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At least 253 records · Page 14Linked to original sources
PubMed2000

Surgical repair of leaking filtering blebs.

PURPOSE: To report the surgical management of leaking filtering blebs occurring after blebitis or persistent hypotony. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Twenty-two eyes of 20 patients with late bleb leak, blebitis or endophthalmitis, hypotony maculopathy, or bleb dysesthesia on presentation to the glaucoma service who required surgical bleb revision from 1990 through 1999. INTERVENTION: Pedicle flap, partial excision, and advancement or free conjunctival autologous graft techniques for surgical bleb revision. Type of bleb revision was dependent on the dimensions of the bleb and quality of surrounding conjunctiva. MAIN OUTCOME MEASURES: Preoperative and postoperative intraocular pressure (IOP), status of bleb leak, reoperation for glaucoma, or requirement for postrevision glaucoma medical therapy, with success defined as the need for two or fewer glaucoma medications after revision. RESULTS: Eighty-six percent (19/22) of eyes that underwent surgical bleb revision had resolution of leak and IOP control using two or fewer medications after one or more bleb revisions. The preoperative IOP (mean +/- standard deviation) was 3.7 +/- 2.6 mmHg (range, 0-8 mmHg). After an average follow-up of 21 months (range, 8-108 months), the IOP was 11.0 +/- 4.4 mmHg for patients taking 0.6 +/- 1.0 glaucoma medications. Eighteen percent (4/22) of eyes required two or more bleb revisions. In one eye, an IOP spike of 36 mmHg developed after revision, which required laser suture lysis on two occasions before the IOP was significantly lowered. The three failures were: one eye that required three or more medications for IOP control, a patient whose eye had a persistent leak after revision and who was not mentally competent to undergo repeat revision, and one eye that required combined glaucoma and cataract surgery after revision. CONCLUSIONS: Surgical bleb revision has a high success rate of closing late bleb leaks, maintaining glaucoma control, and preserving vision, with few postoperative complications. The appropriate surgical procedure for revision must be based on the individual clinical situation and can result in successful bleb revision.

Adult↗
PubMed2003

Memories of colonoscopy: a randomized trial.

Patients' memories of the past may influence their decisions about the future, yet memories are imperfect and susceptible to bias. We tested whether a memory failure observed in psychology experiments could be applied in a clinical setting to lessen patients' memories of the pain of an unpleasant medical procedure. We studied consecutive outpatients undergoing colonoscopy who were medically stable, mentally competent, and able to speak English (n=682). By random assignment, half the patients had a short interval added to the end of their procedure during which the tip of the colonoscope remained in the rectum. Pain during the procedure was measured with a ten point intensity scale. Memory following the procedure was measured using both a rating scale and a ranking task. Randomization resulted in two similar groups. As theorized, patients who underwent the extended procedure experienced the final moments as less painful (1.7 vs. 2.5 on a ten point intensity scale, P<0.001), rated the entire experience as less unpleasant (4.4 vs. 4.9 on a 10 cm visual analogue scale, P=0.006), and ranked the procedure as less aversive compared to seven other unpleasant experiences (4.1 vs. 4.6 with eight as the worst, P=0.002). Rates of returning for a repeat colonoscopy (median duration of follow-up 5.3 years) averaged 50.4% and were slightly higher (odds ratio=1.41, P=0.038) for those who underwent the longer procedure controlling for prior colonoscopy, procedure indications, and abnormal findings. Memory failures observed in experimental conditions can be found in clinical settings involving awake patients and may offer opportunities for improving patients' willingness to undergo future unpleasant medical procedures.

Adult↗
PubMed1998

Medicolegal errors in the ED related to the involuntary confinement of psychiatric patients.

To determine the effectiveness of emergency department (ED) physicians properly and correctly completing documents required for emergency confinement of psychiatric patients, 1,000 Physician Emergency Certificates filed by ED physicians in the Shreveport, Louisiana, region were reviewed for appropriateness and for correctness of completion based on the applicable state law. Of the Physician Emergency Certificates reviewed 4.2% were incomplete or inappropriate. The most significant sources of error involved incomplete documentation of the mental status examination and not documenting the specific reason (dangerous to self, dangerous to others, or gravely disabled) for the patient meeting requirements for involuntary confinement. Other errors included confinement for reasons not appropriate for a psychiatric unit. This study suggests that ED physicians should be more cautious and thorough in completing the documents required for emergency confinement of psychiatric patients, so that the physician is less likely to be sued for malpractice or charged with the false imprisonment of such patients, and the patient's civil liberties are protected.

Emergency Medical Services↗
PubMed1999

Pursuit of assisted dying: a pilot study of inquiries made to a national consumer-based organization.

Legal developments in assisted dying have focused on assisted suicide for mentally competent, terminally ill adults. Requests for assisted dying are likely to represent broader concerns, but studies have been limited to surveys of specific patient groups or recollections of physicians. To describe the nature of inquiries by a broad range of persons seeking assisted dying, a retrospective review was performed of confidential client memoranda summarizing telephone inquiries regarding assisted dying to a counseling service of a national, not-for-profit, consumer-based organization. The review evaluated the underlying medical condition prompting the inquiry, evidence of patient's decisional capacity, and relationship of caller to the patient. Of 125 assisted suicide calls, 111 with medical illness were analyzed. Among 111 inquiries, 71 (64%) were made by someone other than the person suffering from the illness ("the patient"); 52 (47%) of these were family members, 14 (13%) were friends, and 5 (7%) were professionals. Cancer accounted for 25% of cases, HIV/AIDS and amyotrophic lateral sclerosis (ALS) for 10 and 9%, respectively, other neurological diseases for 23%, and chronic or other medical conditions for approximately 17%. In an additional 10 cases, there was no medical illness. Within the group of callers inquiring on behalf of others, 18 (25%) stated the patient lacked ability to communicate his or her wishes and 7 (10%) stated there was uncertainty. Inquiries about assisted dying represent a broader range of concerns than represented by legal initiatives. More study is needed to determine if enhanced knowledge about alternatives, such as palliative care, reduces requests for assisted dying.

Adult↗
PubMed2003

Patient and parent understanding of informed consent in orthodontics.

In both medical and dental settings, researchers have found that patients do not adequately comprehend the information given during informed consent discussions, especially the less educated, low-income patients. Because of the importance of patient compliance with orthodontic treatment regimens, this study examined patient and parent understanding of the child's Phase I orthodontic treatment in a public dental clinic with ethnically diverse, low-income patients. Interviews were conducted with 29 children (ages 6-12) and their parents or guardians at the orthodontic case presentation appointment. The orthodontist explained the reasons for treatment, the orthodontic procedures to be used, the risks, the alternatives, and patient and parent responsibilities during treatment; the session was audiotaped. Interviews were conducted immediately after this discussion and the results compared with the orthodontists' presentations. In general, both children and parents recalled significantly fewer reasons for treatment (1.10, 1.66, and 2.34 items, respectively), procedures (1.55, 1.59, and 2.45, respectively), risks associated with treatment (0.66, 1.48, and 4.66, respectively), and responsibilities of the child during treatment (2.21, 2.07, and 3.38, respectively) than what the orthodontist had told them. They were also less likely to recall the reasons, procedures, and risks that were most frequently cited by the orthodontist. These findings raise concerns about the effectiveness of current informed consent techniques with public health populations, especially the low recall rates within 30 minutes of the case presentations. Low recall of risks by children and their parents, particularly for critical risks such as relapse, caries, and periodontal problems, raises concerns about treatment compliance, success, and more importantly, the effectiveness of the informed consent process itself. Future research should focus on methods to improve the informed consent process among children undergoing orthodontic treatment in a low-income population.

Child↗
PubMed2001

Long-term care in dementia: patients and caregivers.

General principles of managing chronic, age-associated diseases apply as much to Alzheimer's disease (AD) and other late-life dementing disorders as they do to congestive heart failure or osteoarthritis. Beyond efforts to maintain residual tissue or organ function, important physician roles include promoting general well-being and helping patients and their caregivers adjust to disease-related limitations. Physicians provide essential information to patients and their families about the disease, its social and legal ramifications, and community resources to facilitate care. Therefore, physicians must be knowledgeable about broadly intersecting medical, legal, financial, and ethical issues surrounding the long-term management of AD and other dementias. The many challenges faced by patients with dementia and their caregivers over time underscore the need for an ongoing diagnostic and therapeutic alliance with primary care physicians. This article reviews salient aspects of long-term care for patients with AD and other dementias, highlighting the vital and varied roles of physicians in managing these chronic brain disorders.

Aged↗
PubMed1997

Sentenced in sorrow: the role of asylum in the Jean Gianini murder defence.

This paper describes the role played by the notion of asylum in the legal battle over confessed murderer Jean Gianini's mental competence and commitment. Gianini was a 16 year old who murdered his former teacher in a small upstate New York town in 1914. His trial was the first in the US to employ the Binet-Simon intelligence test as a defence and featured a clash of expert witnesses whose credibility was based upon their residence and work in asylums. The verdict of 'not guilty due to criminal imbecility' was due to the defence team's successful portrayal of the asylum as a punishing prison from which the defendant would never be released.

Commitment of Persons with Psychiatric Disorders↗
PubMed1999

The views and outcomes of consenting and non-consenting patients receiving ECT.

BACKGROUND: Current mental health legislation in the UK makes provision for the use of certain treatments in severely ill patients who are unable, or unwilling, to give informed consent. Under the terms of this legislation, electroconvulsive therapy (ECT) may be used, usually to treat severely depressed patients. A number of organizations have challenged this practice, stating that ECT should only be given with fully informed consent: it has been implied that patients receiving compulsory ECT (given without the patient's consent, under the terms of mental health legislation) find the treatment damaging and unhelpful. METHODS: A series of 150 patients receiving ECT in Aberdeen was studied. A proportion of the series (approximately 7%) received compulsory ECT. The views and treatment outcomes of compulsory patients were compared with those of patients giving informed consent for treatment. RESULTS: More than 80% of patients in both consenting and compulsory groups considered ECT to have helped them. Clinical outcome did not differ between the groups. Patients' views showed marked concordance with independent medical evaluation of outcome. CONCLUSIONS: Outcome following ECT in non-consenting patients is equivalent to that seen in consenting patients whether rated by the patients themselves or by clinicians. Overall outcome is good, with more than 80% of patients benefiting from treatment. A ban on compulsory ECT would deny the access of seriously ill patients to an effective and acceptable treatment.

Adult↗
PubMed1999

Capacity to make health care decisions: its importance in clinical practice.

BACKGROUND: Assessment of capacity plays a pivotal role in determining when decisions need to be made on behalf of an individual. It therefore has major clinical management implications for health care professionals and civil liberties implications for the person concerned. In many countries, there is a presumption that adults have the capacity to make health care decisions. However, in persons with a mental disability, capacity may be temporarily or permanently impaired. METHODS: A selective review is presented which considers: (i) the broad approaches taken to determining capacity; (ii) the abilities commonly assessed in determining capacity; and (iii) the principles underlying health care decision-making for adults who are without capacity. RESULTS: Capacity is a functional concept, determined by the person's ability to understand, retain, and weigh up information relevant to the decision in order to arrive at a choice, and then to communicate that choice. We have reviewed the studies that examined decision-making abilities in people with dementia, chronic mental illness or intellectual disabilities. Approaches to decision-making in adults who lack capacity include: anticipatory decisions made through advance health care statements or decisions by proxy based on 'best interests' or 'substituted judgement'. CONCLUSIONS: The understanding of clinical and legal aspects of capacity is still developing. This paper examines current concepts of capacity and decision-making on behalf of those without capacity. We propose a framework, in line with current ethical and legal guidelines, as an aid to clinicians when they are seeking consent for a health care intervention.

Adult↗
PubMed2000

Assessing the capacity of people with intellectual disabilities to be witnesses in court.

BACKGROUND: People with intellectual disabilities who have been victims or other witnesses of crime have had limited access to the criminal justice system, often on the basis of assumptions about their incapacity to be interviewed by the police and to give evidence in court. The aim of this study was to assess their capacity to be witnesses in court. METHODS: Forty-nine men and women with intellectual disabilities, all of whom were potential witnesses of ill-treatment, were assessed in order to provide advice, initially to the police, about their capacity to be interviewed for judicial purposes. The assessments included evaluations of each person's intellectual ability, memory, acquiescence, suggestibility, and their ability to explain concepts relating to the oath. RESULTS: Only 37 (76%) were able to complete the assessments. Most of those with a Full Scale IQ score of > or = 60 had a basic understanding of the oath, compared with only a third of those with IQ scores between 50 and 59, and none of those with IQ scores < 50. Nevertheless, some of the people who were unable to demonstrate an understanding of the oath did understand the words 'truth' and 'lie', especially when asked about these concepts in relation to concrete examples. CONCLUSIONS: While intellectual ability appears to be the best overall predictor of the capacity of people with intellectual disabilities to act as witnesses, confining witnesses to those who could explain the meaning of the oath would mean that a number of persons who might be interviewed by the police and subsequently appear in court could be excluded from the judicial process.

Adult↗