Molly L. Osborne

An Official American Thoracic Society Clinical Policy Statement: Palliative Care for Patients with Respiratory Diseases and Critical Illnesses

Executive Summary Introduction Methods Goals, Timing, and Settings for Palliative Care Decision-making Process Advance Directives Care Planning and Delivery Hospice Care Alternative End-of-Life Decisions Symptom Management Dyspnea Management Pain Management Management of Psychological and Spiritual Distress and Suffering Withdrawal of Mechanical Ventilation Process of Decision Making Process of Withdrawing Mechanical Ventilation Bereavement Care Barriers to Palliative Care Program Development, Education, Training, and Research in Palliative Care

Pneumoperitoneum: a review of nonsurgical causes.

Objective To review causes of nonsurgical pneumoperitoneum (NSP), identify nonsurgical etiologies, and guide conservative management where appropriate. Data Source We conducted a computerized MEDLINE database search from 1970 to 1999 by using key words pneumoperitoneum and benign, nonsurgical, spontaneous, iatrogenic, barotrauma, pneumatosis, diaphragmatic defects, free air, mechanical ventilation, gynecologic, and pelvic. We identified 482 articles by using these keywords and reviewed all articles. Additional articles were identified and selectively reviewed by using key words laparotomy, laparoscopy, and complications. Study Selection We reviewed all case reports and reviews of NSP, defined as pneumoperitoneum that was successfully managed by observation and supportive care alone or that required a nondiagnostic laparotomy. Data Synthesis Each unique cause of nonsurgical pneumoperitoneum was recorded. When available, data on nondiagnostic exploratory laparotomies were noted. Case reports were organized by route of introduction of air into the abdominal cavity: abdominal, thoracic, gynecologic, and idiopathic. Conclusions Most cases of NSP occurred as a procedural complication or as a complication of medical intervention. The most common abdominal etiology of NSP was retained postoperative air (prevalence 25% to 60%). NSP occurred frequently after peritoneal dialysis catheter placement (prevalence 10% to 34%) and after gastrointestinal endoscopic procedures (prevalence 0.3% to 25%, varying by procedure). The most common thoracic causes included mechanical ventilation, cardiopulmonary resuscitation, and pneumothorax. One hundred ninety-six case reports of NSP were recorded, of which 45 involved surgical exploration without evidence of perforated viscus. The clinician should maintain a high index of suspicion for nonsurgical causes of pneumoperitoneum and should recognize that conservative management may be indicated in many cases.

Smoking Cessation in Primary Care Clinics

AbstractOBJECTIVES: To document smoking cessation rates achieved by applying the 1996 Agency for Health Care Policy and Research (AHCPR) smoking cessation guidelines for primary care clinics, compare these quit rates with historical results, and determine if quit rates improve with an additional motivational intervention that includes education as well as spirometry and carbon monoxide measurements. DESIGN: Randomized clinical trial. SETTING: Two university-affiliated community primary care clinics. PATIENTS: Two hundred five smokers with routinely scheduled appointments. INTERVENTION: All smokers were given advice and support according to AHCPR guidelines. Half of the subjects received additional education with spirometry and carbon monoxide measurements. MEASUREMENTS AND MAIN RESULTS: Quit rate was evaluated at 9-month follow-up. Eleven percent of smokers were sustained quitters at follow-up. Sustained quit rate was no different for intervention and control groups (9% vs 14%; [OR] 0.6; 95% [CI] 0.2, 1.4). Nicotine replacement therapy was strongly associated with sustained cessation (OR 6.7; 95% CI 2.3, 19.6). Subjects without insurance were the least likely to use nicotine replacement therapy (p=.05). Historical data from previously published studies showed that 2% of smokers quit following physician advice, and additional support similar to AHCPR guidelines increased the quit rate to 5%. CONCLUSIONS: The sustained smoking cessation rate achieved by following AHCPR guidelines was 11% at 9 months, which compares favorably with historical results. Additional education with spirometry did not improve the quit rate. Nicotine replacement therapy was the strongest predictor of cessation, yet was used infrequently owing to cost. These findings support the use of AHCPR guidelines in primary care clinics, but do not support routine spirometry for motivating patients similar to those studied here.

Educational agendas for interdisciplinary end-of-life curricula.

The importance of an interdisciplinary end-of-life curricula for the intensive care unit is now recognized. Educational agendas for interdisciplinary end-of-life curricula are being developed across the United States. However, the limited database on palliative care education precludes evidence-based recommendations. Through a case-based approach, the need for an interdisciplinary team is explored, including the definition of an interdisciplinary team and the step-wise incorporation of specific members, such as physicians, nurses, social workers, and the chaplain, as patient care evolves. Core competencies for end-of-life care are enumerated including the approaches to end-of-life care, ethical and legal constraints, symptom management, specific end-of-life syndromes/palliative crises, and development of communication skills for trusting relationships. Finally, four phases of ICU management of curative and comfort care are proposed: phase I, focus on checklist for transfer; phase II, focus on life-saving treatments; phase III, focus on the “whole” patient; and phase IV, focus on palliative care.

Twenty year trends in hospital discharges for asthma among members of a health maintenance organization

We examined trends in hospitalizations for asthma from 1967 to 1987 among members of a large health maintenance organization. During this time asthma discharges increased significantly among children, and especially among boys under the age of 5 years. Ninety-five percent of the increase in discharges among boys was explained by a corresponding increase in the number of boys who were hospitalized. Increased readmissions did not account for the rise. Changes in the International Classification of Diseases coding of asthma and diagnostic shift by physicians accounted for only part of the increase. A decline in hospitalizations since 1984 may reflect changes in the management of asthma in the emergency room and not a decline in severe asthma episodes.

Recruiting hard-to-reach subjects: Is it worth the effort?☆

Little information is available on the utility of spending resources to recruit hard-to-reach subjects. In particular, the compliance of such subjects with study protocols and visit schedules has not been documented. We present recruitment data from a two-phase survey of asthma prevalence in which a subset of respondents to a brief screening survey was recruited to attend a 90-min clinic visit. Although 39% of phase I subjects responding to initial contact attempts participated in the second phase of the study, this dropped to 12% among those responding to the sixth contact attempt (a phone follow-up). In studies in which the representatives of the sample is not of paramount importance, we see little benefit in aggressively seeking to recruit hard-to-reach subjects.

Guideline funding and conflicts of interest: article 4 in Integrating and coordinating efforts in COPD guideline development. An official ATS/ERS workshop report.

INTRODUCTION Professional societies, like many other organizations around the world, have recognized the need to use more rigorous processes to ensure that healthcare recommendations are informed by the best available research evidence. This is the fourth of a series of 14 articles prepared to advise guideline developers in respiratory and other disease. It focuses on commercial funding of guidelines and managing conflict of interest effectively in the context of guidelines. METHODS In this review, we addressed the following topics and questions. (1) How are clinical practice guidelines funded? (2) What are the risks associated with commercial sponsorship of guidelines? (3) What relationships should guideline committee members be required to disclose? (4) What is the most efficient way to obtain complete and accurate disclosures? (5) How should disclosures be publicly shared? (6) When do relationships require management? (7) How should individual conflicts of interest be managed? (8) How could conflict of interest policies be enforced? The literature review included a search of PubMed and other databases for existing systematic reviews and relevant methodological research. Our conclusions are based on available evidence, consideration of what guideline developers are doing, and workshop discussions. RESULTS AND DISCUSSION Professional societies often depend on industry funding to support clinical practice guideline development. In addition, members of guideline committees frequently have financial relationships with commercial entities, are invested in their intellectual work, or have conflicts related to clinical revenue streams. No systematic reviews or other rigorous evidence regarding best practices for funding models, disclosure mechanisms, management strategies, or enforcement presently exist, but the panel drew several conclusions that could improve transparency and process.

Endothelium-dependent effects of cigarette smoke components on tone of porcine intrapulmonary arteries in vitro☆

The acute effects of cigarette smoking on the pulmonary vasculature are poorly understood--both vasodilatory and vasoconstrictive effects have been described. To investigate the mechanisms involved, strips of pig intrapulmonary arteries with and without intact endothelium were exposed to an extract of cigarette smoke made by bubbling smoke through phosphate-buffered saline. After contraction with norepinephrine (2.5 X 10(-7) M), smoke extract (concentration range 0.001 to 0.5%) caused a biphasic response in strips with intact endothelium--relaxation at lower concentrations and contraction at higher concentrations. Both relaxation and contraction responses were absent in strips without endothelium. Blockade of muscarinic, beta adrenergic, serotonergic, and histamine type 1 and 2 receptors did not alter the effects. Indomethacin (5 X 10(-6) M) or acetylsalicylic acid (10(-4) M) blocked the relaxation but not contraction effects of smoke extract, suggesting that relaxation was due to cyclooxygenase products of arachidonic acid. Nicotine caused endothelium-dependent contraction of intrapulmonary arteries and the contractile effects of both nicotine and smoke extract were blocked by hexamethonium (10(-6) M). However, the contractile effects of cigarette smoke components are more potent than those of nicotine. These findings help explain previously described acute effects of smoking on the pulmonary vasculature and provide insight into the mechanisms involved.

Self-Reported Food Reactions and Their Associations with Asthma

The role of food reactions in asthma has not been well described. The objectives of this study were to evaluate the types of self-reported reactions to foods in asthmatic patients, and to determine the association between self-reported food reactions and self-reported severity of asthma and asthma health care utilization. We characterized 914 patients, aged 3-55 years, in a large health maintenance organization. We characterized the patients according to demographic data (age, sex, occupation, SES, marital status) and their asthma according to duration, triggers, severity (symptoms, FEVJ percentage predicted) and presence of atopy, Overall, 414 (45.3%) participants, primarily women, reported adverse reactions to food, particularly milk, red wine, eggs, chocolate, and peanuts. Those with food reactions were more likely to report having ever been hospitalized for breathing problems than those without food reactions (31% vs. 22%, two-tailedp = 0.004) although theirasthma was not worse. Self-reportedfood reactions, particularly in females, may be associated with increased asthma health care utilization, and such patients may require closer health care management.

Clinical experiences of medical students in Oregon with dying patients.

BACKGROUND In Oregon only 31% of patients now die in acute care hospitals. This transformation carries profound implications for undergraduate medical education. METHODS Students graduating from Oregon Health Sciences University between 1996 and 1998 were surveyed regarding their direct clinical involvement in the care of dying patients. RESULTS Students had cared for substantial numbers of dying patients, and nearly all had participated in important advance planning discussions. However, student involvement had diminished markedly towards the latter stages of dying. Forty-five percent of the students had cared for two or fewer patients who died while still in the hospital. Even when patients died in the hospital, the students had rarely been present at the bedside at the time of patient death. Forty-two percent of the students had graduated having never witnessed a patient death. CONCLUSIONS The findings highlight the need to create opportunities for students to care for dying patients in settings outside the acute care hospital.