Bridge to nowhere: A retrospective single-center study on patients using chronic intravenous inotropic support as bridge therapy who do not receive surgical therapy

Background

Many patients with advanced heart failure (HF) are administered chronic intravenous inotropic support (CIIS) as bridge to surgical therapy; some ultimately never receive surgery. We aimed to describe reasons patients “crossover” from CIIS as bridge therapy to palliative therapy, and compare end-of-life outcomes to patients initiated on CIIS as palliative therapy.

Methods

Single-institution, retrospective cohort study of patients on CIIS as bridge or palliative therapy between 2010 and 2016; data obtained through review of health records and multi-disciplinary selection meeting minutes, was analyzed using descriptive and inferential statistics.

Results

Of 246 patients discharged on CIIS as bridge therapy, 37 (16%) (male n = 28, 76%; African American n = 22, 60%) ultimately never received surgery. 67 matched patients on CIIS as palliative therapy were included for analysis (male n = 47, 70%; African American n = 47, 70%). The most common reasons for “crossover” from CIIS as bridge therapy to palliative therapy were frailty (n = 10, 27%), cardiac arrest (n = 5, 13.5%), and progressive non-cardiac illnesses (n = 6, 16.2%). A similar percentage of patients in the bridge (n = 28, 76%) and palliative (n = 48, 72%) groups died outside the hospital (P=0.66); however, fewer bridge patients received hospice care compared to the palliative group (35% vs 69%, P < 0.001). Comparing patients who died in the hospital, bridge patients (n = 9; 100%) were more likely to die in the intensive care unit than palliative patients (n = 8; 42%) (P < 0.001).

Conclusion

Patients on CIIS as bridge therapy who do not ultimately receive surgical therapy “crossover” to palliative intention due to frailty, or development of or identification of serious illnesses. Nevertheless, these “bridge to nowhere” patients are less likely to receive palliative care or hospice and more likely to die in the intensive care unit than patients on CIIS as palliative therapy.

Cardiovascular response patterns and speech: a study of air traffic controllers

The present study examined the relationship between cardiovascular (CVS) response and speech among air traffic controllers (ATCs). During two one-hour work sessions continuous EKG, ear pulse, and audio recordings were obtained individually from 24 male ATCs. In one session the controller actively controlled aircraft, while in the other he worked in a support/coordinator position. Session time in both conditions was partitioned on the basis of audio recordings into four mutually exclusive activities: Radio/Phone Talk, Radio/Phone Listening, Casual Talk, and Silence. Change in cardiovascular response pattern as a function of these activities, as well as the influence of a series of moderator variables on cardiovascular response, was assessed by examining heart rate (HR) and the EKG R-wave to ear pulse interval (RPI) relative to a pre-session baseline. The RPI index was employed as a means of unobtrusively tracking blood pressure on a beat-by-beat basis. Although reliable, the overall changes in CVS response were modest. Speech-associated reactivity was expressed exclusively by the RPI index. HR changes were not evident in response to speech, rather, the HR index appeared to be most sensitive to situational demand. Discrepancies between the present pattern and magnitude of speech-associated CVS response and those reported previously are discussed in terms of the nature of speech in laboratory versus field settings and measurement methodologies.

Treatment patterns for schizophrenia in psychiatric hospitals

This paper analyzes the patterns of clinical treatments prescribed to patients diagnosed with schizophrenia who were admitted to state and county mental hospitals, private for-profit psychiatric hospitals, and private nonprofit psychiatric hospitals in July 1980. Treatment patterns were specified by examining the distribution of treatment types provided to patients over a 3-month period through standard tabular arrays and matrix analysis that holds constant the number of treatment types received by the patients. Data for this study are based on nationwide patient sample surveys and facility enumerations conducted in 1980 by the Survey and Reports Branch, National Institute of Mental Health. Clear differences and similarities emerged among the three types of hospitals in terms of the number and type of treatments provided to patients with schizophrenia. In general, patients with schizophrenia admitted to private psychiatric hospitals received a more comprehensive care regimen (generally inclusive of individual therapy) than similarly diagnosed patients admitted to state and county mental hospitals; private nonprofit psychiatric hospitals had marginally discernible treatment patterns from private for-profit psychiatric hospitals, especially with respect to assignment of group and self-care skill training.

The 'offset effect' of mental health treatment on ambulatory medical care utilization and charges. Month-by-month and grouped-month analyses of a five-year study

The five-year ambulatory medical care experience of 400 patients with mental disorders was studied to test the "offset" hypothesis that patients receiving timely mental health specialist treatment have lower subsequent utilization of, and charges for, care than patients not receiving such specialist treatment. Specialist treatment was associated with significant offset savings in utilization and charges for the non-psychiatric medical care of treated patients with either severe or less severe mental disorders. However, the visits and charges for such specialist treatment boosted the overall (nonpsychiatric plus mental health specialist) care utilization and charges of the specialist-treated patients above those of patients treated solely by their nonpsychiatric physicians; this overall increase was especially pronounced for patients with severe mental disorders. The findings suggest the need for randomized prospective offset studies comparing utilization, cost, and clinical outcomes.

Nonverbal expressiveness and EMG activity in tension headache sufferers and controls

This study explored the relationship between musculoskeletal responses and nonverbal expressiveness in response to psychosocial stress. Muscle-contraction headache subjects and normal controls were confronted with a psychological stressor while forehead and neck EMG activity were recorded. Indices of nonverbal expressiveness (head and hand movements, facial tension, facial activity, and facial expressiveness) were obtained concomitantly with the muscle data. The headache subjects showed greater muscle activation than the controls in response to stress, greater evidence of facial tension, and less evidence of facial and bodily expressiveness. Overall, these data provided support for the notion that under some conditions a negative relationship exists between expressiveness and somatic activation.

A large submucous fibroid polyp causing inversion of the uterus

A case of chronic inversion of the uterus, with involvement of bladder and ureters, due to the prolapse through the cervix and vagina of a submucous fibroid, is presented. A safe scheme of operative treatment is outlined.

Spontaneous rupture of the spleen in late pregnancy

Two cases of spontaneous rupture of the spleen are described. The first patient presented with fetal distress in the second stage of labour; the second with hypovolaemic shock. Both mothers and babies survived.