecting one option from a preset range of answers to vignettes and compare these justifications with predetermined 'expert' consensus. We describe the development of and reliability estimation for such a method -- the Ethics in Health Care Instrument (EHCI). Seven raters classified the responses of ten subjects to nine vignettes, on two occasions. The first stage of analysis involved raters' judging how consistent with consensus were subjects' justifications using generalizability theory, and then rating consensus responses on the action justification and values recognition hierarchies. The inter-rater reliability was 0.39 for the initial rating. Differential performance on questions was identified as the largest source of variance. Hence reliability was investigated also for students' total scores over the nine consensus vignettes. Rater effects were the largest source of variance identified. Examination of rater performance showed lack of rater consistency. D-studies were performed which showed acceptable reliability could nevertheless be obtained using four raters per EHCI. This study suggests that the EHCI has potential as an assessment instrument although further testing is required of all components of the methodology.     

Cancer‐related fatigue – a difference of opinion? Results of a multicentre survey of healthcare professionals,patients and caregivers

The objective of this study was to investigate the perceptions of patients with cancer, their caregivers and healthcare professionals (HCPs) about fatigue and its impact on quality of life. It was a cross-sectional survey, the respondents were patients with cancer attending three UK regional cancer centres ( n  = 1370), their informal caregivers ( n  = 1370) and a random selection of HCPs (oncologists/nurses/radiographers/haematologists; n  = 1098). The response rates for patients, caregivers and HCPs were 42%, 33% and 34% respectively. Fatigue was reported to affect 56% of patients and to have a considerable impact on quality of life. Caregivers also recognized that fatigue was a common problem, with significant effects on patients' quality of life and impact on themselves. Healthcare professionals recognized that fatigue was a common problem for their patients but overestimated its impact on some aspects of patients' daily lives. Although most HCPs reported that they prescribed/recommended treatment for over half of their patients, only 14% of patients reported receiving any such treatment. The most common advice was to take more rest and relaxation. Conclusions: patients with cancer report that fatigue is a common and distressing symptom and the importance of this symptom is generally recognized by both HCPs and lay-carers. Healthcare professionals need more information about the effectiveness of existing interventions for cancer-related fatigue and further research is required to improve the current management of this debilitating symptom.