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Biomedical subjects

A J Cunningham

Publications and source records attributed to A J Cunningham.

138 records · Page 8Linked to original sources
PubMedDate not supplied

Delivering a very brief psychoeducational program to cancer patients and family members in a large group format.

It is well established that brief psychoeducational programs for cancer patients will significantly improve mean quality of life. As this kind of adjunctive treatment becomes integrated into general cancer management, it will be necessary to devise cost-effective and efficacious programs that can be offered to relatively large numbers of patients. We have developed a very brief 4-session program that provides this service to 40-80 patients and family members per month (and seems capable of serving much larger numbers, depending on the capacity of the facility in which they assemble). Patients meet in a hospital auditorium for a large group, lecture-style program that offers training in basic coping skills: stress management, relaxation training, thought monitoring and changing, mental imagery and goal setting. Over the first year we have treated 363 patients and 150 family members. Improvements were assessed by changes in the POMS-Short Form, and both patients and family members were found to improve significantly over the course of the program. While this is not a randomized comparison, it suggests that the benefits gained from a large group in a classroom are not substantially less than the improvements that have been documented in the usual small group format, where more interactive discussions are possible.

Adaptation, Psychological↗
PubMedDate not supplied

A prospective, longitudinal study of the relationship of psychological work to duration of survival in patients with metastatic cancer.

This study is a prospective, longitudinal investigation of the psychological factors associated with the duration of survival in patients with metastatic cancers of various kinds who were receiving group psychotherapy. A correlative approach rather than an experimental (trials) design was used in the study because our aim was to relate the psychological attributes of each individual to survival rather than to test the efficacy of the intervention. Twenty-two patients with medically incurable metastatic cancer of various kinds received weekly group psychotherapy for up to 1 year, the great majority remaining well enough to attend the group for at least 8 months. During this time, they provided extensive verbal data, through written homework, and from notes taken by the therapists at interviews and during group sessions. These data were subjected to detailed qualitative analysis, as a result of which a number of psychological themes were defined. A quantitative rating was assigned to the data for each theme in each individual patient through team discussions. The scores for the individual themes were summed to produce a 'total psychological score', representing the degree of each patient's involvement with psychological self-help work. The values for each patient were then related to his or her survival duration. Cox regression analyses showed that this composite score, and five of six major themes, were significantly related to survival duration. These themes were: ability to act and change; willingness to initiate change; application to self-help work; relationships with others; and quality of experience. In contrast, there was no relationship between survival and four standard psychometric measures taken at the onset of therapy. However, results on a 5-point scale measuring the subject's expectancy that psychological efforts would affect the disease showed a strong relationship to survival. To control for differences in severity of disease as a factor possibly influencing psychological work, the analyses were repeated, using the survival duration predicted for each patient by a panel of oncologists as a covariate. Closely similar results were obtained. Limitations on the interpretation of the results are discussed. Within these limits, it appears that there is a strong association between longer survival and psychological factors related to the involvement of cancer patients in psychological self-help activities. While causality cannot be inferred, reasons are given for believing that this is not a result of the disease influencing the patients' psychology, but rather the converse.

Adaptation, Psychological↗
PubMedDate not supplied

Preoperative evaluation of a patient for abdominal aortic aneurysm repair.

Coexistent cardiovascular disease is common in patients presenting for repair of aortic aneurysms. However, preoperative cardiac evaluation prior to abdominal aortic aneurysm (AAA) surgery remains contentious with significant variations in practice between countries, institutions and individual anesthetists. The following case report raises some everyday issues confronting clinical anesthetists.

Aged↗
PubMedDate not supplied

Anesthetic implications of laparoscopic surgery.

Minimally invasive therapy aims to minimize the trauma of any interventional process but still achieve a satisfactory therapeutic result. The development of "critical pathways," rapid mobilization and early feeding have contributed towards the goal of shorter hospital stay. This concept has been extended to include laparoscopic cholecystectomy and hernia repair. Reports have been published confirming the safety of same day discharge for the majority of patients. However, we would caution against overenthusiastic ambulatory laparoscopic cholecystectomy on the rational but unproven assumption that early discharge will lead to occasional delays in diagnosis and management of postoperative complications. Intraoperative complications of laparoscopic surgery are mostly due to traumatic injuries sustained during blind trocar insertion and physiologic changes associated with patient positioning and pneumoperitoneum creation. General anesthesia and controlled ventilation comprise the accepted anesthetic technique to reduce the increase in PaCO2. Investigators have recently documented the cardiorespiratory compromise associated with upper abdominal laparoscopic surgery, and particular emphasis is placed on careful perioperative monitoring of ASA III-IV patients during insufflation. Setting limits on the inflationary pressure is advised in these patients. Anesthesiologists must maintain a high index of suspicion for complications such as gas embolism, extraperitoneal insufflation and surgical emphysema, pneumothorax and pneumomediastinum. Postoperative nausea and vomiting are among the most common and distressing symptoms after laparoscopic surgery. A highly potent and selective 5-HT3 receptor antagonist, ondansetron, has proven to be an effective oral and IV prophylaxis against postoperative emesis in preliminary studies. Opioids remain an important component of the anesthesia technique, although the introduction of newer potent NSAIDs may diminish their use. A preoperative multimodal analgesic regimen involving skin infiltration with local anesthesia. NSAIDs to attenuate peripheral pain and opioids for central pain may reduce postoperative discomfort and expedite patient recovery/discharge. There is no conclusive evidence to demonstrate clinically significant effects of nitrous oxide on surgical conditions during laparoscopic cholecystectomy or on the incidence of postoperative emesis. Laparoscopic cholecystectomy has proven to be a major advance in the treatment of patients with symptomatic gallbladder disease.

Anesthesia↗
PubMedDate not supplied

Abdominal aortic surgery: anesthetic implications.

The objectives of the review are to highlight the clinical characteristics of the patient population; to assess multivariate risk factor analysis and the invasive/non-invasive techniques available for risk factor identification and management in this high-risk surgical population; to assess the major hemodynamic, metabolic, and regional blood flow changes associated with aortic cross-clamping/unclamping procedures and techniques for their modification or attenuation; and to assess the influence of perioperative anesthetic techniques and management on patient outcome.

Anesthesia↗
PubMedDate not supplied

Acute respiratory distress syndrome--two decades later.

Twenty years have now elapsed since Ashbaugh and Petty first described the syndrome of acute respiratory failure associated with a wide spectrum of clinical conditions. During the past two decades, significant advances have emerged in our understanding of the clinical conditions associated with the syndrome and the pathophysiological changes affecting the alveolar-capillary membrane responsible for the characteristic non-cardiogenic pulmonary edema. Recent data have reaffirmed the notion that mortality rates in ARDS remain in excess of 60 percent, essentially unchanged since the first description of the syndrome, despite all the advances in critical care medicine in the intervening years. The incidence of ARDS has been difficult to establish because of lack of agreement on precise definition criteria. The lack of agreed definition criteria has hampered evaluation of the natural history of the syndrome, its epidemiology and mortality rates, and the efficacy or otherwise of a variety of therapeutic interventions. This review will highlight a recent, clinically appropriate, expanded definition of ARDS. New understandings of the roles of sepsis and multi-system organ failure in mortality associated with ARDS will be discussed. Several mediators, both locally in the lung and in the systemic circulation, have been implicated in the pathophysiology of ARDS. This review will discuss the evidence for and against neutrophils, platelets, cytokines derived from mononuclear cells and macrophages, complement, prostaglandins/leukotrienes, oxygen-derived radicals, and a variety of proteases. Current treatment strategies for ARDS are designed to increase tissue oxygen delivery by increasing arterial oxygen tension and cardiac output while simultaneously attenuating the pulmonary and systemic injury by appropriate pharmacologic and surgical interventions. Recent data advocating pharmacological augmentation of cardiac index and oxygen delivery will be highlighted. The persistently high mortality rates of 60-70 percent in patients with established ARDS have provoked recurring interest in new techniques of providing mechanical ventilation. Most studies have shown, however, that mortality in ARDS patients is attributable mainly to sepsis and multi-system organ failure rather than primarily to respiratory failure. Established and speculative intervention to reduce sepsis and multi-system organ failure associated with ARDS will be featured in the review.

Adrenal Cortex Hormones↗
PubMedDate not supplied

Myocardial ischemia--association with perioperative cardiac morbidity.

The development of ambulatory electrocardiographic recorders and analysers and the application of transesophageal echocardiography in the mid-1980's enabled investigators to quantify and describe the occurrence of silent as well as symptomatic ischemia in the perioperative period. Several technical advances which have recently occurred in ECG monitoring include the use of miniaturized digital computing equipment to store and analyze data. In addition, real time ST-segment analysis has become widely available on multicomponent monitors in both the operating room and intensive care units. The incidence of perioperative myocardial ischemia depends on the patient population, the surgical procedure, and the monitoring technique used. Several studies in the early 1990's have shown that cardiac morbidity in patients undergoing major, noncardiac surgery is best predicted by postoperative myocardial ischemia, rather than tradition preoperative clinical predictors. Long duration postoperative ischemia may be the factor most significantly associated with adverse cardiac outcome. Postoperative pain, physiological and emotional stress may all combine to cause tachycardia, hypertension, increase in cardiac output, and fluid shifts which, in high risk patients, might result in subendocardial ischemia and eventual myocardial infarction. If postoperative myocardial ischemia is the cause of late postoperative myocardial infarction in patients undergoing non-cardiac surgery, then treatment of postoperative myocardial ischemia should reduce morbidity. In addition, reducing pain and stress and avoiding postoperative hypoxemia might prevent postoperative myocardial ischemia and minimize the need for extensive preoperative cardiac evaluation.

Electrocardiography↗
PubMedDate not supplied

Regional anesthesia for major vascular surgery.

The relative merits of general vs regional anesthesia for patients undergoing major vascular surgery has been the subject of debate over the past decade. Previous studies of regional vs general anesthesia often were deficient in experimental design and, therefore, did not produce definitive answers. Some of these deficiencies related to non-standardized, poorly conducted, and/or described general anesthetic techniques, nonstandardized methods of postoperative analgesia in the general anesthesia groups, and variations in preoperative cardiac status in the study groups. Furthermore, most studies did not conclusively demonstrate a cause and effect relationship between the proposed mechanisms of the beneficial effect of regional anesthesia and outcome. Recent studies, however, have claimed improvements in outcome following regional anesthesia in patients undergoing peripheral vascular procedures. The reported beneficial effects have included amelioration of the neuroendocrine stress response to surgery, improvement in pulmonary function, cardiovascular stability, enhancement of lower limb blood flow, reduction in the incidence of graft thrombosis, and a reduction in the thrombic response to surgery. Skeptics still question whether recent studies have the power to determine whether regional anesthesia decreases the incidence of cardiac and pulmonary complications following major vascular surgery. Furthermore, the issue of whether the beneficial effects of regional anesthesia on the incidence of graft thrombosis and the thrombotic response to surgery relating to intraoperative or postoperative regional anesthesia/analgesia, to regional anesthesia per se, or to the systemic effects of absorbed local anesthetics remains unresolved.

Anesthesia, Conduction↗
PubMedDate not supplied

Evolution in microcosm: the rapid somatic diversification of lymphocytes.

The characteristic task of the immune system is learning to respond specificially to entirely novel antigens. How it may do this is discussed under 6 headings. 1. -- Vertebrate and invertebrate immune strategies are contrasted. Whereas among invertebrates whole individuals appear to be selected for their immunological fitness, vertebrates have developed an internal population of lymphocytes among which variants arise and are selectively stimulated by antigen to give a response which protects the "host". 2. -- The genetic mechanism underlying this variation of lymphocytes is of great interest, but its discovery will not, given present ignorance of eukarote DNA, answer those questions about variation at the phenotypic level which are vital to the rest of immunology: e.g. when, how fast, and under what conditions do variantes arise? 3. -- A great deal of indirect evidence suggests that the production of entirely new variant lymphocytes occurs throughout life, particularly after antigenic stimulation. 4. -- Experimental approaches are discussed which might provide direct evidence for or against the idea of rapid variation among stimulated lymphocytes. The method used was based on detecting the cross-reactive specificity of antibody produced by single cells. 5. -- Evidence obtained with this technique is briefly described. There were two main kinds of experiment. In the first, rapid variation (at the rate of about one variation event per 30 divisions) was demonstrated within single clones of proliferating antibody-forming cells. In the second group of experiments, it was shown that certain uncommon antibody-forming cell specificities present at the peak of a primary response were entirely absent at earlier stages. 6. -- A new immunological paradigm may emerge from work on the generation of diversity and on active control of response. There may be relatively few types of lymphocytes with germ-line-coded receptors. These are stimulated by environmental antigens and mitogens, and perhaps by self stimulated by environmental antigens and mitogens, and perhaps by self antigens. Extensive proliferation and variation occurs, which in turn elicits suppressor reactions directed against antigen or against idiotypes of responding clones. The immune repertoire of the adult vertebrate is a product of the evolution of its lymphocytes under the competing pressures of antigenic stimulation and active suppression.

Aging↗