Barriers to accessing hospice services before a late terminal stage

Although hospice care has been available in the United States for over 25 years, the trend of late terminal access persists. Quality assessments and interventions that will continue through a year of bereavement are based on early interactions and the formation of caring and trusting bonds. A qualitative research study was conducted to identify and describe barriers to timely access as perceived by those involved in hospice care: caregivers, hospice staff and volunteers, and referring physicians. Major findings include persistent knowledge deficits including misconceptions and lack of awareness of components and skill associated with hospice care: reluctance to disclose, discuss, or acknowledge patient terminality, and access of hospice care being perceived as giving up on the patient.

Comparison of the effects of halothane, isoflurane and methoxyflurane on the electroencephalogram of the horse

We have investigated in eight ponies the effects of three different end-tidal concentrations of halothane, isoflurane and methoxyflurane on median (F50) and 95% spectral edge (F95) frequencies of the EEG and the second differential (DD) of the middle latency auditory evoked potential (MLAEP). The three concentrations of each agent were chosen to represent approximately the minimum alveolar concentration (MAC), 1.25 MAC and 1.5 MAC for each agent. During halothane anaesthesia, F95 decreased progressively as halothane concentration increased, from mean 13.9 (SD 2.6) at 0.8% to 11.9 (1.1) at 1.2%. DD was lower during anaesthesia with the highest concentration (21 (6.5)) compared with the lowest (27.6 (11.4)). There were no significant changes in F50. During isoflurane anaesthesia, there was a small, but significant increase in F95 between the intermediate and highest concentrations (10.2 (1.5) to 10.8 (1.6)). There were no changes in F50 and DD. Values of F95, F50 and DD at all isoflurane concentrations were similar to those of halothane at the highest concentration. During methoxyflurane anaesthesia, F95 and F50 decreased progressively as methoxyflurane concentration was increased, from 21.3 (0.7) and 6.5 (1), respectively, at 0.26%, to 20.1 (0.6) and 5.6 (0.8), respectively, at 0.39%. DD was lower during anaesthesia with the highest concentration of methoxyflurane (25.7 (7.8)) compared with the lowest (39.7 (20.6)). Values of F95, F50 and DD at all methoxyflurane concentrations were higher than those seen with halothane at the lowest concentration. The different relative positions of the dose-response curves for EEG and MLAEP changes compared with antinociception (MAC) changes suggest differences in the mechanisms of action of these three agents. These differences may explain the incomplete adherence to the Meyer-Overton rule.

Hospice: what gets in the way of appropriate and timely access

Although hospice is viewed as highly effective in managing a good death, this service remains on the fringe of traditional medical care and is underutilized in the United States today. The same reimbursement criteria that facilitate access to hospice care for many also create barriers for others or exclude them altogether. The article examines who is and who is not receiving hospice care and why. Interventions and corrective actions are proposed.

Cardiovascular effects of surgical castration during anaesthesia maintained with halothane or infusion of detomidine, ketamine and guaifenesin in ponies

Sixteen colts were premedicated with acepromazine and anaesthesia was induced with detomidine and ketamine. Ponies were randomly allocated to receive halothane (HAL) or infusion of detomidine, ketamine and guaiphenesin (DKG) to maintain anaesthesia. Heart and respiratory rate, ECG, mean arterial blood pressure (MABP), cardiac index (CI), blood gases and plasma cortisol, ketamine and guaiphenesin were measured. Surgical castration took place between 45 and 75 min and anaesthesia lasted 90 min. MABP with DKG was significantly higher than with HAL, and, with HAL, MABP increased from pre-surgery (64 +/- 6 mmHg) to mid-surgery (80 +/- 5 mmHg) but did not change with DKG. At 30 min, CI was similar in both groups (57 +/- 7 ml/kg bwt/min); it decreased during surgery with HAL and remained low, but it increased slightly with DKG, and was higher than with HAL at 60 and 90 min. Plasma cortisol decreased in both groups until 40 min then increased with HAL only during surgery. Ketamine concentration reached a plateau (1.3-1.8 microg/ml) between 20 and 90 min and guaiphenesin concentration between 60 and 90 min (99-101 microg/ml). Recovery was generally smooth in both groups. This study demonstrated that during HAL the increase in blood pressure associated with surgical stimulus is accompanied by decreased CI; this did not occur during DKG which is likely to lead to better tissue perfusion than HAL. The adrenocortical activity seen during HAL was absent during DKG which may result from pituitary depression, analgesic effects of total intravenous anaesthesia (TIVA) or better perfusion.

Comparison of detomidine/ketamine and guaiphenesin/thiopentone for induction of anaesthesia in horses maintained with halothane

This prospective clinical study compared the physiological effects of two commonly used anaesthetic induction techniques in horses maintained with halothane. One hundred horses admitted for elective surgery were randomly allocated to receive either guaiphenesin (to effect) and thiopentone (5 mg/kg), or detomidine (20 microg/kg) and ketamine (2 mg/kg) for the induction of anaesthesia after acepromazine premedication. Anaesthesia was maintained with halothane in oxygen. There were no significant differences in breed, age, sex, weight, type of surgery and duration of anaesthesia between the groups. Immediately after induction of anaesthesia heart rate was higher after guaiphenesin and thiopentone, and arterial blood pressure was higher after detomidine and ketamine. Thereafter hypotension, often necessitating an infusion of dobutamine, developed in both groups. Arterial blood gases and respiratory rates were similar in the two groups. There were no significant differences between the groups in the subjectively scored quality of induction and recovery, or in recovery time.

Effects of alfentanil on the equine electroencephalogram during anaesthesia with halothane in oxygen

Opioids have variable effects on the minimum alveolar concentration of inhaled anaesthetics in the horse. During halothane anaesthesia at an end-tidal halothane concentration between 0.75 and 0.85 percent, the electroencephalogram (EEG) frequency power spectrum and the auditory evoked potential were recorded continuously in eight ponies during an infusion of approximately 40 micrograms kg-1 alfentanil over five minutes, and for a further 55 minutes. The spectral edge and median frequency of the EEG and the mid-latency of the auditory evoked potential at the time of maximum change of these variables were compared with those recorded before the start of the infusion. The mean (SD) spectral edge and median frequencies were reduced by 26 (5) percent and 36 (6) percent respectively. The mid-latency of the auditory evoked potential did not change. These cortical effects of alfentanil in the horse are qualitatively the same as in other species, suggesting that the alfentanil-induced excitement observed in horses in not of cortical origin.

Isolation of cholesterol oxidation products from animal fat using aminopropyl solid-phase extraction

Cholesterol oxidation products were separated from triglycerides and cholesterol in a single step on an aminopropyl solid-phase extraction column. The products were purified by subsequent transesterification and saponification, derivatized to trimethylsilyl ethers and analyzed by gas chromatography. Heated cholesterol-containing fat samples were autoxidized by bubbling air through them. When the flow-rate of air was set at 100 ml/min, the concentration of cholesterol oxidation products in the fat increased to a maximum after 1-2 h and then decreased to almost a zero level after 8 h. The concentration of cholesterol oxidation products in the fat increased over a similar time period, without reaching a maximum, when the flow-rate of air was decreased to 5 ml/min.

Intra-articular morphine and saline injections induce release of large molecular weight proteoglycans into equine synovial fluid

Both morphine and physiologic saline injected intra-articularly into healthy equine tarsocrural joints induced a release of large molecular size proteoglycan (PG) subunits into the synovial fluid (SF) analysed 24 h postinjection. High-performance liquid chromatography (HPLC) with a size-exclusion column was used to assess the high molecular weight proteoglycans in equine synovial fluid (SF). The PG peaks of SF samples eluated separately from SF hyaluronate and other molecular components of the SF in the HPLC chromatographies indicating no interaction between hyaluronate and PG in the SF. Individual elution profiles varied between joints and horses. The amount of PG release was measured by relative area index from the HPLC chromatograms. The synovial fluid PG content was significantly increased (P < 0.05) after morphine but not in saline injected joints compared with pretreatment but there were no significant differences between the two groups. It was concluded that intra-articular injections of both morphine and physiologic saline are able to elicit a marked PG release into the SF from articular cartilage within 24 h of injection.

Evaluation of a modification of the Hudson demand valve in ventilated and spontaneously breathing horses

Hypoxaemia commonly develops during general anaesthesia and in the recovery period in horses. The Hudson demand valve has been used to increase arterial PO2, but it has been found to increase airway resistance considerably when used during spontaneous ventilation. This paper evaluates a modification of the valve designed to reduce this resistance. The effects of the valve and its modification on arterial oxygen (PaO2), and carbon dioxide (PaCO2) tensions were evaluated in four ponies anaesthetised by a total intravenous technique. The valve increased PaO2 from 8.3 +/- 1.1 to 32.7 +/- 7.6 kPa during spontaneous ventilation and to 44.2 +/- 7.4 kPa during intermittent positive pressure ventilation. With the modification, the PaCO2 was increased to 9.0 +/- 2.5 kPa during spontaneous ventilation PaO2 was unchanged by the valve (7.2 +/- 0.4 kPa to 7.1 +/- 0.7 kPa) but it was reduced to 6.4 +/- 0.9 kPa with the modification. The valve was also evaluated in 20 clinical cases during their recovery from halothane anaesthesia. It increased PaO2 from 7.4 +/- 2.1 kPa to 17 +/- 18.3 kPa during spontaneous ventilation and from 8.0 +/- 1.8 kPa to 23.4 +/- 22.2 kPa during positive pressure ventilation. With the modification, PaO2 was increased from 7.8 +/- 1.4 kPa to 10.4 +/- 3.8 kPa during spontaneous ventilation and from 7.6 +/- 1.5 kPa to 14.8 +/- 8.4 kPa during positive pressure ventilation. During spontaneous ventilation PaCO2 was increased from 5.9 +/- 0.4 kPa to 6.2 +/- 0.6 kPa with the unmodified valve and from 6.3 +/- 0.5 kPa to 6.6 +/- 0.5 kPa with the modification.(ABSTRACT TRUNCATED AT 250 WORDS)

Early adoption of cyclosporine and recombinant human erythropoietin: clinical, economic, and policy issues with emergence of high-cost drugs

The discovery of new drugs and their introduction into US markets will become an intense area of focus should health care reform result in Medicare insurance coverage for prescription drugs. Particular attention will be focused on high-cost drugs. Two high-cost drugs, cyclosporine and recombinant human erythropoietin (rHuEPO), introduced into the clinical management of patients with kidney disease during the past decade, provide some experience concerning the forces affecting the use of expensive drugs in a cost-conscious health care system. The decision to prescribe a drug will depend on provider's judgements of the drug's clinical benefits and costs compared with those of other possible therapies. It may also depend on payment policy. Both cyclosporine and rHuEPO were adopted rapidly and extensively by providers of end-stage renal disease care following US Food and Drug Administration approval, despite their high costs. Both drugs were remarkably effective, relatively safe, and able to be administered without great difficulty compared with the therapies they have replaced. There was no additional payment to hospitals for the initial use of cyclosporine, which was introduced in 1983 at the time when Medicare's prospective payment was established, since choice of immunosuppressive agent did not affect the fixed, per-admission payment determined by the diagnosis-related group for kidney transplantation. Medicare coverage for continuing outpatient use of cyclosporine was not initially provided, in contrast to rHuEPO, which was introduced in 1989 with Medicare outpatient coverage and payment of 80% of the allowed charge. Despite their high costs and different methods of insurance payment both drugs achieved a rather quick and high penetration rate into their respective populations.(ABSTRACT TRUNCATED AT 250 WORDS)

Analysis of the frequency spectrum of the equine electroencephalogram during halothane anaesthesia

The electroencephalogram (EEG) has been used in human clinical anaesthesia as an indicator of cortical activity and as an indicator of the depth of anaesthesia. It would be useful if it provided a reliable indication of the depth of anaesthesia of horses. In this study anaesthesia was induced with thiopentone and maintained with halothane in nine ponies. The end tidal halothane concentration (PE-Hal) was monitored and 20 seconds of EEG were recorded at 0.8 per cent, 1.0 per cent and 1.2 per cent halothane, equivalent to the minimum alveolar concentration (MAC), 1.25 MAC and 1.5 MAC. Each 20 second block of data was divided into one second segments and averaged to give one second of averaged EEG from which a frequency spectrum was obtained by using a fast Fourier transformation. The power of the waveform at low frequency (1 to 3 Hz) was compared with that at higher frequency (9 to 11 Hz). The median frequency and 95th percentile (spectral edge) were also calculated. The spectral edge frequency had the best correlation with PE-Hal.

Postoperative analgesia using phenylbutazone, flunixin or carprofen in horses

Horses undergoing surgery were randomly assigned to one of three groups to receive phenylbutazone at 4 mg/kg (n = 72), flunixin at 1 mg/kg (n = 68) or carprofen at 0.7 mg/kg (n = 63) by slow intravenous injection at the end of surgery, just before they were disconnected from halothane. Pain was assessed by either of two resident surgical clinicians (who did not know which non-steroidal anti-inflammatory drug had been given) when the horses first stood up, two and four hours later and the next morning. If repeated doses of analgesic drugs were given the time was recorded and taken as an end point for the study. The presence or absence of side effects was also recorded. In the three groups there was no significant difference between the types of surgery performed, the numbers of horses requiring further analgesia or the pain scores at any time. In the horses needing further analgesia there was a significant difference in the time after surgery at which the further analgesia was given between those in the flunixin group, 12.8 +/- 4.3 hours (mean +/- sd) and those in the phenylbutazone group, 8.4 +/- 4.6 hours; the carprofen group had an intermediate interval of 11.7 +/- 6.9 hours. Significantly fewer of the horses that received butorphanol during surgery needed further analgesia than of those that did not receive any opioid.

Job analysis 1992: infection control practitioner

The Certification Board of Infection Control directed its Research Subcommittee to compose a Job Analysis Committee in 1991. This 9-member Job Analysis Committee, in collaboration with Applied Measurement Professionals, Inc., conducted a job analysis of ICPs during 1992. The reassessment of the previous Certification Board of Infection Control task analysis, formation of a job-analysis survey tool, and the actual job-analysis process and its results are described in this article. The previous and newly revised test specification outlines are compared. The national Certification Examination for Infection Control for November 1993 will reflect the efforts of this endeavor.

Action spectrum for the effect of day-extensions on flowering and apex elongation in green, light-grown wheat (Triticum aestivum L.)

Fluence-rate response curves for wavelengths from 640 nm to 730 nm were constructed for the day-extension promotion of flowering in green, light-grown, wheat (Triticum aestivum L., cv. Alexandria), a long-day plant. The resultant action spectrum had action maxima at 660 nm and 716 nm and resembles spectra for the high-irradiance reaction (HIR) seen in etiolated plants. Because, the HIR is thought to be controlled by type I pytochrome (that which is most abundant in etiolated tissue) our results indicate the involvement of type I phytochrome in the photomorphogenesis of a light-grown, green plant.

Fatty acid composition of fats of differing melting points extracted from ram subcutaneous tissue

The observation that the subcutaneous fat of pasture-fed Southdown rams consists of two distinct regions is reported. Fatty acid composition of fat from the outer and inner regions of subcutaneous tissue taken from the rib region of eight Southdown rams fed pasture were determined. Relative to the harder inner regions (mean melting point 43.1 degrees C), the softer outer regions (mean melting point 31.8 degrees C) were shown to contain more 9:0-, 15:0-, 17:0-, 17:1-, 18:1-cis and total 18:1 fatty acids; less 14:0-, 16:0-, 18:0- and 18:1-trans fatty acids; and a greater variety and a greater concentration of branched-chain components. Proportions of medium chain-length fatty acids, other than 9:0, did not differ between the layers. The fatty acid contents of serial samples taken at 1-mm intervals through these tissues were determined. Changes in concentrations of components among samples were gradual through the tissues. There was no clear connective tissue sheet, as has been reported for pigs. The inner region of the tissues contains apparently nonrandom fluctuating changes in fatty acid composition.

A unique approach to peritoneal dialysis in infants

Little recorded experience exists concerning the use of chronic peritoneal dialysis in the infant. We herein report the results of a multidisciplinary approach to two infants who were treated with a unique modification of "short-dwell" peritoneal dialysis. A single-bag technique was devised in the hopes of reducing glucose absorption and protein losses while concomitantly permitting a simplified manual method of cycling peritoneal dialysis. The desired nutritional needs of the infants consisted of a caloric intake of 140 calories/kg/d and a protein intake of 3.0 to 4.0 g/kg/d, a goal that often required administration through a nasogastric tube. The timely initiation of peritoneal dialysis and the strict adherence to the prescribed dietary regimen was associated with continued growth in both patients. Repeated developmental assessments of each child were conducted and revealed normal development in one patient and mild delay, but gradual improvement, in the other.

The monounsaturated acyl- and alkyl- moieties of wax esters and their distribution in commercial orange roughy (Hoplostethus atlanticus) oil

Wax esters were isolated from commercial orange roughy (Hoplostethus atlanticus) oil by column chromatography and fractionated by argentation thin layer chromatography. Following transesterification, the resultant fatty acid methyl esters and fatty alcohols were analyzed by gas chromatography. Both acyl- and alkyl-moieties were mainly of the monoene structure within the 16:1-22:1 range. After derivatization, the positions of the double bonds of even numbered fatty acid and fatty alcohol isomers were located by chromatography-mass spectrometry and compared. Results of these positional analyses indicate that the primary desaturation reactions takes place in the delta 9 position of pre-existing (C14 to C24) acyl chains. It is proposed that acyl components from 18:1 are subjected to chain elongation to form a mixture of 24:1 isomers as the final product. Apart from the 24:1 acyl moiety of the wax esters, in which the double bond was almost exclusively in the delta 15 position, de novo biosynthetic reactions on acids and alcohols appear to yield related acyl- and alkyl-moieties of resynthesized wax esters.

Time use of mothers with preschool children: a pilot study

This pilot study describes and compares the time use for physical child care of two groups of mothers--those with physically handicapped preschoolers (N = 16) and those with normal preschoolers (N = 21). Each mother completed a questionnaire on the time she spent in three categories of physical child care activities. These activities included feeding, personal care, and transportation for physical care. Investigators collected data on both frequency and duration. They reported descriptive data for all categories separately and combined. The results of the study show that the mothers of the physically handicapped preschoolers spent significantly more time engaged in physical child care activities than did the mothers of normal preschoolers. Results also show a high correlation between frequency and duration data for physical child care. The results strongly suggest that the mothers of physically handicapped preschoolers spend significantly more time in physical child care than do the mothers of normal preschoolers. They also suggest that frequency data alone could be collected in further studies in this area without appreciably reducing the accuracy of the results.

The carbon dioxide laser in podiatric medicine

The CO2 laser has several distinct advantages in its application to soft tissue lesions of the foot. A dry field is obtained with good hemostasis and clear vision, with easy access in confined areas. The laser beam sterilizes as it cuts, reducing the incidence of infection. In sealing lymphatic channels, it may theoretically diminish the risk of metastasis in malignant lesions. Healing occurs with minimal postoperative swelling, scarring, or pain, leading to increased patient comfort. Other areas in which the laser can be helpful are porokeratosis, keloids, spider web varicosities, and tattoos.

Combined phenotypic and genotypic analysis of ringed sideroblasts in acquired idiopathic sideroblastic anemia

Bone marrow from an 81-year-old male with acquired idiopathic sideroblastic anemia was found to be mosaic for 45,X/46,XY cell lines. Analysis of ringed sideroblasts for the presence or absence of a quinicrine fluorescent Y body indicated that all sideroblastic cells had lost the Y chromosome. The demonstration that the ringed sideroblasts were cytogenetically abnormal in this patient provides evidence that the cytogenetic changes often found in patients with sideroblastic anemia may not be due to randomly acquired chromosome aberrations accompanying tissue aging unrelated to the disease process.

Reese Osteotomy Guide System

This paper has been developed to provide surgeons with a new technique called the Reese Osteotomy Guide System. This technique allows surgeons to perform and determine osteotomies with more precision, resulting in better bone healing, greater stability, and more predictable results.