Factors affecting physicians' decisions on caring for an incompetent elderly patient: an international study.

OBJECTIVES: To determine what treatment decisions physicians will make when faced with a hypothetical incompetent elderly patient with life-threatening gastrointestinal bleeding and to examine the relative importance of physician characteristics and factors (legal and ethical concerns, hospital costs, level of dementia, patient's age, physician's religion, patient's wishes and family's wishes) in making those decisions. DESIGN: Survey. SETTING: Family practice, medical and geriatrics rounds in academic medical centres and community hospitals in seven countries. PARTICIPANTS: Physicians who regularly cared for incompetent elderly patients. MAIN OUTCOME MEASURES: A self-administered questionnaire describing the elderly patient. Respondents were asked to choose one of four levels of care and to identify the level of importance factors had in making that decision. Older physicians, those less concerned about litigation, those for whom the level of dementia was important and those for whom the patient's age was important were expected to give less aggressive care than the other physicians. MAIN RESULTS: Supportive care was chosen by 8.1% of the respondents, limited therapeutic care by 41.5%, maximum therapeutic care without admission to the intensive care unit (ICU) by 32.2% and maximum care with admission to the ICU by 18.2%. The patient's wishes were reported by 91.0% as being extremely or very important in choosing the treatment. Stepwise logistic regression analysis revealed that the following variables independently predicted the level of treatment: level of dementia, country of residence, duration of practice, legal concerns, patient's age and ethical concerns. These factors were significantly correlated with the physicians' treatment choices (p less than 0.05). CONCLUSIONS: The importance that the physicians placed on the level of dementia was the strongest predictor of the level of care that would be provided. A societal consensus on the influence of cognitive function on the appropriate level of care as well as training of physicians in ethical issues are required.     

Nonepileptic Posttraumatic Seizures

Summary: Purpose: Epileptic posttraumatic seizures (PTSs) are a well-recognized consequence of head injury (HI), but HI and nonepileptic seizures (NESs) have not been related. We describe a significant subset of patients with NESs who had their seizures attributed to HI.
Methods: We reviewed the records of all patients diagnosed with NES at the University of Maryland Medical Center over a 6-year period (1989–1995) and selected patients with seizures attributed to a head injury occurring ≥3 years before the onset of their seizures.
Results: Of 157 patients with video-EEG confirmed NES, 37 (24%) had the onset of their seizures attributed to an HI. Their average age was 34 years (range, 15–56 years); 68% were women. Nonepileptic PTS usually developed within the first year after HI (89%). Convulsive symptoms were present in 54%. Whereas epileptic PTSs characteristically follow severe HI, the majority (78%) of our patients with nonepileptic PTSs sustained only mild HI. Before their HI, 76% of our patients were employed, working in the home, or students, but only 11% could continue those activities after developing nonepileptic PTSs.
Conclusions: Nonepileptic PTSs are frequently mistaken for epileptic PTSs and result in serious disability. The misdiagnosis of nonepileptic PTSs leads to ineffective and inappropriate treatment. Patients with intractable seizures after HIS, articularly mild HIS, should be carefully evaluated for NESs.     

Mitigating disparity in children with acute appendicitis: Impact of patient-driven protocols

PurposePrevious reports in the literature demonstrate racial and ethnic disparities for children diagnosed with acute appendicitis, with minorities experiencing worse outcomes. At our institution, we have developed an evidence based patient driven protocol for children following laparoscopic appendectomy. However, the influence of such protocol on mitigating racial and ethnic disparities in outcomes remains unknown. The purpose of our study is to assess the impact of our protocol by evaluating the influence of race and ethnicity on surgical outcomes among children treated for acute appendicitis.Material and methodsA retrospective review of prospectively collected data was conducted. Children undergoing a laparoscopic appendectomy at our freestanding children's hospital between December 2015 and July 2017 were included. Demographic data, post-operative length of stay, same day discharge rates and hospital readmission rates were abstracted from patient medical records. Patients were classified by their race and ethnic background. Comparative analysis was performed in STATA with a p value < .05 determined as significant.ResultsA total of 786 children were included, with the majority being either White (70%, n = 547), Black (8%, n = 62) or Hispanic (17%, n = 133); 569 patients (72%) were found to have non-perforated appendicitis. There was no statistically significant difference in the rates of same day discharge among White, Black or Hispanic children respectively (88% vs. 77% vs. 86%, p = .126). Of the 217 children with perforated appendicitis, Hispanic children had increased rates of perforation (41%, n = 55) compared to White and Black children respectively (23%, n = 128 and 29%, n = 18, p = .001). However, average post-operative length of stay were similar among White, Black and Hispanic children (96 h vs. 95 h vs. 98 h, p = .015). On multivariate analysis, the only significant risk factor for an elevated post-operative length of stay was the presence of a perforation.ConclusionOur evidence based patient driven protocol effectively mitigates racial and ethnic disparities found in children with acute appendicitis. Further prospective investigation into the role of such patient-driven protocols to mitigate healthcare disparities is warranted.Levels of EvidenceTherapeutic study; Level 3.     

Attitude,Willingness, and Associated Factors in Organ Donation Among Health Professionals in Gondar,Northwest Ethiopia

BackgroundOrgan transplantation is considered one of the greatest advances of modern science, and it has given many patients a renewed lease on life. The demand for organs far exceeds the supply. Health professionals are fundamental in the process of organ procurement.ObjectiveTo assess the attitude, willingness, and associated factors in organ donation among health professionals of Gondar, Ethiopia.MethodsOur cross-sectional study was conducted among 382 randomly selected health professionals in Gondar using a self-administered questionnaire. Multivariable logistic regression analysis was applied to analyze the data.ResultsAmong health professionals, 79.1% had favorable attitude toward organ donation and 74.6% were willing to donate their organs. After adjusting for covariates, the odds of having a favorable attitude about organ donation were 3.2 and 11.9 times higher in the professions of laboratory technologists and medical doctors, respectively. By keeping all other variables constant, attitude was found to be positively associated with awareness (adjusted odds ratio [aOR] 12.74, 95% confidence interval [CI] 3.71-43.8) and being a member of the Red Cross Association (aOR 5.24, 95% CI 1.46-18.96). Willingness was positively associated with awareness (aOR 6.25, 95% CI 2.0-19.53), a member of the Red Cross Association (aOR 5.09, 95% CI 1.5-17.22), a laboratory technologist (aOR 3.57, 95% CI 1.37-9.29), and a medical doctor (aOR 6.52, 95 % CI 1.93-22.01).ConclusionsThe main findings indicated that the majority of health professionals in Gondar had a favorable attitude toward organ donation and were willing to donate their organs in times of need.     

Novel multi-marker proteomics in phenotypically matched patients with ST-segment myocardial infarction: association with clinical outcomes

Journal of Thrombosis and Thrombolysis - Early prediction of significant morbidity or mortality in patients with acute ST-segment elevation myocardial infarction (STEMI) represents an unmet...     

An adolescent with significant emotional and medically unexplained complaints: case report and proposal of an intervention

Background

Ethiopia is a country in which child and adolescent mental health needs are often not met. In order to promote capacity building, a Collaborative International Exchange Programme has been established between Jimma University at Jimma, Ethiopia, and Ludwig-Maximilian University in Munich, Germany. The programme focuses on training non-physician health professionals in mental health speciality. One of the courses in the training programme, child psychiatry, involves a child psychiatrist and a children’s nurse supporting the management of a patient described in this case report. Its conceptual framework is based on the section “significant emotional and medically unexplained complaints” of the “WHO mental health GAP intervention guide for mental, neurological and substance use disorders in non-specialized health settings”.

Objective

The purpose of this case report is to promote confidence in mental health professionals when managing patients with similar conditions, and to stimulate further evaluation of the conceptual approach in developing countries.

Patient

The subject of this case report is a 14-year-old adolescent girl admitted to the psychiatric clinic at Jimma University Teaching Hospital. She was admitted for intractable retching, inability to eat, weight loss, and inability to walk. Challenges included the combination of medical and psychiatric symptoms, and the significant impairment of functioning in this adolescent. The first aim in the management of this patient was to guarantee vital functions. In a problem-oriented approach, different domains were addressed to restore nutritional, social, emotional, and motor functions. Treatment consisted of various elements of psychosocial interventions. The patient improved in 2 weeks and the final diagnosis was conversion disorder.

Conclusion

Psychosocial interventions can be developed in cooperation, and applied in a setting where little child mental health expertise is available. Case-based learning relying on local expertise is suitable in meeting local needs and in developing mental health services for children and adolescents.

     

Defaulters from antiretroviral treatment in Jimma University Specialized Hospital, Southwest Ethiopia

Objective To determine the prevalence of and factors associated with defaulting from antiretroviral treatment (ART) in Jimma, Ethiopia. Methods Unmatched case control study: cases were individuals who had missed two or more clinical appointments (i.e. had not been seen for the last 2 months) between January 2005 and February 2007; controls were individuals who had been on ART at least for 1 year and were rated as excellent adherers by the providers. Data were collected from patient records, and by telephone call and home visit to identify the reason for defaulting. Results Of 1270 patients who started ART, 915 (72.0%) were active ART users and 355 (28.0%) had missed two or more clinical appointments. The latter comprised 173 (13.6%) defaulters, 101 (8.0%) who transferred out, 75 (5.9%) who died, and 6 (0.5%) who restarted ART. Reasons for defaulting were unclear in most cases. Reasons given were loss of hope in medication, lack of food, mental illness, holy water, no money for transport, and other illnesses. Tracing was not successful because of incorrect address on the register in 61.6% of the cases. Taking hard drugs (cocaine, cannabis and IV drugs), excessive alcohol consumption, being bedridden, living outside Jimma town and having an HIV negative or unknown HIV status partner were associated with defaulting ART. Conclusion A significant proportion of patients defaulted from ART treatment. ART clinics should ensure that patients’ addresses are correct and complete. Programmatic and counseling efforts to decrease ART defaulting should address illicit drug and excessive alcohol use, decentralise ART services, institute home‐based treatment options for seriously ill and bedridden patients, and address patients concerns.     

Nucleotide sequences that distinguish Oka vaccine from parental Oka and other varicella-zoster virus isolates

The sequences of approximately 34 kb from the 3' end of the varicella-zoster virus (VZV) Oka vaccine strain and the previously sequenced Dumas strain were compared. Sequence differences were noted in the coding sequences of several VZV open reading frames (ORFs), including ORFs 48, 51, 52, 55, 56, 58, 59, 60, 62, 64, and 68. Tests based on differences in the ORF62 gene and in the ORF64 poly-A region successfully distinguished the Oka vaccine strain from its wild-type parent and from other Japanese and US clinical isolates. These changes remained stable after passage of the virus in humans.     

Evaluation of the mosquitocidal effect of Birbira (Mellitia ferruginea) seed extract against Anopheles arabiensis (Diptera: Culicidae) from Ethiopia

Mosquito control using insecticides has been the most successful intervention known to reduce malaria prevalence and/or incidence. However, over time success has been hampered due to the development of resistance by mosquitoes against chemical insecticides recommended for public health use. Development of effective botanical mosquitocidal compounds however can be potential alternatives tool in malaria vector control. Thus, the present study aimed at investigating the mosquitocidal effect of “Birbira” (Mellitia ferruginea) seed extract against the primary malaria vector, Anopheles arabiensis from Ethiopia. The mosquitocidal activity of M. ferruginea was assessed following WHO susceptibility test procedure. Methanol extract of M. ferruginea seeds was evaluated against third & fourth instar larvae, pupae and, non-blood fed 3–5 days old laboratory strains and field populations of A. arabiensis under laboratory condition. Mortality was then recorded after 24 h exposure. The seed extract of M. ferruginea showed high mosquitocidal activity against larvae, pupae and adult stages of both the laboratory strain and field population of A. arabiensis. The LC₅₀ values for larvae and pupae population from a laboratory strains was, respectively, 14.7 and 41.33 mg/L. While the LC₅₀ values for the larvae and a pupa of the field population were, respectively, 30.88 and 74.54 mg/L. In addition, the LC₉₉ and LD₉₉ values were also identified. The findings of this study indicated that, the extract could be applied on mosquito breeding sites. The plant extract could be also used for indoor residual sprays after conducting the persistency test.