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Biomedical subjects

M D Sullivan

Publications and source records attributed to M D Sullivan.

At least 19 recordsLinked to original sources
PubMed2001

Ethical dilemmas in pain management.

The purpose of this study was to survey the membership of the American Pain Society and the American Academy of Pain Medicine to determine their beliefs about ethical dilemmas in pain management practice. Respondents rated ethical dilemmas for their importance as well as their own competence in dealing with these ethical issues. The survey also included an open-ended question that asked respondents to describe clinical situations in which they had encountered ethical dilemmas. A total of 1,105 surveys were analyzed, with physicians (N = 612), nurses (N = 189), and psychologists (N = 166) representing the professions with the greatest response. Management of pain at the end of life, general undertreatment of pain, and undertreatment of pain in the elderly were the most frequently encountered dilemmas. Qualitative data were analyzed to identify ethical issues in the case examples provided by the respondents. Major themes included inappropriate pain management, barriers to care, interactions and conflicts with others, regulatory/legal issues, euthanasia, assisted suicide, and research issues. We conclude that ethical dilemmas are common in pain management practice and that resolution of these dilemmas requires commitment by individual professionals as well as health systems.

Journal Article↗
PubMed2001

Finding pain between minds and bodies.

Physicians and patients alike find it easy to divide pain into mental pain and physical pain. But close examination of this distinction shows that it fails on clinical and philosophical grounds. The body is not a passive conduit for information about tissue damage. Nociception is modified and analyzed throughout the nervous system. The mind is not a central theater where pain is finally apprehended. Pain perception cannot be understood as the private observation of a pain sensation. Pain must have mental (e.g., aversion) and physical (e.g., location) elements if it is to qualify as pain. We understand our pain as well as the pain of others in terms of socially categorized pain behavior. Pain thus originates, not in mind or body, but between minds and bodies. The dualism of mental and physical pain cannot be overcome if the biological individual is considered in isolation. Mental and physical pain can only be reconciled if their common interpersonal roots are understood. This interpersonal view of pain can help clarify some clinical and moral dilemmas in the care of patients with pain.

Humans↗
PubMed2001

A treatment for vocal cord dysfunction in female athletes: an outcome study.

OBJECTIVES: This article reports the outcome of a speech pathology treatment program for vocal cord dysfunction (VCD) in 20 adolescent female athletes. STUDY DESIGN: A retrospective, nonrandomized group design was used to collect the outcome data. METHODS: Twenty consecutive referrals of female athletes diagnosed as having symptoms of VCD during exercise were assessed, treated, and followed for at least 6 months after treatment. RESULTS: Ninety-five percent of the participants reported the ability to control symptoms of VCD during exercise up to 6 months after treatment. Asthma medications were no longer used by 80% of the athletes. All of the females continued to participate in athletics. CONCLUSION: Speech pathology intervention focusing on respiratory control of VCD in adolescent female athletes is an effective treatment resulting in the athletes' ability to control the symptoms of VCD in exercise for at least 6 months after treatment.

Adolescent↗
PubMed2001

Methodological issues in the recruitment of primary care patients with depression.

OBJECTIVE: To compare two strategies of patient recruitment, waiting room (WR) screening and screening after physician referral (PR), for participation in a treatment-outcome study of minor depression and dysthymia in primary care. The influence of demographic factors on patients' refusal to participate in WR screening was also examined. METHOD: Of a convenience sample of 3,344 first stage patients, a total of 609 patients were evaluated in a semi-structured manner using a two-stage screening procedure from the mood module of the Primary Care Evaluation of Mental Disorders (PRIME-MD). RESULTS: Male and older patients were more likely to refuse participation in screening than female and younger patients. Waiting room screens yielded a higher number of qualified patients compared to PR screens, but PR screens yielded a higher percentage of patients who qualified for further participation. CONCLUSIONS: The recruitment of male and older primary care patients is complicated by their tendency to refuse participation in WR screening for a treatment-outcome study of milder depression. Although each recruitment strategy offers advantages and disadvantages, the simultaneous use of both is recommended to recruit the most patients in the least amount of time.

Adolescent↗
PubMed2000

Models of health-related quality of life in a population of community-dwelling Dutch elderly.

OBJECTIVE: Though health-related quality of life (HRQoL) is now commonly measured as an outcome in clinical trials, the relationships between its components remain unclear. The relation of physical symptoms, physical function, and psychological symptoms to each other and to overall quality of life is of special interest. METHOD: Cross-sectional data from 5,279 community-dwelling elders who participated in the Groningen Longitudinal Aging Study were analyzed using structural equation modeling techniques. Three models were examined. One "Linear" model included: number of chronic medical conditions, physical symptoms, physical functioning, activity interference, social function, perceived health and overall quality of life in a simple linear progression. Another 'non-linear' model included these variables, but allowed effects between non-adjacent variables. A third 'non-linear' model included these variables plus anxiety and depressive symptoms. RESULTS: The Linear Model did not satisfactorily account for the observed data [X2(15df) = 2946.96], so the saturated Non-Linear Model, incorporating paths between non-adjacent components, is described. When anxiety and depressive symptoms were added to this Non-Linear Model, they fit best in a position mediating the relation between perceived health and overall quality of life [X2(5df) = 136.78]. CONCLUSIONS: Overall quality of life appears to be related to symptom status as directly as it is related to functional status. Anxiety and depressive symptoms appear to mediate the relation between general health perceptions and overall quality of life. Quality of life measures should therefore include assessments of physical and psychological symptom severity as well as functional status if they are to truly reflect what matters to patients. The disability-adjusted life year (DALY) measure used by the WHO may inadequately reflect the effect of symptoms on patient's quality of life.

Aged↗
PubMed1999

Evidence that the human foamy virus genome is DNA.

The genomes of the spumaviruses, of which human foamy virus (HFV) is the prototype, are very similar to those of other complex retroviruses. However, in some aspects of the viral replicative cycle, HFV more closely resembles pararetroviruses such as hepatitis B virus. Previous work indicated that HFV extracellular particles contain apparently full-length double-stranded DNA, as well as RNA. We have further characterized the amount of DNA in particles and the role that this DNA has in viral replication. Experiments with the reverse transcriptase inhibitor 3'-azido-3'-deoxythymidine (AZT) suggest that reverse transcription is largely complete before extracellular virus infects new cells. In addition, we have been able to show that DNA extracted from virions can lead to production of virus after transfection. Taken together, these data suggest that complete, or nearly complete, proviral-length DNA is present in viral particles and that this DNA is sufficient for new rounds of viral replication.

3T3 Cells↗
PubMed1999

Chronic pain: the need for a "second-person" account.

Clinicopathological correlation between first-person patient complaints and third-person objective tissue pathology often fails for patients with chronic pain. It is, in fact, difficult to reconcile first- and third-person perspectives on much of clinical pain. One root for this problem is our belief in the privacy of pain. The idea of private pain is critiqued using the work of Ludwig Wittgenstein who contends that pain and pain behavior are inextricably linked. This allows us to appreciate the essentially social nature of human pain. A second-person theory of pain is sketched, which sees pain as intersubjective action. This theory allows us to escape our current dualistic, and often damaging, notions about chronic pain.

Chronic Disease↗
PubMed1997

Functional status in coronary artery disease: a one-year prospective study of the role of anxiety and depression.

PURPOSE: Although coronary disease is the second most common cause of work and functional disability, little is known about the relative contributions of biomedical and psychosocial factors to this disability. This study was conducted to determine the associations of depression and anxiety with self-reported physical function and activity interference in patients with coronary artery disease. METHODS: This was a 1-year prospective cohort study of 198 HMO members who had elective cardiac catheterization for coronary artery disease in 1992. Measures included: severity of coronary artery stenosis from cardiac catheterization reports; anxiety and depression severity using interviewer-administered Hamilton Anxiety and Depression Rating Scales; and self-reported physical function and activity interference. RESULTS: At the time of catheterization, patients' self-reported physical function differed significantly by number of main coronary vessels stenosed >70% (P <0.03), by anxiety quartiles (P = 0.001), and by depression quartiles (P = 0.001). At 1 year, physical function was no longer associated with the number of main coronary vessels stenosed at baseline, but still was significantly associated with baseline anxiety (P <0.001) and depression quartiles (P = 0.01). Moreover, change in physical function scores from baseline to 12 months was associated with baseline anxiety (P <0.001) or depression (P <0.001) quartiles, but not with baseline number of occluded coronaries. Results for activity interference were similar to those for physical function. These associations were largely unchanged when corrected for age, sex, education, social class, medical versus surgical management of CAD, and degree of medical comorbidity. CONCLUSION: Anxiety and depression have a significant and persistent effect on physical function in patients with coronary artery disease. Although current treatment methods appear to neutralize the influence of coronary stenosis on physical function during the year following catheterization, this is not true for anxiety and depression.

Age Factors↗
PubMed1997

Maintaining good morale in old age.

Traditional aging studies have seen life's later years as a time of inevitable biological and social decline. Psychological decline might also be expected, but this is not true for most older people, according to epidemiologic studies. Thus, we must ask: Why is aging not as emotionally threatening as might be expected? Why do some older people do better than others? How should medicine address these issues? It is only possible to understand the successful emotional aging of most elders if the customary diathesis-stress model is supplemented by a developmental perspective. Expectations as well as capacities diminish with aging. This means that subjective health appears more tightly linked with morale than objective health. Some older people experience recurrence of mental disorders (for example, major depression) first present earlier in life. Others experience new disorders such as minor depression in response to biological or social losses. As geriatric medicine comes to increasingly focus on chronic disease, attention to morale is an important strategy for maximizing quality of life. Physicians will need improved skills in the detection and treatment of problems in morale if they are to provide optimum care for their older patients.

Adaptation, Psychological↗
PubMed1996

Psychiatric training in medicine residencies: current needs, practices, and satisfaction.

The purpose of this study was to determine the current level of psychiatric training in internal medicine residencies, satisfaction with this training, and perceived need, if any, for more training. Surveys were mailed to all training directors of accredited primary care (N = 178) and categorical (N = 410) internal medicine residencies in the United States; 110 primary care (62%) and 238 categorical (58%) training directors returned the surveys. Seventy-five percent of categorical and 66% of primary care training directors thought their program should spend more time on psychiatric disorders. For all categories of psychiatric disorder, training intensity was greater and satisfaction with training higher in the primary care programs, but less than half of the directors were satisfied with their current level of training, e.g., 33% of categorical and 47% of primary care directors were satisfied with their residents training concerning depression. Training in somatoform disorders, psychotropic drugs, and office psychotherapy were most frequently identified as deficient. The most favored additions to the curriculum were psychiatric consultants in medical clinics and on medical wards. Although most outpatient care for psychiatric disorders is given by primary care physicians, internal medicine training directors perceive current levels of training in their residencies as inadequate. Innovative collaborations between medicine and psychiatry departments will be necessary if treatment of psychiatric disorders in primary care is to be improved.

Attitude of Health Personnel↗
PubMed1996

Psychiatry and physician-assisted suicide.

The psychiatric literature on physician-assisted suicide is scant and almost universally opposed to legalization. This opposition stems from the traditional perspective of suicide as a symptom of mental illness and the tendency of psychiatrists to extend their view of suicide in the medically well to the terminally ill. This article examines the basis for and validity of this opposition and makes recommendations about the role of the psychiatrist in physician-assisted suicide.

Attitude of Health Personnel↗
PubMed1996

Women's psychological reactions to breast cancer.

Breast cancer is the cancer most studied in terms of psychological and psychosocial aspects because of the high prevalence and mortality of the disease and the psychological effects of surgery on an organ rich in meaning. The diagnosis of breast cancer, treatment, and treatment sequelae are major stressors for any woman; however, the psychological impact of the diagnosis and women's emotional responses vary considerably depending on medical parameters of the disease, the patient's psychological make-up and coping abilities, and the availability of emotional and financial support. We document the experience of breast cancer at all phases of the disease for a majority of psychologically healthy women and describe the emotional responses of women who are at high genetic risk of developing breast cancer. Having a comprehensive understanding of psychologically healthy women's reactions to breast cancer is necessary as we attempt to define standards of care and treatment guidelines for both psychologically healthy women with breast cancer and for those with psychiatric disorders that antedate or complicate breast cancer treatment.

Adaptation, Psychological↗
PubMed1994

Symptoms as a clue to otologic and psychiatric diagnosis in patients with dizziness.

Dizziness is a common symptom that often remains unexplained despite extensive medical evaluation. Psychiatric disorders are usually considered only after all medical causes of dizziness have been ruled out. Sixty-five patients referred to an otolaryngology practice received a structured psychiatric interview, an otologic evaluation, and a dizziness questionnaire modified to assess psychiatric symptoms. They were divided into four diagnostic groups: psychiatric diagnosis only, otologic diagnosis only, both diagnoses, or neither diagnosis. Eleven questionnaire items were significantly associated with diagnostic groupings. Stepwise discriminant function analysis utilizing age, gender, rapid/irregular heartbeat, extremity weakness, nausea/vomiting, and difficulty with speech resulted in correct group classification for 70% of subjects. The presence of dizziness symptoms like vertigo or lightheadedness was not significantly different between groups. This study suggests that assessment of psychiatric and autonomic symptoms should accompany, not follow, otologic evaluation of dizziness. These symptoms may be more important diagnostically than dizziness quality.

Adult↗
PubMed1994

Depression, competence, and the right to refuse lifesaving medical treatment.

OBJECTIVE: The authors explore the possibility that psychiatrists inappropriately extend their views on suicide by the medically well to refusal of lifesaving treatment by the seriously medically ill. METHOD: The legal and bioethics literature on competence to refuse lifesaving treatment and the possible impact of depression on this refusal is reviewed. RESULTS: Over the past 20 years, the burden of proof concerning the mental competence of seriously medically ill patients who refuse lifesaving treatment has shifted to the persons who seek to override these refusals. However, in psychiatry a patient's desire to die is generally considered to be evidence of an impaired capacity to make decisions about lifesaving treatment. This contrast between ethical traditions is brought into clinical focus during the evaluation and treatment of medically ill patients with depression who refuse lifesaving treatment. The clinical evaluation of the effect of depression on a patient's capacity to make medical decisions is difficult for several reasons: 1) depression is easily seen as a "reasonable" response to serious medical illness, 2) depression produces more subtle distortions of decision making than delirium or psychosis (i.e., preserving the understanding of medical facts while impairing the appreciation of their personal importance), and 3) a diagnosis of major depression is neither necessary nor sufficient for determining that the patient's medical decision making is impaired. CONCLUSIONS: Depression can be diagnosed and treated in patients with serious medical illness. But after optimizing medical and psychiatric treatment and determining that the patient is competent to make medical decisions, it may be appropriate to honor the patient's desire to die.

Attitude to Health↗