Disclosing Medical Errors to Patients: It’s Not What You Say, It’s What They Hear

BACKGROUND  There is consensus that patients should be told if they are injured by medical care. However, there is little information on how they react to different methods of disclosure. OBJECTIVE  To determine if volunteers’ reactions to videos of physicians disclosing adverse events are related to the physician apologizing and accepting responsibility. DESIGN  Survey of viewers randomized to watch videos of disclosures of three adverse events (missed mammogram, chemotherapy overdose, delay in surgical therapy) with designed variations in extent of apology (full, non-specific, none) and acceptance of responsibility (full, none). PARTICIPANTS  Adult volunteer sample from the general community in Baltimore. MEASUREMENTS  Viewer evaluations of physicians in the videos using standardized scales. RESULTS  Of 200 volunteers, 50% were <40 years, 25% were female, 80% were African American, and 50% had completed high school. For designed variations, scores were non-significantly higher for full apology/responsibility, and lower for no apology/no responsibility. Perceived apology or responsibility was related to significantly higher ratings (chi-square, 81% vs. 38% trusted; 56% vs. 27% would refer, p < 0.05), but inclination to sue was unchanged (43% vs. 47%). In logistic regression analyses adjusting for age, gender, race and education, perceived apology and perceived responsibility were independently related to higher ratings for all measures. Inclination to sue was reduced non-significantly. CONCLUSIONS  Patients will probably respond more favorably to physicians who apologize and accept responsibility for medical errors than those who do not apologize or give ambiguous responses. Patient perceptions of what is said may be more important than what is actually said. Desire to sue may not be affected despite a full apology and acceptance of responsibility. Presented in part at the 28th Annual Meeting of the Society for General Internal Medicine, New Orleans, LA, May 11–14, 2005     

HERPES SIMPLEX ESOPHAGITIS IN THE ELDERLY

Herpes simplex esophagitis (HSE) occurs mostly in immunocompromised patients and rarely in immunocompetent patients. We encountered an elderly patient, a biologically immunocompromised patient with HSE who had characteristic endoscopic features and responded to acyclovir therapy. An 82‐year‐old woman presented with high‐grade fever and epigastric discomfort for several days. A diagnosis of bacterial pneumonia was made based on imaging studies and cultures. Despite antibiotic treatment, epigastric discomfort persisted. Endoscopy revealed multiple exudative and circumscribed shallow ulcers with slightly raised edges in the mid‐distal esophagus. Esophageal biopsy specimens showed multinucleated giant cells with Cowdry type A intranuclear inclusion bodies in epithelial cells, which were positive for herpes simplex virus‐type 1 DNA by polymerase chain reaction. Because a diagnosis of HSE was made, she was treated with acyclovir, resulting in esophageal mucosal healing. In elderly patients with esophageal symptoms, HSE should be considered.     

NO EVIDENCE FOR PATIENT‐TO‐PATIENT TRANSMISSION OF HEPATITIS C VIRUS DURING UPPER GASTROINTESTINAL ENDOSCOPY: MOLECULAR STUDIES ON THREE ACUTE HEPATITIS C PATIENTS

Background: The risk of patient‐to‐patient transmission of hepatitis C virus (HCV) during endoscopy remains controversial. Using molecular approaches, we examined the possibility of patient‐to‐patient transmission of HCV in three patients who developed acute hepatitis C 1–6 months after examination by upper gastrointestinal endoscopy (UGIE) in a hospital endoscopy unit in Japan. Methods: For the source of HCV infection, we used frozen sera obtained from potential candidates who underwent UGIE earlier than three index patients on the same days in the same unit. HCV genotype was determined by multiplex polymerase chain reaction (PCR) with genotype‐specific primers. The 1087‐nucleotide (nt) sequence of the NS5B region of the HCV genome was compared between index patients and their HCV‐viremic candidates. Results: The three index patients were exclusively infected with HCV of genotype 1b. Among a total of 60 candidate patients who underwent UGIE earlier than the index patients, 14 were positive for anti‐HCV, of whom 12 had detectable HCV‐RNA (1b, n = 9; 2a, n = 1; 2b, n = 2) on sera collected during each UGIE. Shared identity within the 1087‐nt NS5B sequence was less than 95.0% between index patients and HCV/1b‐infected candidates (n = 3, 1 and 5, respectively). None of the remaining 46 candidates who were negative for anti‐HCV at UGIE examination tested positive for HCV‐RNA, nor seroconverted to anti‐HCV on their sera, which most likely excludes the possibility of HCV viremia despite the anti‐HCV‐negative serology at UGIE examination. Conclusion: The present study suggests that patient‐to‐patient transmission of HCV during UGIE is infrequent.     

EEG delta band as a marker of brain damage in aphasic patients after recovery of language

In this study spectral delta percentage was used to assess both brain dysfunction/inhibition and functional linguistic impairment during different phases of word processing. To this aim, EEG delta amplitude was measured in 17 chronic non-fluent aphasic patients while engaged in three linguistic tasks: Orthographic, Phonological and Semantic. Average mapping of aphasics’ structural lesion showed core damage in the left cortical-subcortical perisylvian areas. Delta amplitude was overall significantly higher in aphasics with respect to matched controls, a result in line with the view that diaschisis/cortical inhibition persists to some extent also in the chronic phase. Analysis of regions of interest revealed a peak of delta activity in left perilesional EEG sites, posterior to the core damage where residual suffering tissue probably projects its dysfunctional activity. Time course of word processing showed in patients greater delta percentage/inhibition in the first interval after word offset in correspondence of which verbal working memory is engaged. The significant interaction including group and task factors points to greater left posterior inhibition in aphasics across all tasks and left vs. right anterior relative disinhibition only during the Phonological task, whereas controls showed greater left vs. right disinhibition at anterior sites in all tasks. Delta band, in addition to its ability to reflect structural damage, was effective in the assessment of functional impairment as well as of linguistic reorganization of aphasics at hemispheric level with a spatial scalp distribution consistent with lesion map.     

ICU护士胸肺物理治疗能力的系统化培训

目的 探讨系统化培训对提高ICU护士胸肺物理治疗能力的作用.方法 对21名ICU护士进行胸肺物理治疗能力培训,包括理论和实践操作培训.结果 系统化培训后护士胸肺物理治疗能力及操作成绩显著提高(均P＜0.01).结论 系统化培训可在短期内提高ICU护士胸肺物理治疗能力和专科护理水平.