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Biomedical subjects

Alexander A Kon

Publications and source records attributed to Alexander A Kon.

12 recordsLinked to original sources
PubMed2007

Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005.

OBJECTIVE: To develop clinical practice guidelines for the support of the patient and family in the adult, pediatric, or neonatal patient-centered ICU. PARTICIPANTS: A multidisciplinary task force of experts in critical care practice was convened from the membership of the American College of Critical Care Medicine (ACCM) and the Society of Critical Care Medicine (SCCM) to include representation from adult, pediatric, and neonatal intensive care units. EVIDENCE: The task force members reviewed the published literature. The Cochrane library, Cinahl, and MedLine were queried for articles published between 1980 and 2003. Studies were scored according to Cochrane methodology. Where evidence did not exist or was of a low level, consensus was derived from expert opinion. CONSENSUS PROCESS: The topic was divided into subheadings: decision making, family coping, staff stress related to family interactions, cultural support, spiritual/religious support, family visitation, family presence on rounds, family presence at resuscitation, family environment of care, and palliative care. Each section was led by one task force member. Each section draft was reviewed by the group and debated until consensus was achieved. The draft document was reviewed by a committee of the Board of Regents of the ACCM. After steering committee approval, the draft was approved by the SCCM Council and was again subjected to peer review by this journal. CONCLUSIONS: More than 300 related studies were reviewed. However, the level of evidence in most cases is at Cochrane level 4 or 5, indicating the need for further research. Forty-three recommendations are presented that include, but are not limited to, endorsement of a shared decision-making model, early and repeated care conferencing to reduce family stress and improve consistency in communication, honoring culturally appropriate requests for truth-telling and informed refusal, spiritual support, staff education and debriefing to minimize the impact of family interactions on staff health, family presence at both rounds and resuscitation, open flexible visitation, way-finding and family-friendly signage, and family support before, during, and after a death.

Critical Care↗
PubMed2006

Resident-generated versus instructor-generated cases in ethics and professionalism training.

BACKGROUND: The emphasis on ethics and professionalism in medical education continues to increase. Indeed, in the United States the ACGME will require residency programs to include professionalism training in all curricula by 2007. Most courses focus on cases generated by the course instructors rather than on cases generated by the trainees. To date, however, there has been no assessment of the utility of these two case discussion formats. In order to determine the utility of instructor-generated cases (IGCs) versus resident-generated cases (RGCs) in ethics and professionalism training, the author developed an innovative course that included both case formats. The IGCs were landmark cases and cases from the experience of the course instructors, while the RGCs were selected by the residents themselves. Residents were then surveyed to assess the strengths and weaknesses of each format. RESULTS: Of twenty-two second and third year residents, fourteen completed surveys (response rate 64%). Residents were nearly evenly split in preferring RGCs (38%), IGCs (31%), or not preferring one to the other (31%). 29% stated that they learn more from the RGCs, 21% stated that they learn more from the IGCs, and 50% stated that they did not find a difference in their learning based on format. In general, residents surveyed prefer a mix of formats. Residents tended to find the RGCs more relevant and interesting, and felt the IGCs were necessary to ensure adequate breadth of cases and concepts. CONCLUSION: Based on our relatively small sample at a single institution, we believe that educators should consider incorporating both instructor-generated and resident-generated cases in their ethics and professionalism curricula, and should evaluate the utility of such a model at their own institution. Further work is needed to illuminate other potential improvements in ethics and professionalism education.

Curriculum↗
PubMed2004

How pediatricians counsel parents when no "best-choice" management exists: lessons to be learned from hypoplastic left heart syndrome.

BACKGROUND: Hypoplastic left heart syndrome (HLHS) is a life-threatening congenital cardiac defect. Three mutually exclusive management options exist: the Norwood palliative procedure, cardiac transplantation, and comfort care without surgical intervention. OBJECTIVES: To assess which management options are presented to parents of infants with HLHS, and to determine what factors influence physicians' recommendations. DESIGN: Cross-sectional survey. SETTING: Fourteen of the largest pediatric cardiac surgery centers in the United States. PARTICIPANTS: Attending physicians in neonatology, cardiology, critical care practice, and cardiac surgery. INTERVENTION: A survey was distributed asking physicians what options they present to parents of infants with HLHS and what their recommendations are in general, as well as physician perceptions of HLHS outcomes and demographic information. MAIN OUTCOME MEASURES: Which options physicians discuss and which they recommend. RESULTS: Of 454 eligible physicians 257 (57%) responded to the survey, of which 110 make treatment recommendations to parents. Neonatologists were least likely to recommend surgery. Physicians who recommend surgery recommend procedures performed at their own institution over those performed elsewhere (odds ratio, 2.80; 95% confidence interval, 2.24-3.51). Twenty-six percent of physicians do not discuss nonsurgical management, and 25% of those at centers that do not perform cardiac transplantation do not discuss this option. The recommendations physicians make to parents are poorly associated with their predictions of postoperative outcomes. CONCLUSIONS: Physician recommendations to parents are poorly associated with their estimates of outcomes, and some physicians recommend the treatment preferred at their own institution over other options even when they predict better outcomes from another approach. Further, many physicians do not disclose all reasonable management options to parents of infants with HLHS. These findings raise doubts as to whether parents are given adequate information to make truly informed decisions.

Adult↗
PubMed2004

The association of race and ethnicity with rates of drug and alcohol testing among US trauma patients.

BACKGROUND: Racial and ethnic minority patients often receive differential medical care compared to Caucasians. The aim of this study was to evaluate the association of race and ethnicity with rates of alcohol and drug testing among adult US trauma patients. METHODS: Data for 79,246 adults admitted to 58 institutions participating in the US National Trauma Data Bank were evaluated using multivariable, hierarchical, mixed-effects analyses to determine the odds of receiving alcohol and drug testing among different racial/ethnic groups. The primary outcome variable was whether an alcohol or drug test was performed. The secondary outcome variable was the results of those tests. Participants were stratified by injury severity using the Injury Severity Score. Additional case-mix variables included: gender, age, Glasgow Coma Scale, day and time of arrival, and payment source. RESULTS: Black and Hispanic males in all injury severity groups were tested for alcohol more frequently than Caucasian males (odds ratio for Black men 1.31, 95% confidence interval 1.16-1.47; and for Hispanic men 1.45, 95% confidence interval 1.19-1.77, in the moderate injury group). Hispanic males in the moderate injury group were also tested for drugs more frequently then Caucasian males (odds ratio 1.33, 95% confidence interval 1.09-1.63). CONCLUSION: Racial and ethnic minority trauma patients in the US are tested for alcohol and drugs at higher rates after adjusting for potential confounders. Because having a positive alcohol or drug test can adversely affect a patient's medical care, differential testing that is racially or ethnically biased may place minority patients at risk of receiving disparate care.

Adult↗
PubMed2004

Assessment of physician directiveness: using hypoplastic left heart syndrome as a model.

OBJECTIVE: To test the hypothesis that surgeons are more directive than pediatricians in discussions with parents of critically ill children. STUDY DESIGN: We designed a novel tool to assess physician directiveness in discussions with parents of children with hypoplastic left heart syndrome. We sent surveys containing the assessment tool as well as demographic questions to all attending physicians in Neonatology, Pediatric Critical Care, Pediatric Cardiology, and Congenital Cardiac Surgery at 14 of the largest pediatric cardiac surgery centers in the United States. Responses to the tool were used to determine a "directiveness score" for each physician. We then performed univariate and multivariable linear regression analyses to assess the association of physician specialty, race/ethnicity, religion, gender, and years in practice with the directiveness score. RESULTS: Responses from 138 physicians were analyzed. In univariate analyses, with neonatologists as the reference group, surgeons were most directive (regression coefficient 3.02, 95% confidence interval 0.69 to 5.35, P=0.01), followed by cardiologists (regression coefficient 1.67, 95% confidence interval 0.13 to 3.20, P=0.03). No other variable was associated with physician directiveness score. These results were similar in the multivariable analysis. CONCLUSIONS: These results suggest that physician specialty is associated with directiveness. It is unclear, however, what amount of direction parents of critically ill children prefer.

California↗
PubMed2003

Evaluation of race and ethnicity on alcohol and drug testing of adolescents admitted with trauma.

OBJECTIVES: To describe the incidence of alcohol and drug testing in adolescents admitted for traumatic injury and to analyze these results with reference to race, ethnicity, and gender differences. METHODS: Data were collected on adolescents (aged 12 through 17 years) from the National Trauma Data Bank. Testing statuses for alcohol and drugs were the two primary outcome variables. The results of these tests were the secondary outcome variables. Additional casemix variables included: race, ethnicity, gender, age, Glasgow Coma Scale score, Injury Severity Score, day and time of arrival, and payment source. Hierarchical, multivariable logistic regression models were used to assess the relationship of race, ethnicity, and gender with the primary and secondary outcome variables. RESULTS: Differences noted in the likelihood of alcohol and drug testing among the different racial, ethnic, and gender groups demonstrated an increased likelihood of Hispanic males and African American females to receive alcohol testing (odds ratio [OR]: 1.48; 95% CI = 1.06 to 2.06; and OR: 1.30; 95% CI = 1.01 to 1.67, respectively). Results of testing revealed that females of all races were less likely than males to test positive for alcohol and drugs. Drug and alcohol testing was more common during evenings, nights, and weekends, as well as in the presence of neurologic injury. CONCLUSIONS: Whereas small disparities in alcohol and drug testing were noted in some minority race-based groupings, systematic racial bias is not evident in adolescent trauma patients.

Adolescent↗
PubMedDate not supplied

Home pediatric compassionate extubation: bridging intensive and palliative care.

Compassionate home extubation for pediatric patients is a topic that seldom appears in the literature and is of unknown clinical importance. However, standards in pediatric intensive care unit (PICU) and among pediatric critical care physicians regarding end-of-life decisions are changing, including where and when patient extubation occurs. The authors' hospice recently consulted on an infant with spinal muscular atrophy in the PICU requiring mechanical ventilation, for whom further life-sustaining care was deemed futile. In consultation with the family, nursing staff, physicians, and the ethics committee, and following protocol guidelines, arrangements were made for this infant and his parents to be transported home. Once comfortable with his family, a small amount of lorazepam was given and the endotracheal tube removed. The infant died quietly about 20 minutes later. This case prompted the authors to review the current state of published articles covering this topic, suggest a protocol for implementing home extubation, realize imposed barriers, and discuss potential solutions. A well-developed plan for home extubation procedures may improve interactions with PICU and hospice services and at the same time provide additional choices for parents and patients wishing to maximize end-of-life quality outside the hospital setting.

Decision Making↗