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Biomedical subjects

R Frankel

Publications and source records attributed to R Frankel.

At least 19 recordsLinked to original sources
PubMed2002

Power spectral analysis of heart rate variability during positive pressure pneumoperitoneum: the significance of increased cardiac sympathetic expression.

BACKGROUND: Positive pressure pneumoperitoneum (PPP) effects on the autonomic nervous system (ANS) might be of clinical importance, as imbalance in the autonomic cardiac control might lead to serious consequences. METHODS: Fifteen healthy patients undergoing elective laparoscopic cholecystectomy were analyzed for cardiac autonomic nervous activity by spectral heart rate variability, during awake state, before and after intubation, during CO2 PPP (14 mmHg), and after CO2 evacuation. The very low, low, high and very high frequency (VLF, LF, HF, VHF respectively) bands of the spectral density of the heart rate variability (HRV) and their normalized values, as well as the LF/HF ratio, were obtained from the power spectra of R-R intervals, using the fast-Fourier transformation algorithm. RESULTS: Using Friedman's nonparametric test, only the difference between the power of LF during anesthesia (median 30.74) and the middle of PPP (median 195.66) was found to be significant (p<0.012). Such change was recorded in 14 patients (p = 0.001, sign test). CONCLUSIONS: Increased LF power reflects sympathetic cardiac activation. As the LF range accounts for regulation of blood pressure and baroreflex, several mechanisms may explain this activation. This in turn may predispose patients who suffer from cardiac disease to higher risk of developing ventricular arrhythmias, besides the possible adverse hemodynamic consequences of PPP.

Adult↗
PubMed2001

Coronary artery dissection during pregnancy and the postpartum period: two case reports and review of literature.

Spontaneous coronary dissection is a rare event occurring particularly in women during the peripartum and postpartum period. Two cases related to the early postpartum period with a successful outcome are described, together with a comprehensive review of all the previously published cases. Diagnostic and therapeutic considerations of this unique clinical entity are discussed and reviewed.

Adult↗
PubMed2001

Personal growth in medical faculty: a qualitative study.

BACKGROUND: A physician's effectiveness depends on good communication, and cognitive and technical skills used with wisdom, compassion, and integrity. Attaining the last attributes requires growth in awareness and management of one's feelings, attitudes, beliefs, and life experiences. Yet, little empiric research has been done on physicians' personal growth. OBJECTIVE: To use qualitative methods to understand personal growth in a selected group of medical faculty. DESIGN: Case study, using open-ended survey methods to elicit written descriptions of respondents' personal growth experiences. SETTING: United States and Great Britain. PARTICIPANTS: Facilitators, facilitators-in-training, and members of a personal growth interest group of the American Academy on Physician and Patient, chosen because of their interest, knowledge, and experience in the topic area and their accessibility. MEASUREMENTS: Qualitative analysis of submitted stories included initially identifying and sorting themes, placing themes into categories, applying the categories to the database for verification, and verifying findings by independent reviewers. RESULTS: Of 64 subjects, 32 returned questionnaires containing 42 stories. Respondents and nonrespondents were not significantly different in age, sex, or specialty. The analysis revealed 3 major processes that promoted personal growth: powerful experiences, helping relationships, and introspection. Usually personal growth stories began with a powerful experience or a helping relationship (or both), proceeded to introspection, and ended in a personal growth outcome. Personal growth outcomes included changes in values, goals, or direction; healthier behaviors; improved connectedness with others; improved sense of self; and increased productivity, energy, or creativity. CONCLUSIONS: Powerful experiences, helping relationships, and introspection preceded important personal growth. These findings are consistent with theoretic and empiric adult learning literature and could have implications for medical education and practice. They need to be confirmed in other physician populations.

Adult↗
PubMed2000

A technique to retrieve stents dislodged in the coronary artery followed by fixation in the iliac artery by means of balloon angioplasty and peripheral stent deployment.

An unwelcome complication of the increasingly applied technique of coronary stenting is stent dislodgment, which may cause arterial occlusion or distal embolization, both with potentially adverse sequel. Stent dislodgment tends to occur when negotiating a tortuous artery with a balloon-mounted stent, especially if the artery is irregularly calcified or when applying a rigid stent. We have successfully applied in several patients at our laboratory a technique to retrieve a dislodged stent from the coronary artery, tow it to the iliac artery, and then deploy it locally by a peripheral balloon when retrieval through the vascular sheath seems impossible. Finally, the retrieved stent is secured by local anchoring with a peripheral stent. This technique was found to be useful and may prevent further complications and more costly interventions and hence result in a more benign clinical course. Cathet. Cardiovasc. Intervent. 49:77-81, 2000.

Aged↗
PubMed2000

A comparison of minidose lidocaine-fentanyl and conventional-dose lidocaine spinal anesthesia.

The syndrome of transient neurologic symptoms (TNS) after spinal lidocaine has been presumed to be a manifestation of local anesthetic neurotoxicity. Although TNS is not associated with either lidocaine concentration or dose, its incidence has never been examined with very small doses of spinal lidocaine. One hundred ten adult ASA physical status I and II patients presenting for arthroscopic surgery of the knee were randomly assigned to receive spinal anesthesia with either 1% hypobaric lidocaine 50 mg (Group L50) or 1% hypobaric lidocaine 20 mg + 25 microg fentanyl (Group L20/F25). Hemodynamic data, block height and regression, and time to first micturition and discharge were recorded. Follow-up phone calls were made by a blinded researcher at 48-72 h using a standardized questionnaire. Both groups had a median peak cephalad block level of T10. Lidocaine 50 mg was associated with a greater decrease in systolic blood pressure and a greater need for ephedrine. Time until block regression to the S2 dermatome (80 vs. 110 min) and outpatient time to void (130 vs 162 min) and discharge (145 vs. 180 min) were faster in the L20/F25 group. Complaints of TNS were found in 32.7% of the patients in the L50 group and in 3.6% of the patients in the L20/F25 group. We conclude that spinal anesthesia with lidocaine 20 mg + fentanyl 25 microg provided adequate anesthesia with greater hemodynamic stability and faster recovery than spinal anesthesia with lidocaine 50 mg. The incidence of TNS after spinal lidocaine 20 mg + fentanyl 25 microg was significantly less than that after spinal lidocaine 50 mg.

Adjuvants, Anesthesia↗
PubMed2000

Minidose bupivacaine-fentanyl spinal anesthesia for surgical repair of hip fracture in the aged.

BACKGROUND: Spinal anesthesia for surgical repair of hip fracture in the elderly is associated with a high incidence of hypotension. The synergism between intrathecal opioids and local anesthetics may make it possible to achieve reliable spinal anesthesia with minimal hypotension using a minidose of local anesthetic. METHODS: Twenty patients aged > or = 70 yr undergoing surgical repair of hip fracture were randomized into two groups of 10 patients each. Group A received a spinal anesthetic of bupivacaine 4 mg plus fentanyl 20 microg, and group B received 10 mg bupivacaine. Hypotension was defined as a systolic pressure of < 90 mmHg or a 25% decrease in mean arterial pressure from baseline. Hypotension was treated with intravenous ephedrine boluses 5-10 mg up to a maximum 50 mg, and thereafter by phenylephrine boluses of 100-200 microg. RESULTS: All patients had satisfactory anesthesia. One of 10 patients in group A required ephedrine, a single dose of 5 mg. Nine of 10 patients in group B required vasopressor support of blood pressure. Group B patients required an average of 35 mg ephedrine, and two patients required phenylephrine. The lowest recorded systolic, diastolic, and mean blood pressures as fractions of the baseline pressures were, respectively, 81%, 84%, and 85% versus 64%, 69%, and 64% for group A versus group B. CONCLUSIONS: A "minidose" of 4 mg bupivacaine in combination with 20 microg fentanyl provides spinal anesthesia for surgical repair of hip fracture in the elderly. The minidose combination caused dramatically less hypotension than 10 mg bupivacaine and nearly eliminated the need for vasopressor support of blood pressure.

Adjuvants, Anesthesia↗
PubMed1999

Testing a model of long-term alliance success.

The remarkable consistency of buyer and supplier perspectives was the most striking feature of this research. Although significant differences did exist, the dominant perspective illustrated a strong cohesion between partners. AS such, it would appear that these alliances do represent "best in class" relationships and thus may provide valuable insight for academics and practitioners into what makes alliances succeed--or fail.

Contract Services↗
PubMed1997

A model of empathic communication in the medical interview.

OBJECTIVE: To formulate an empirically derived model of empathic communication in medical interviews by describing the specific behaviors and patterns of interaction associated with verbal expressions of emotion. DESIGN: A descriptive, qualitative study of verbal exchanges using 11 transcripts and 12 videotapes of primary care office visits to a total of 21 physicians. SETTING: An urban health maintenence organization (HMO), an urban university-based general medicine clinic, and an urban community hospital general medicine clinic. ANALYTIC METHOD: Individual review of transcripts by each research team member to identify instances of expressed or implied emotional themes and to observe the physicians' responses. Individual ratings were compared in group discussions to achieve consensus about the classifications. Similar consensus-based classification was used for review of videotapes. RESULTS: We observed that patients seldom verbalize their emotions directly and spontaneously, tending to offer clues instead. If invited to elaborate, patients may then express the emotional concern directly, and the physician may respond with an accurate and explicit acknowledgment. In most of the interviews, the physicians allowed both clues and direct expressions of affect to pass without acknowledgment, returning instead to the preceding topic, usually the diagnostic exploration of symptoms. With emotional expression so terminated, some patients attempted to raise the topic again, sometimes repeatedly and with escalating intensity. We noted a parallel dynamic for encounters in which patients sought praise. We summarized the full interactional sequence in a simple descriptive model. CONCLUSIONS: This empirically derived model of empathic communication has practical implications for clinicians and students who want to improve their communication and relationship skills. Based on our observations, the basic empathic skills seem to be recognizing when emotions may be present but not directly expressed, inviting exploration of these unexpressed feelings, and effectively acknowledging these feelings so the patient feels understood. The frequent lack of acknowledgment by physicians of both direct and indirect expressions of affect poses a threat to the patient-physician relationship and warrants further study.

Communication↗
PubMed1997

'Being a foreigner, I may be punished if I make a small mistake': assessing transcultural experiences in caring for patients.

BACKGROUND: Emotionally charged issues that arise during graduate medical education often are unrecognized and consequently not addressed by training programmes. Little attention has been given to the emotional challenges encountered by international medical graduates (IMG) in caring for patients transculturally. OBJECTIVES: We aimed to examine the value of qualitative approaches to assessing the transcultural experiences of IMG residents during primary care training. METHODS: Two qualitative research techniques (the critical incident and the focus group) were used to assess the transcultural challenges in caring for patients of IMG and American medical graduates (AMG) resident in a primary care residency programme. Each resident wrote a narrative describing a challenging experience and facilitators then conducted a focus group to discuss these experiences. Key themes were identified from the written narratives and from the transcript of the videotaped focus group. RESULTS: Previously unacknowledged feelings emerged during the assessment. Themes of struggles for acceptance, fear of rejection, and fear of disappointing patients were identified from analysis of the written narrative, while themes of struggle to express caring transculturally were identified from the focus group transcript. Based on these findings, significant changes were made to the residency training curriculum. CONCLUSIONS: Qualitative methods are useful for assessing the transcultural experiences of IMG residents and for informing curricular changes in residency training. These methods may help other training programmes to identify the particular needs of their trainees in addressing emotionally laden experiences.

Attitude of Health Personnel↗
PubMed1996

Failure to detect Chlamydia pneumoniae in coronary atheromas of patients undergoing atherectomy.

To further investigate a proposed relationship between Chlamydia pneumoniae and coronary heart disease, coronary atheromas were collected from patients undergoing percutaneous atherectomy. Fifty-eight atheroma specimens were examined by culture and polymerase chain reaction (PCR) and 22 by electron microscopy. All were negative for C. pneumoniae, except a single specimen that was PCR-positive. These results differ from studies in other populations, in which this organism was identified by nonculture methods within coronary atheromas obtained at autopsy. Anti-C. pneumoniae antibody titers from 65 of the patients were compared with those of 28 asymptomatic controls. IgG titers were higher in controls than in patients. There is no evidence that C. pneumoniae exists within atheromas in this study population, nor does seroprevalence correlate with the presence of coronary disease in these patients.

Adult↗
PubMed1994

A new diagnostic approach to congenital stridor using a laryngeal mask airway and rigid endoscope.

Neonates with symptoms of stridor from birth, present a difficult diagnostic problem. We have demonstrated that by the use of a laryngeal mask airway in an anaesthetized baby breathing spontaneously, we are able to reach a diagnosis. This is accomplished by the introduction of a rigid fibre-optic endoscope through a Portex swivel connector and visualizing the glottis and larynx.

Anesthesia, General↗
PubMed1994

Getting the most from a 20-minute visit.

The four core skills--active listening, soliciting attribution, providing support, and establishing agreement--are at the heart of the model of co-participation between physician and patient. Used effectively, they provide a mutually satisfying environment in which psychosocial as well as biologic aspects of a problem can be explored in a humane, caring, and surprisingly efficient way.

Interviews as Topic↗
PubMed1993

Mechanical manipulation of thrombus: coronary thrombectomy, intracoronary clot displacement, and transcatheter aspiration.

Recanalization of occluded arteries during acute myocardial infarction has been proven to prolong life and improve left ventricular function. Patients who could not receive thrombolytic therapy for failed thrombolysis and/or angioplasty were treated by mechanical manipulation of the thrombus. Three techniques were used: transcatheter aspiration, clot displacement, and thrombectomy. Five patients in shock had the thrombus aspirated from the left main and right coronary arteries. Eight patients had the clot pushed by the balloon from the mid-left anterior descending (LAD) to the apical LAD in order to reduce the area of ischemic myocardium, and 13 patients underwent a thrombectomy of the right coronary artery. These procedures enjoyed a high rate of success in reestablishing patency and a favorable long-term clinical and angiographic follow-up. Although the applicability and role of these interventions in acute myocardial infarction are not yet defined, we conclude that they are feasible and have an acceptable success and complication rate.

Aged↗
PubMed1993

Primary care of patients with human immunodeficiency virus infection. The physician's perspective.

OBJECTIVE: To examine physicians' perceptions, motivations, and influences on their willingness to care for patients with human immunodeficiency virus (HIV). DESIGN: Interviews with 30 physicians. Qualitative content and narrative analyses were performed. SETTINGS: Community-based primary care practices in six moderate-sized cities in the northeastern United States with at least a moderate incidence or prevalence of reported acquired immunodeficiency syndrome cases. PARTICIPANTS: Thirty community-based primary care physicians who had cared for at least two patients with HIV during the previous 2 years. MAIN OUTCOME MEASURE: Qualitative study designed to provide rich descriptive data. RESULTS: Care of patients with HIV was regarded as part of the scope of primary care, and was perceived to be similar to the care of patients with other chronic illnesses. Many physicians were motivated by personal rewards in taking care of patients, intellectual challenge, and desire to serve the underserved. Most believed that practicing physicians have an ethical obligation to care for all patients, regardless of diagnosis. No one "type" of physician could be identified who provides care to patients with HIV. CONCLUSIONS: Primary care physicians can apply their skills in the management of other chronic diseases to the care of patients with HIV. Practicing physicians can find caring for patients with HIV rewarding, stimulating, and enjoyable. Educational programs for physicians need to emphasize psychosocial aspects of HIV care. In addition, physicians need opportunities to recognize and deal effectively with their own emotional responses to the care of patients with HIV.

Adult↗
PubMed1993

Coronary atherectomy versus angioplasty: the CAVA Study.

Directional coronary atherectomy was developed with the hope that it would lower the risk of acute closure and restenosis by leaving a larger smoother lumen and fewer dissections than angioplasty. To evaluate this hypothesis, we compared the clinical and angiographic results of directional coronary atherectomy with those of percutaneous transluminal coronary angioplasty in well-matched groups. We studied 126 consecutive atherectomies and 127 angioplasties performed on similar lesions. Procedural results were evaluated with regard to dissections, complications, acute closure, and residual stenosis. Each patient's clinical course was followed, and each patient was contacted at 6 months for evaluation of recurrent angina, need for repeat catheterization, and angiographic rate of restenosis. Baseline clinical and angiographic characteristics of the two groups were well matched and met the criteria established as being appropriate for atherectomy. The angiographic success rate was 98% after angioplasty and 99% after atherectomy. There were fewer dissections after atherectomy (13%) compared with the number after angioplasty (22%; p = 0.03). Residual stenosis was 8.3 +/- 9% after atherectomy compared with 15 +/- 12% after angioplasty (p = 0.0001). However, there were more complications after atherectomy (p = 0.03). There was no significant difference between the two groups in the recurrence rate of angina or in the angiographic restenosis rate at 6 months. It was concluded that when lesion characteristics and vessel size are appropriate for atherectomy, the procedural success rate of either atherectomy or angioplasty is extremely high. Although atherectomy leads to a larger residual lumen and fewer dissections, the complication rate after atherectomy is higher than that after angioplasty. There is a trend toward more occlusions after atherectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗