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Biomedical subjects

B Lo

Publications and source records attributed to B Lo.

At least 91 records · Page 5Linked to original sources
PubMed1990

Counseling patients seropositive for human immunodeficiency virus. An approach for medical practice.

Persons at risk for infection with the human immunodeficiency virus are being encouraged to learn their serostatus. While such knowledge can help patients seek appropriate medical care, it can also be distressing. We describe an approach, based on crisis counseling, for physicians to use in working with patients infected with HIV. It can help physicians in assisting patients with emotional reactions to the diagnosis as well as in directing patients to manage practical issues of concern. Methods for discussing safer sex or injection practices are also presented.

Adaptation, Psychological↗
PubMed1989

Decisions about resuscitation: inequities among patients with different diseases but similar prognoses.

STUDY OBJECTIVE: To assess whether decisions about "do-not-resuscitate" (DNR) orders are made equitably in patients with different diseases but similar prognoses. DESIGN: Retrospective cohort study. SETTING: Three teaching hospitals: a university referral center, a county hospital serving a largely indigent population, and a Veterans Administration hospital. PATIENTS: Consecutive patients with any of the four following discharge diagnoses: the acquired immunodeficiency syndrome (AIDS) (100 patients); unresectable non-small-cell lung cancer (51 patients); cirrhosis with esophageal varices (51 patients); and severe congestive heart failure with coronary artery disease (115 patients). MEASUREMENTS AND MAIN RESULTS: Do-not-resuscitate orders were written for 52% of patients with AIDS and 47% of patients with cancer but for only 16% of patients with cirrhosis and 5% of patients with congestive heart failure (P less than 0.0001). Although DNR orders were associated with functional and mental status, reason for admission, and severity of illness, the strong association between DNR orders and disease category persisted after adjustment for these potential confounders by multiple logistic regression. A survey of housestaff showed that DNR orders were discussed more frequently with patients who had AIDS or lung cancer than with patients who had cirrhosis or heart failure, despite an accurate understanding of the generally similar prognoses among the four groups. CONCLUSIONS: Despite relatively similar prognoses, patients with AIDS or lung cancer are much more likely to receive DNR orders than patients with cirrhosis or severe congestive heart failure. This discrepancy cannot be explained by differences in severity of illness among patients or by misunderstandings of prognosis by clinicians. From our data, we cannot determine if patients with cirrhosis or heart failure receive too few DNR orders or if patients with AIDS or lung cancer receive too many. Our findings should encourage physicians to determine the preferences of patients about life-sustaining treatments more equitably.

Acquired Immunodeficiency Syndrome↗
PubMed1989

Voluntary screening for human immunodeficiency virus (HIV) infection. Weighing the benefits and harms.

Voluntary screening for human immunodeficiency virus (HIV) infection may help prevent the spread of the HIV epidemic if persons who test positive alter behaviors that may transmit infection. Protecting persons from unknowingly being exposed to HIV infection must be balanced against respecting the autonomy of individuals being screened. Seropositive patients may feel a stigma and be subjected to discrimination if confidentiality of test results is breached. In patients without high-risk behaviors, the positive predictive value of HIV testing may be substantially increased if tests are done in reference laboratories and if further confirmatory tests are run on a second blood specimen. For persons with high-risk behaviors, HIV testing can be recommended to those who want to reduce uncertainty about their HIV status or whose medical care would change if they were seropositive. Health care workers can maximize benefits of screening and minimize harm by educating and counseling patients before HIV testing, discussing the confidentiality of HIV test results, urging patients to disclose positive test results to sex partners, and advising patients on how to reduce high-risk behaviors.

Acquired Immunodeficiency Syndrome↗
PubMed1989

The physician's responsibility toward hopelessly ill patients. A second look.

Physicians have a specific responsibility toward patients who are hopelessly ill, dying, or in the end stages of an incurable disease. In a summary of current practices affecting the care of dying patients, we give particular emphasis to changes that have become commonplace since the early 1980s. Implementation of accepted policies has been deficient in certain areas, including the initiation of timely discussions with patients about dying, the solicitation and execution in advance of their directives for terminal care, the education of medical students and residents, and the formulation of institutional guidelines. The appropriate and, if necessary, aggressive use of pain-relieving substances is recommended, even when such use may result in shortened life. We emphasize the value of a sensitive approach to care--one that is adjusted continually to suit the changing needs of the patient as death approaches. Possible settings for death are reviewed, including the home, the hospital, the intensive care unit, and the nursing home. Finally, we consider the physician's response to the dying patient who is rational and desires suicide or euthanasia.

Ethics, Medical↗
PubMed1989

Community-acquired bacteremia in patients with acquired immunodeficiency syndrome: clinical presentation, bacteriology, and outcome.

PURPOSE: Community-acquired bacteremia is an easily treatable infection occurring in patients with acquired immunodeficiency syndrome (AIDS). Although other studies have reported bacterial infections in AIDS patients, none have clearly described the clinical presentation of these patients. In this survey, we sought to define how frequently AIDS patients presented to our institution with community-acquired bacteremia; which organisms and sources of bacteremia were involved; the frequency that these patients presented with abnormal vital signs and white blood cell counts; and the in-hospital outcome of these patients. PATIENTS AND METHODS: We retrospectively identified patients with AIDS hospitalized at San Francisco General Hospital in the 16 months between August 1986 and December 1987 in whom a positive blood culture was drawn within 24 hours of admission. Each of the patient's charts was reviewed for demographic data, relevant past medical history, clinical admission information, laboratory data, and discharge status. RESULTS: We identified 44 episodes of community-acquired bacteremia in 38 patients with AIDS. These episodes represented approximately 5% of the admissions of patients with AIDS. The patients were young (mean age, 38 +/- 7 years), homosexual (43 of 44), and in some cases intravenous drug users (nine of 44). On admission, only 57% of the patients were febrile (temperature greater than 38.3 degrees C) and 23% of the patients presented with normal vital signs. Twenty-seven percent were neutropenic (less than 1,000 neutrophils/mm3). The most common sources of the bacteremia were pneumonia (10), an indwelling central venous line (eight), and cellulitis (seven). A total of 14 patients had no apparent source. Staphylococcus aureus, Streptococcus pneumoniae, and Escherichia coli were the most common organisms. Only four of the 44 patients died during their hospitalization. CONCLUSION: We conclude that patients with AIDS and community-acquired bacteremia can present to the hospital without abnormal vital signs or white blood cell counts. Clinicians cannot depend on these data to assist them in excluding the possibility of bacteremia in patients with AIDS. In addition, due to the variety of organisms found in our survey, we recommend that broad-spectrum antibiotics should be the empiric therapy in patients with a suspected bacterial infection.

Acquired Immunodeficiency Syndrome↗
PubMed1989

Life-sustaining treatment for patients with AIDS.

Physicians increasingly are being called upon to make difficult decisions about intensive care for patients with the acquired immunodeficiency syndrome (AIDS). AIDS patients who require intensive care have a poor prognosis; the in-hospital mortality rate of those receiving mechanical ventilation for P carinii pneumonia is 86-100 percent in most studies. However, in the past year, two studies documenting improved outcome have been published. Physicians should understand these outcome data and use well-established ethical principles to allow informed competent patients with AIDS to express their preferences regarding intensive care. Patients should be encouraged to provide advanced directives regarding life-sustaining treatments or to designate surrogate decision-makers to be consulted should they lose mental competence. The health care system should provide alternatives to the ICU for compassionate terminal care. However, arbitrary policies denying intensive care to AIDS patients for whom it is medically indicated and desired are not warranted.

Acquired Immunodeficiency Syndrome↗
PubMed1989

To tell or not to tell: the ethical dilemmas of HIV test notification in epidemiologic research.

Epidemiologic studies involving HIV (human immunodeficiency virus) antibody testing create ethical dilemmas, particularly about notifying asymptomatic seropositive subjects. Four study designs address this problem: mandatory notification, optional notification, anonymous testing, and blind testing. No single design consistently optimizes the trade-off between valid and ethical research. Each strategy differs substantially from the others in its effect on response rates, bias, ability to perform longitudinal studies, numbers of subjects who learn their test results, and the number of subjects counseled about HIV risk reduction. Both local institutional review boards and potential subjects of study (and their sexual partners) should participate in decisions regarding the conduct of sensitive AIDS (acquired immunodeficiency syndrome) research.

Epidemiologic Methods↗
PubMed1989

Knowledge and concerns about acquired immunodeficiency syndrome and their relationship to behavior among adolescents with hemophilia.

The knowledge and concerns regarding acquired immunodeficiency syndrome (AIDS) and their relationship to certain behaviors among adolescents with hemophilia, a pediatric risk group with human immunodeficiency virus (HIV) antibody positivity rate as high as 70% to 90%, are described. Information was obtained from 26 patients, 13 to 19 years of age, through the use of a confidential self-administered questionnaire and a semistructured interview. In general, subjects demonstrated a high level of factual knowledge regarding the cause, natural history, transmission, and prevention of AIDS. Despite this, participants frequently behaved in ways that were potentially harmful to themselves and others. Specifically, although aware of the importance of using condoms, sexually active adolescents with hemophilia were not practicing safe sex. Restriction in the use of heat-treated clotting factor because of concerns about AIDS was also frequently reported. Professionals providing AIDS education and counseling for these individuals need to be cognizant of the concerns and social skills of this population; they should focus not only on factual information but also on the social and situational pressures confronting these teenagers, which may be more immediate determinants of their behavior and well-being. As AIDS continues to spread into the general population, these findings have relevance to AIDS education and health policy efforts aimed at all adolescents.

Acquired Immunodeficiency Syndrome↗
PubMed1988

Artificial feeding--solid ground, not a slippery slope.

Decisions about artificial feeding arouse more controversy than those involving any other life-sustaining treatment. Because food and water are generally considered basic elements of humane care, representing love and concern for the helpless, it is often thought that they must always be provided. In a landmark decision, the Supreme Judicial Court of Massachusetts ruled that a feeding tube could be removed from a patient in a persistent vegetative state if this was consistent with his previously expressed wishes. The case of Paul E. Brophy, Sr., is part of an emerging medical and legal consensus on the withholding of artificial feeding from adult patients. The view is growing that tube and intravenous feeding should be likened to other medical interventions and not to the routine provision of nursing care or comfort. Competent patients have the right to refuse such feeding. Feeding can also be stopped incompetent patients who have earlier stated such a wish.

Coma↗