Clinical manifestations of blunt cardiac injury: a challenge to the critical care practitioner

Life-threatening cardiac emergencies following blunt chest trauma demand accurate assessments and rapid interventions to prevent unnecessary complications and death. Critical care practitioners must recognize the subtle clues that indicate cardiac trauma and the decompensation that occurs if the injuries are not recognized early. Blunt cardiac trauma can manifest as myocardial concussion with an associated low mortality or as cardiac rupture with an excessive mortality. Traditional diagnostic laboratory studies such as cardiac enzymes have proven ineffective in the trauma patient population. Therefore, the role of the critical care practitioner is centered on assessing patients for the clinical manifestations of decreased myocardial performance, particularly those patients with limited cardiac reserve.     

Latex sensitivity: a public health care challenge

Latex sensitivity is becoming epidemic in the health care arena. Providers of health care need to be aware of the signs and symptoms, the treatments, and the consequences of latex sensitive reactions. In this article, I will provide information about latex sensitivities that will enable health care workers and their patients to have a better understanding of the phenomena. Resource information is provided for the latest information pertaining to latex sensitivities to aid in the education of health care providers and their patients.     

Familial aorto-cervicocephalic arterial dissections and congenitally bicuspid aortic valve

BACKGROUND: A primary arteriopathy is often implicated in the etiology of spontaneous cervicocephalic arterial dissections, but its exact nature usually remains unknown. We describe the familial occurrence of spontaneous arterial dissections and congenitally bicuspid aortic valve (BAV) and propose a common developmental defect in these families. SUMMARY OF REPORT: In the first family, a 63-year-old man suffered an extracranial internal carotid artery (ICA) dissection, and his 43-year-old cousin with BAV suffered an intracranial vertebral artery (VA) dissection. Two other family members had pathologically proven BAV. In the second family, a 31-year-old woman suffered bilateral extracranial ICA and VA dissections. Her father, at age 46, suffered an aortic dissection associated with cystic medial necrosis and BAV. Her paternal uncle died from an aortic dissection at age 59. In the third family, a 39-year-old woman suffered extracranial ICA and VA dissections, and her brother died at age 48 from an aortic dissection associated with a BAV. CONCLUSIONS: The familial occurrence of spontaneous arterial dissections and BAV suggests a common developmental defect. The aortic valvular cusps and the arterial media of the aortic arch and its branches are derived from neural crest cells, suggesting that a neural crest defect may be the underlying abnormality in these families.     

Continuity of care: a challenge for ambulatory oncology nursing

Continuity of care has many facets and challenges both as a philosophy and in practice. In an abstract sense, it represents an ideal to which health care professionals strive. It is becoming a professional and consumer expectation that each health care professional contribute to continuity of care. Although a variety of organizational models for providing continuity of care have been established in which nursing plays a prominent role, recent research suggests that some frontline nursing personnel may not fully understand their responsibility to continuity of care. There is a need for nursing curricula in both basic and continuing education programs to address continuity of care concepts, models, and methodologies to strengthen awareness of patient care needs across the disease continuum and across care settings. Performance expectations that include professional accountability for continuity of care also encourage greater attention to this issue.     

Multisystem complications of bulimia: a critical care case

Bulimia is an eating disorder characterized by behaviors which can lead to very serious health problems. Behaviors such as binging and purging and abuse of emetics, diuretics, or laxatives can cause serious complications, sometimes of a critical nature. Nurses must maintain a high index of suspicion for this disorder and use skillful assessment and intervention to prevent the critical multisystem complications of bulimia.     

Managing wounds in a managed care environment: the integration concept

Integration is being discussed at all levels today in healthcare. The term is confusing and the literature provides numerous definitions and explanations. In general, integration refers to the coordination and reorganization of various healthcare units (such as home health care, acute care hospitals, and skilled nursing facilities) either horizontally, vertically, or via a combination of both. To discuss integration, a healthy understanding of managed care and healthcare trends are essential. With current and projected future trends serving as a backdrop, this article will attempt to describe various integration delivery models. The application of the above to wound care as a specific disease state serves as the closing message.     

Informal care; a critical observation

In this article the policy aimed at cutting down expenses for professional care and at optimizing the contribution of informal, unpaid care (e.g. family caregivers and volunteers) is questioned. After a brief outline of the non-professional care system for the elderly, some problematic aspects of informal care are discussed, especially the influence of such care in terms of (over)burden, the quality of care and the consequences for the relationship between caregiver and person being cared for. Voluntary services are also questioned, particularly the lack of control, the power of volunteers and their knowledge, attitude and skills. It is concluded that expectations towards nonprofessional caregivers should not be too great. The importance of a finely tuned coordination and clear division of tasks in the care network is underlined. Finally a number of recommendations is made to settle the observed bottlenecks.     

Managing risk in a changing health care system

This article examines the information requirements and other strategies needed to manage business and financial risk in health care organizations. The business and financial risk of providers in the changing health care market is defined. The major factors that are increasing risk are outlined, and strategies for measuring and managing risk are discussed. The interaction of business and financial risk is described, and strategic goals that will minimize the effect of this interaction are presented.     

Bringing political ecology into critical medical anthropology: a challenge to biocultural approaches

This essay presents an effort to incorporate the "environment" into critical medical anthropology. Rather than relying upon the multifactorial approach characteristic of medical ecology or biocultural approaches in medical anthropology, it urges critical medical anthropologists to turn to the burgeoning literature on eco-Marxism, eco-socialism, or political ecology in their efforts to develop a political ecology of health. Given that political ecologists generally advocate democratic eco-socialism as a meaningful alternative to the capitalist world system, this essay also presents a critical examination of the environmental record of post-revolutionary societies.     

Challenges of traction in critical care: a case study

PROBLEM/CONDITIONS: Despite widespread availability of a safe and effective vaccine against tetanus, 124 cases of the disease were reported during 1995-1997. Only 13% of patients reported having received a primary series of tetanus toxoid (TT) before disease onset. Of patients with known illness outcome, the case-fatality ratio was 11%. REPORTING PERIOD COVERED: 1995-1997. DESCRIPTION OF SYSTEM: Physician-diagnosed cases of tetanus are reported by state and local health departments to CDC's National Notifiable Diseases Surveillance System. In addition, since 1965, supplemental clinical and epidemiologic information for cases has been provided to CDC's National Immunization Program. RESULTS: From 1995 through 1997, a total of 124 cases of tetanus were reported from 33 states and the District of Columbia, accounting for an average annual incidence of 0.15 cases per 1,000,000 population. Sixty percent of patients were aged 20-59 years; 35% were aged > or =60 years; and 5% were aged <20 years, including one case of neonatal tetanus. For adults aged > or =60 years, the increased risk for tetanus was nearly sevenfold that for persons aged 5-19 years and twofold that for persons aged 20-59 years. The case-fatality ratio varied from 2.3% for persons aged 20-39 years to 16% for persons aged 40-59 years and to 18% for persons aged > or =60 years. Only 13% of patients reported having received a primary series of TT before disease onset. Previous vaccination status was directly related to severity of disease, with the case-fatality ratio ranging from 6% for patients who had received one to two doses to 15% for patients who were unvaccinated. No deaths occurred among the 16 patients who previously had received three or more doses. Tetanus occurred following an acute injury in 77% of patients, but only 41% sought medical care for their injury. All patients who sought care were eligible for TT as part of wound prophylaxis, but only 39% received it. Tetanus in injecting-drug users (IDUs) with no known acute injury comprised 11% of all cases, compared with 3.6% during 1991-1994. None of the IDU-associated tetanus cases occurred among persons who were known to have been vaccinated. Sixty-nine percent of IDU-associated tetanus cases were reported from California, and 77% of these cases occurred in heroin users. INTERPRETATION: Tetanus remains a severe disease that primarily affects unvaccinated or inadequately vaccinated persons. Adults aged > or =60 years continue to be at highest risk for tetanus and for severe disease. However, the overall incidence of tetanus has decreased slightly since the late 1980s and early 1990s, from 0.20 to 0.15, a result primarily of a decreased incidence among persons aged > or =60 and <20 years. ACTIONS TAKEN: Tetanus is preventable through both routine vaccination and appropriate wound management. In addition to decennial booster doses of diphtheria and tetanus toxoids during adult life, the Advisory Committee on Immunization Practices (ACIP) recommends vaccination visits for adolescents at age 11-12 years and for adults at age 50 years to enable health-care providers to review vaccination histories and administer any needed vaccine. Every contact with the health-care system, particularly among older adults and IDUs, should be used to review and update vaccination status as needed.     

Culturally competent health care: a challenge for nurses in Saudi Arabia

An emerging global reality is the presence of a culturally diverse workforce in health care environments. Not only are nurses delivering care to culturally diverse clients, the nurses themselves may come from different cultural and educational backgrounds. In order to provide culturally competent health care, such diversity must be molded into professional collaboration and respect. To date, health care to the citizens of Saudi Arabia has been provided largely by a foreign labor force, the vast majority of whom are non-Arabic speaking. This paper explores a number of strategies aimed at educating expatriate non-Saudi health professionals in the provision of culturally competent and culturally congruent health care. Leininger's transcultural health care theory is identified as the framework for achieving this goal. The theory has proved to be of great relevance in a hospital setting where some 40 different nationalities are represented among the work force. In such a setting, the potential for cultural conflict and stress is very real. Health professionals new to the Kingdom are introduced to the cultural dimensions of health care as it relates to patient care modes, as well as living and working together in a transcultural environment. Transcultural nursing is a major component of a professional nurse practice model which provides a visionary perspective for nursing care. Within the practice model, transcultural care principles are used to guide education, clinical practice and nursing research. Furthermore, Leininger's theory serves to grasp a comprehensive view of generic (folk) and professional health systems and to identify ethical issues confronted by nurses in the transcultural setting.     

False positive results: a challenge for psychiatric screening in primary care

OBJECTIVE: The goal of this study was to characterize primary care patients with false positive results on screens for mental disorders. METHOD: A sample of 1,001 primary care patients completed self-administered screens and structured interviews for DSM-IV diagnoses. RESULTS: A substantial proportion of the patients with false positive screen results for at least one diagnosis met the diagnostic criteria for other psychiatric disorders. They also had significantly greater functional impairment and higher rates of recent use of mental health services than the subjects with true negative results on the screens. CONCLUSIONS: Although the positive predictive values of screens for specific mental disorders are in line with those of other medical screens, false positive results are not uncommon. This may be due in part to the sensitivity of brief screening instruments to nonspecific symptoms. The results suggest that as with other screens used in primary care, patients with false positive results on screens for mental disorders should receive clinical attention.     

Graduate education in primary care: the challenge

One can summarize the current status of calcium antagonists to treat heart failure as follows: Usually there is a favorable acute response to these drugs in heart failure patients but long-term effects in the patients treated with nifedipine, diltiazem, and verapamil have produced rather disappointing results. Thus, they should not be used routinely in heart failure patients. Their main problems were related to the negative inotropic effects of the drugs, the lack of reduction in ventricular filling pressure, and activation of the neurohumoral systems which have an adverse effect on cardiovascular performance, for example, renin-angiotensin. In contrast, the second-generation calcium antagonists have more selective vasodilating properties and fewer negative inotropic properties, which, I believe, justifies their use in selected heart failure patients. Unfortunately, there are no large randomized controlled long-term trials to evaluate morbidity and mortality in heart failure patients treated with these agents. One can rationalize that the symptomatic elderly patient with isolated diastolic dysfunction can be treated effectively with calcium antagonists but, once again, there are no major trials evaluating any drug in the management of patients with isolated diastolic function not due to hypertrophic cardiomyopathy. Rationale for using calcium antagonists could be best supported in patients with active ischemic heart disease and symptoms of heart failure. In this instance the coronary vasodilator effects may relieve myocardial ischemia and, by that mechanism, improve myocardial systolic and diastolic function.