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Biomedical subjects

R M Epstein

Publications and source records attributed to R M Epstein.

At least 37 records · Page 2Linked to original sources
PubMed1997

Calibrating the physician. Personal awareness and effective patient care. Working Group on Promoting Physician Personal Awareness, American Academy on Physician and Patient.

Physicians' personal characteristics, their past experiences, values, attitudes, and biases can have important effects on communication with patients; being aware of these characteristics can enhance communication. Because medical training and continuing education programs rarely undertake an organized approach to promoting personal awareness, we propose a "curriculum" of 4 core topics for reflection and discussion. The topics are physicians' beliefs and attitudes, physicians' feelings and emotional responses in patient care, challenging clinical situations, and physician self-care. We present examples of organized activities that can promote physician personal awareness such as support groups, Balint groups, and discussions of meaningful experiences in medicine. Experience with these activities suggests that through enhancing personal awareness physicians can improve their clinical care and increase satisfaction with work, relationships, and themselves.

Attitude of Health Personnel↗
PubMed1995

Communication between primary care physicians and consultants.

Optimal communication between primary care physicians and consultants includes transfer of relevant clinical information, including the patient's perspectives and values, and provides a means of collaboration to provide meaningful and health-promoting interventions. Communication difficulties arise because of lack of time, lack of clarity about the reason for referral, patient self-referral, and unclear follow-up plans. Also, primary care physicians and consultants may have different core values and may have little day-to-day contact with each other. Poor communication leads to disruptions in continuity of care, delayed diagnoses, unnecessary testing, and iatrogenic complications. Changes in the health care system offer the opportunity for improved collaboration between physicians by creating smaller administrative units within large health care systems that facilitate contact between primary care physicians and consultants; incorporation of discussions of uncertainty, patient preferences, and values into referral letters; adoption of a friendlier consultant letter format; and the improvement of the transfer of clinical data.

Adult↗
PubMed1993

Primary care of patients with human immunodeficiency virus infection. The physician's perspective.

OBJECTIVE: To examine physicians' perceptions, motivations, and influences on their willingness to care for patients with human immunodeficiency virus (HIV). DESIGN: Interviews with 30 physicians. Qualitative content and narrative analyses were performed. SETTINGS: Community-based primary care practices in six moderate-sized cities in the northeastern United States with at least a moderate incidence or prevalence of reported acquired immunodeficiency syndrome cases. PARTICIPANTS: Thirty community-based primary care physicians who had cared for at least two patients with HIV during the previous 2 years. MAIN OUTCOME MEASURE: Qualitative study designed to provide rich descriptive data. RESULTS: Care of patients with HIV was regarded as part of the scope of primary care, and was perceived to be similar to the care of patients with other chronic illnesses. Many physicians were motivated by personal rewards in taking care of patients, intellectual challenge, and desire to serve the underserved. Most believed that practicing physicians have an ethical obligation to care for all patients, regardless of diagnosis. No one "type" of physician could be identified who provides care to patients with HIV. CONCLUSIONS: Primary care physicians can apply their skills in the management of other chronic diseases to the care of patients with HIV. Practicing physicians can find caring for patients with HIV rewarding, stimulating, and enjoyable. Educational programs for physicians need to emphasize psychosocial aspects of HIV care. In addition, physicians need opportunities to recognize and deal effectively with their own emotional responses to the care of patients with HIV.

Adult↗
PubMed1993

Understanding fear of contagion among physicians who care for HIV patients.

BACKGROUND: Fear of contagion has been identified as a potential deterrent for primary care physicians who would otherwise care for HIV patients. This study examines physicians' fears of occupational HIV transmission and the ways that they cope with those fears. METHODS: Thirty community-based primary care physicians who were caring for HIV patients were interviewed about their experiences with HIV patients and the meanings they ascribe to those experiences. Qualitative content and narrative analysis were used. RESULTS: Fear of contagion was common despite the relatively low reported self-assessment of risk by primary care physicians. Most physicians considered their level of risk acceptable, but for some it seemed to take a high emotional toll. Some physicians identified their fear as "irrational." Physicians reported tension between fear of contagion and ethical responsibility to care for HIV patients. Some physicians were overattentive to infection control measures, whereas others used universal precautions inconsistently. Physicians continued to care for HIV patients despite their fears. Some physicians' family members needed information and reassurance about transmission of HIV. CONCLUSIONS: Some physicians who care for HIV patients are poorly equipped to deal with their own fears. There is a need to examine in greater depth the relationship between fear of contagion and willingness to provide care, and to examine other factors that may be contributing to the expression of these fears.

Adult↗
PubMed1993

Perspectives on patient-doctor communication.

Until recently, the content, structure, and function of communication between doctors and patients has received little attention and has been excluded from the realm of scientific inquiry; as a result, most clinicians have had little formal training in communication skills. In this paper leaders in doctor-patient communication present four approaches that are currently used as the basis for clinical training and research, summarize the progress made in forming a consensus, and outline the implications of these perceptions for practicing physicians.

Communication↗
PubMed1985

The influence of naloxone on regional hemodynamics in hemorrhaged rats.

Naloxone increases arterial pressure in hemorrhaged animals, but its effects on organ blood flows are not well established. We measured central and regional hemodynamics immediately before and 25 min or 55 min after hemorrhage in 33 anesthetized rats. Fifteen minutes after the beginning of hemorrhage, animals received either vehicle (n = 17) or naloxone (n = 16), 10 mg/kg, intravenously. At 25 min, animals treated with naloxone had a greater blood flow to the left cerebral hemisphere than those receiving vehicle, but all other measurements were similar. At 55 min, the mean arterial pressure and heart rate were greater in animals treated with naloxone, but blood flow was increased to the spleen only. Vascular resistance values were greater in the gastrointestinal tract and less in the spleen in animals receiving naloxone. The data confirmed that, in anesthetized rats, naloxone increased mean arterial pressure and splenic blood flow and transiently increased cerebral blood flow, but other regional flows and cardiac output were similar to those in rats receiving vehicle only.

Analysis of Variance↗
PubMed1984

Captopril reduces the dose requirement for sodium nitroprusside induced hypotension.

The authors studied 12 patients who required deliberate hypotension for spinal fusion operations in order to investigate the efficacy of captopril for reducing dose requirement for sodium nitroprusside (SNP). Six patients, selected at random, were pretreated with captopril, 3 mg/kg po, and the remaining six patients served as controls. All patients received a similar anesthetic technique, consisting of thiopental 3 mg/kg, pancuronium 0.1 mg/kg, morphine 0.5 mg/kg, plus nitrous oxide 70% in oxygen. SNP was used to maintain mean arterial pressure (MAP) at 50-55 mmHg during deliberate hypotension lasting 140 +/- 13 minutes (mean +/- SE). Patients who received captopril required less SNP than untreated patients both early during hypotension (1.4 +/- 0.5 micrograms X kg-1 X min-1 vs. 4.8 +/- 0.8 micrograms X kg-1 X min-1, P less than 0.05), as well as late during hypotension (2.2 +/- 0.2 micrograms X kg-1 X min-1 vs. 5.6 +/- 0.6 micrograms X kg-1 X min-1, P less than 0.05). Whole blood cyanide was significantly lower in the patients pretreated with captopril than the untreated controls both early in the hypotensive period (2.7 +/- 0.6 mumol/l vs. 13 +/- 4 mumol/l, P less than 0.05) and also late in the hypotensive period (3.7 +/- 0.8 mumol/l vs. 30 +/- 10 mumol/l, P less than 0.05). MAP was reduced by captopril pretreatment both following induction of anesthesia (64 +/- 4 mmHg captopril vs. 80 +/- 4 mmHg control, P less than 0.05) and during surgery before deliberate hypotension (86 +/- 5 mmHg captopril vs. 100 +/- 4 control, P less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1984

Photodegradation of sodium nitroprusside: biologic activity and cyanide release.

Because the belief that cyanide is released from nitroprusside in vivo recently was challenged, the authors performed a series of experiments that examined the conditions under which nitroprusside is degraded. These experiments include an examination of the release of cyanide and nitric oxide from nitroprusside in vitro, the release of cyanide in vivo, and a comparison of the biologic activity of intact and degraded nitroprusside. Nitroprusside in aqueous solution degraded when exposed to white or blue light but not to red light. While light at 20 microW X cm-2 produced 40% apparent photodegradation after 6 h exposure, while white light at 220 microW X cm-2 produced 100% apparent photodegradation after 2 h exposure. At 10% apparent photodegradation, 10% of the nitrosyl ligand was recovered as free nitric oxide, and 0.4% of the cyanide ligand was recovered as free cyanide. Following a 2-h infusion of light-protected nitroprusside in seven patients, cyanide concentrations ranged from 1.4 to 45.5 microM and 0.09 to 3.2 microM in blood and plasma, respectively. These values were not changed by exposing the samples to white light (220 microW X cm-2) for 4 h. Intact and photodegraded nitroprusside produced identical hypotensive responses in rats as would be expected, since the nitrosyl ligand was detected in solution following degradation, and it mediates this action. Cyanide was released from nitroprusside, both on its exposure to light in vitro and also in vivo. The latter was not an artifact of the assay for cyanide. Nitroprusside releases cyanide in vivo, and cyanide toxicity is a true complication of its use.

Animals↗
PubMed1981

Resonance Raman studies on protocatechuate 3,4-dioxygenase-inhibitor complexes.

Resonance Raman spectra of a number of protocatechuate 3,4-dioxygenase-inhibitor complexes were studied by use of the available lines of an argon and a krypton laser. Three types of inhibitors were investigated-hydroxybenzoates, dicarboxylates, and 4-nitrocatechol. The hydroxybenzoate study shows that the hydroxy group in 3-hydroxybenzoate does not coordinate to the active site iron, in agreement with earlier suggestions, and confirms the coordination of the hydroxy group in the isomeric 4-hydroxybenzoate. The dicarboxylate study demonstrates that both glutarate and terephthalate perturb the active-site environment, shifting the charge-transfer interaction to lower energy. The pH dependence of terephthalate binding as well as the spectral similarities of the dicarboxylate complexes to the ESO2 intermediate provides further evidence for the suggestion that this intermediate is a tightly bound enzyme-product complex. The 4-nitrocatechol study indicates that, unlike the substrate catechols, 4-nitrocatechol does not bind to the iron; a binding configuration wherein the acidic phenolate group interacts with the carboxylate binding site has been suggested by others. Finally the spectra of the 4-hydroxybenzoate and terephthalate complexes demonstrate the presence of two tyrosines coordinated to the active-site iron as suggested by others; these tyrosines have different vCO's and excitation profiles.

Catechols↗
PubMed1980

Whole-body distribution of radioactively labelled microspheres in the rat during anesthesia with halothane, enflurane, or ketamine.

Cardiac output and distribution of blood flow using 15-micron radioactively labelled microspheres were determined in 25 Wistar rats. In seven awake control animals, first and second injections of microspheres did not change cardiac output (137 +/- 8 ml/min) or result in alteration in apparent blood flow to the various organs studied. Halothane anesthesia (n = 6) (1.3 per cent inspired) resulted in a decrease in cardiac output, with increases in the percentages of cardiac output going to the brain, kidney, liver and large intestine. Enflurane anesthesia (n = 6) (2.2 per cent inspired) did not decrease cardiac output. The percentages of cardiac output going to the liver, lung, spleen, and large intestine increased. Both halothane and enflurane caused decreases in the percentages of cardiac output going to the heart and skeletal muscle. Ketamine anesthesia (n = 6) (125 mg/kg, im) differed from the other two agents in that few changes occurred from the awake state except in brain, lung and muscle, Microspheres that were trapped after the first injection were released from muscle and skin with ketamine anesthesia, resulting in an apparent decrease in the distribution of cardiac output to muscle in the controls and an apparent increase in "flow" to the lung. The microsphere method gives reliable information about cardiac output and distribution of flow in rats anesthetized with halothane or enflurane. Further studies are necessary to determine whether microsphere studies are valid indicators of organ flow during ketamine anesthesia in the rat.

Anesthesia↗
PubMed1979

Halothane mimics oxygen in oxygen microelectrodes.

The effects of halothane and enflurane on the polarographic measurement of oxygen with five platinum and three gold microelectrodes were examined. Oxygen microelectrodes were calibrated in saline solution equilibrated with either nitrogen (N2) or air, then either halothane, 1.0 per cent, or enflurane, 2.0 per cent, was added to the gas mixture. For each electrode, polarographic curves were determined during exposure to five equilibrating gas mixtures: N2, air, N2 plus halothane, air plus halothane, and N2 plus enflurane. Halothane variably increased the current produced (and therefore the estimated oxygen tension) at all polarizing voltages in saline solution equilibrated with either N2 or air. The effect was present in both conical platinum electrodes and recessed-tip gold electrodes and was not prevented by membrane coatings of polystyrol, Rhoplex or collodion. Enflurane did not alter the polarographic measurement of oxygen. It is concluded that tissue oxygen tension measurements, made with these microelectrodes and membranes, may be unreliable in the presence of halothane.

Calibration↗