How Primary Care Clinicians Process Patient Death: Logistics, Emotions, and Opportunities for Structural Support

BACKGROUND

Navigating the logistics and emotional processing of a patient's death is an inevitable part of many physicians' roles. While research has primarily examined how inpatient clinicians cope with patient loss, little work has explored how primary care clinicians (PCCs) handle patient death in the outpatient setting, and what support resources could help PCCs process loss.

OBJECTIVE

To explore PCCs' experiences with the logistics and emotional processing of patient deaths and suggestions for supportive resources.

DESIGN

Qualitative study using semi-structured interviews conducted between March and May 2023.

PARTICIPANTS

Recruitment emails were sent to 136 PCCs (physicians and nurse practitioners) at three San Francisco academic primary care clinics. Twelve clinicians participated in the study.

APPROACH

This study used a template analysis approach. Interview transcripts were analyzed in an iterative fashion to identify themes for how PCCs navigate patient death.

RESULTS

Participants (n=12) described outpatient death notification as inconsistent, delayed, and rife with uncertainty regarding subsequent actions. They felt various emotions, notably sadness and guilt, especially with deaths of young, vulnerable patients or those from preventable illnesses. Participants identified strategies for emotional processing and recommended improvements including clear procedural guidance, peer debriefings, and formal acknowledgements of deceased patients.

CONCLUSIONS

Interviewing PCCs about their experiences following a patient death revealed key themes in logistical and emotional processing, and clinic resource recommendations to better support PCCs. Given the distinct characteristics of primary care-such as enduring patient relationships, greater isolation in ambulatory settings compared to inpatient environments, and rising burnout rates-enhancing guidance and support for PCCs is crucial to mitigate administrative burdens and grief after patient loss.

Can Assessment of the Tongue on Brain MRI Aid Differentiation of Seizure from Alternative Causes of Transient Loss of Consciousness?

BACKGROUND AND PURPOSE

Transient loss of consciousness is commonly evaluated in the emergency department. Although typically caused by epileptic seizure, syncope, or psychogenic nonepileptic seizure, the underlying etiology is frequently misdiagnosed. Lateral tongue bites are reportedly a specific clinical finding of seizure. We have observed tongue signal abnormality suggesting bite injury on brain MR imaging after seizures. We hypothesized an association between tongue signal abnormality and seizure diagnosis among patients in the emergency department imaged for transient loss of consciousness. Our purposes were to determine the prevalence of tongue signal abnormality among this population and the predictive performance for seizure diagnosis.

MATERIALS AND METHODS

For this retrospective study including 82 brain MR imaging examinations, 2 readers independently assessed tongue signal abnormality on T2-weighted and T2-weighted FLAIR images. Discrepancies were resolved by consensus, and interrater reliability (Cohen κ) was calculated. The final diagnosis was recorded. Proportions were compared using the Fisher exact test.

RESULTS

Tongue signal abnormality was present on 19/82 (23%) MR imaging examinations. Interrater reliability was "substantial" (κ = 0.77). Seizure was diagnosed among 18/19 (95%) patients with tongue signal abnormality and 29/63 (46%) patients without it (P < .001). In our cohort, tongue signal abnormality conveyed 97% specificity, 95% positive predictive value, and 63% accuracy for seizure diagnosis.

CONCLUSIONS

Tongue signal abnormality was observed in 23% of the study cohort and conveyed 97% specificity and 95% positive predictive value for seizure diagnosis. By assessing and reporting tongue signal abnormality, radiologists may facilitate a timely and accurate diagnosis of seizure among patients imaged for transient loss of consciousness.

Correction of mildly dysplastic hips with periacetabular osteotomy demonstrates promising outcomes, achievement of correction goals, and excellent five-year survivorship

AIMS

The aim of this study was to compare patient-reported outcome measures (PROMs), radiological measurements, and total hip arthroplasty (THA)-free survival in patients who underwent periacetabular osteotomy (PAO) for mild, moderate, or severe developmental dysplasia of the hip.

PATIENTS AND METHODS

We performed a retrospective study involving 336 patients (420 hips) who underwent PAO by a single surgeon at an academic centre. After exclusions, 124 patients (149 hips) were included. The preoperative lateral centre-edge angle (LCEA) was used to classify the severity of dysplasia: 18° to 25° was considered mild (n = 20), 10° to 17° moderate (n = 66), and < 10° severe (n = 63). There was no difference in patient characteristics between the groups (all, p > 0.05). Pre- and postoperative radiological measurements were made. The National Institute of Health's Patient Reported Outcomes Measurement Information System (PROMIS) outcome measures (physical function computerized adaptive test (PF CAT), Global Physical and Mental Health Scores) were collected. Failure was defined as conversion to THA or PF CAT scores < 40, and was assessed with Kaplan-Meier analysis. The mean follow-up was five years (2 to 10) ending in either failure or the latest contact with the patient.

RESULTS

There was no significant difference in PROMs for moderate (p = 0.167) or severe (p = 0.708) groups compared with the mild dysplasia group. The numerical pain scores were between 2 and 3 units in all groups at the final follow-up (all, p > 0.05). There was no significant difference (all, p > 0.05) in the proportion of patients achieving target correction for the LCEA between groups. The mean correction was 12° in the mild, 15° in the moderate (p = 0.135), and 23° in the severe group (p < 0.001). Failure-free survival at five years was 100% for mild, 79% for moderate, and 92% for severely dysplastic hips (p = 0.225).

CONCLUSION

Although requiring less correction than hips with moderate or severe dysplasia, we found PAO for mild dysplasia to be associated with promising PROMs, consistent with that of the general United States population, and excellent survivorship at five years. Future studies should compare these results with the outcome after arthroscopy of the hip in patients with mild dysplasia. Cite this article: Bone Joint J 2019;101-B(6 Supple B):16-22.

A reduction in cardiac arrests and duration of clinical instability after implementation of a paediatric rapid response system

OBJECTIVE

To determine the effects of a multifaceted paediatric rapid response system on the duration of predefined clinical instability and the subsequent rate of cardiac arrests.

METHODS

An interrupted time series study coupled with a retrospective chart review to evaluate the effects of implementing a four component paediatric rapid response system. All patients in a 136-bed university-affiliated paediatric hospital from August 2003 to May 2007 were considered. The main outcome measures included rate of cardiac arrests as indicated by the number of patient days between ward paediatric cardiac arrests and duration of predefined clinical instability before evaluation by critical care personnel.

RESULTS

The mean time interval between cardiac arrests increased significantly with the establishment of the rapid response system from a baseline of 2512 to 9418 patient days. The median duration of clinical instability decreased from 9 h 55 min to 4 h 15 min post intervention (p=0.028).

CONCLUSIONS

The implementation of a paediatric rapid response system is associated with a significant reduction in the rate of cardiac arrests and duration of clinical instability before evaluation by critical care personnel. This study provides evidence that implementation of a rapid response system brings emergency personnel to deteriorating patients earlier, thus preventing cardiac arrests.

The stereochemical outcome of electrophilic addition reactions on the 5,6-double bond in the spinosyns

The electrophilic addition of reagents to the 5,6-double bond in spinosyn A and spinosyn D systems occurred with high pi-diastereofacial selectivity. Addition occurred preferentially from the beta face of the molecule with selectivities ranging from 5:1 to better than 30:1. Various NMR properties were investigated in order to distinguish the beta and alpha isomers with the help of theoretical models of the products. These NMR properties include a (13)C gamma effect to C-11 and vicinal coupling between H-4 and H-5. To help rationalize the selectivity, computational studies on the transition states for epoxidation were calculated using density functional theory. The results indicate that beta epoxidation is favored and that the geometries of the transition structures are consistent with torsional steering being the source of the selectivity.

Reactions of Azotobacter vinelandii nitrogenase using Ti(III) as reductant

Nitrogenase-catalyzed reactions using Ti(III) were examined under a wide variety of conditions to determine the suitability of Ti(III) to serve as a general nitrogenase reductant. Solutions prepared from H2-reduced TiCl3, aluminum-reduced TiCl3, TiCl2, evaporated TiCl3 from an HCl, solution, and TiF3 were evaluated as reductants. Three general types of reactivity were observed. The first showed that, below Ti(III) concentrations of about 0.50 mM, nitrogenase catalysis utilized Ti(III) in a first-order reaction. The second showed that, above 0.50 mM, the rate of nitrogenase catalysis was zero order in Ti(III), indicating the enzyme was saturated with this reductant. Above 2.0-5.0 mM, nitrogenase catalysis was inhibited by Ti(III) depending on the titanium source used for solution preparation. This inhibition was investigated and found to be independent of the buffer type and pH, while high salt and citrate concentrations caused moderate inhibition. [Ti(IV)] above 2.0-3.0 mM and [Ti(III)] above about 5.0 mM were inhibitory. ATP/2e values were 4-5 for [Ti(III)] at or below 1.0-2.0 mM, 2.0 from 5.0 to 7.0 mM Ti(III) where nitrogenase is not inhibited, and 2.0 above 7.0 mM Ti(III) where severe inhibition occurs. For nitrogenase-catalyzed reactions using Ti(III) as reductant, the potential of the solution changes with time as the Ti(III)/Ti(IV) ratio changes. From the change in the rate of product formation (Ti(III) disappearance) with change in solution potential, the rate of nitrogenase catalysis was determined as a function of solution potential. From such experiments, a midpoint turnover potential of -480 mV was determined for nitrogenase catalysis with an associated n = 2 value.

Homology model directed alignment selection for comparative molecular field analysis: application to photosystem II inhibitors

The use of a computational docking protocol in conjunction with a protein homology model to derive molecular alignments for Comparative Molecular Field Analysis (CoMFA) was examined. In particular, the DOCK program and a model of the herbicidal target site, photosystem II (PSII), was used to derive alignments for two PSII inhibitor training sets, a set of benzo- and napthoquinones and a set of butenanilides. The protein design software in the QUANTA molecular modeling package was used to develop a homology model of spinach PSII based on the reported amino acid sequence and the X-ray crystal structure of the purple bacterium reaction center. The model is very similar to other reported PSII protein homology models. DOCK was then used to derive alignments for CoMFA modeling by docking the inhibitors in the PSII binding pocket. The molecular alignments produced from docking yielded highly predictive CoMFA models. As a comparison, the more traditional atom-atom alignments of the same two training sets failed to produce predictive CoMFA models. The general utilities of this application for homology model refinement and as an alternative scoring method are discussed.

Enhanced efficiency of ATP hydrolysis during nitrogenase catalysis utilizing reductants that form the all-ferrous redox state of the Fe protein

The amount of MgATP hydrolyzed per pair of electrons transferred (ATP/2e) during nitrogenase catalysis (1.0 atm N(2), 30 degrees C) using titanium(III) citrate (Ti(III)) as reductant was measured and compared to the same reaction using dithionite (DT). ATP/2e values near 2.0 for Ti(III) and 5.0 for DT indicate that nitrogenase has a much lower ATP requirement using Ti(III) as reductant. Using reduced Azotobacter vinelandii flavoprotein (AvFlpH(2)), a possible in vivo nitrogenase reductant, ATP/2e values near 2.0 were also observed. When the reaction was conducted using Ti(III) under N(2), 5% CO in N(2), Ar, 5% CO in Ar, or acetylene, ATP/2e values near 2.0 were also observed. With Ti(III) as reductant, ATP/2e values near 2.0 were measured as a function of temperature, Fe:MoFe protein ratio, and MoFe:Fe protein ratio, in contrast to measured values of 4.0-25 when DT is used under the same conditions. Both Ti(III) and AvFlpH(2) are capable of forming the [Fe(4)S(4)](0) cluster state of the Fe protein whereas DT is not, suggesting that ATP/2e values near 2.0 arise from operation of the [Fe(4)S(4)](2+)/[Fe(4)S(4)](0) redox couple with hydrolysis of only 2 ATPs per pair of electrons transferred. Additional experiments showed that ATP/2e values near 2. 0 correlated with slower rates of product formation and that faster rates of product formation produced ATP/2e values near 5.0. ATP/2e values of 5.0 are consistent with the operation of the [Fe(4)S(4)](2+)/[Fe(4)S(4)](1+) redox couple while ATP/2e values of 2.0 could arise from operation of the [Fe(4)S(4)](2+)/[Fe(4)S(4)](0) redox couple. These results suggest that two distinct Fe protein redox couples may be functional during nitrogenase catalysis and that the efficiency of ATP utilization depends on which of these redox couples is dominant.

The Iowa Articulation Story. Collaboration works

Historically, Iowa has had a majority of diploma and associate degree nursing graduates. Although educational mobility for registered nurses to obtain baccalaureate nursing degrees was available in Iowa before 1991, direct nursing education articulation did not exist. The impetus for developing a statewide nursing articulation plan to facilitate the entry of registered nurses to baccalaureate nursing programs was the result of a recommendation from the Iowa Board of Nursing's 1988 Statewide Plan for Nursing. The Iowa Articulation Plan for Nursing Education: RN to Baccalaureate, implemented in 1991, resulted from collaboration among nurse educators from all levels of nursing and nursing service representatives. The plan consists of four separate options and can be adapted for use in other parts of the country. The Iowa articulation story describes the process used and outcomes achieved when nurses collaborate to advance nursing education.

Steady-state kinetic studies of dithionite utilization, component protein interaction, and the formation of an oxidized iron protein intermediate during Azotobacter vinelandii nitrogenase catalysis

Steady-state kinetic analysis of the two-component protein system of Azotobacter vinelandii (Av) nitrogenase is reported. A precisely obeyed half-order reaction in dithionite was observed at concentrations up to 21 mM with no indication of saturation by this substrate. This behavior was monitored by optical, amperometric, and manometric kinetic techniques, and the results were mathematically fit to establish the half-order reaction in dithionite. Under conditions where the MgATP and dithionite concentrations remain unchanged, Av2 (the Fe protein component) interacts with Av1 (the MoFe protein component according to the rate law, suggesting a rapid 1:1 Av2-Av1 interaction: [formula: see text]. with [Av2] the free Fe protein concentration, K = 5.9 microM, and Vmax = 2314 nmol of H2 min-1 (mg of Av1)-1. Under dithionite-depleted conditions, Av2 undergoes an Av1-mediated, one-electron oxidation, consistent with its proposed role as a specific, single-electron reductant for Av1. During steady-state turnover as a function of Av2/Av1 ratio, optical spectroscopy demonstrated the presence of 25-30% oxidized Av2 as an enzyme intermediate. Computer-averaged EPR spectra showed that Av1 was > 95% EPR-silent and Av2 was up to 30% oxidized (Av2ox), consistent with the optical measurements. These optical and EPR results show that up to six Av2ox per Av1 can accumulate in the presence of dithionite during catalysis, suggesting that the conversion of Av2ox back into Av2red is a relatively slow process.

Activity of the Escherichia coli mutT mutator allele in an anaerobic environment

Mutation frequencies for an Escherichia coli mutT strain were measured in both aerobic and anaerobic environments. When cells were grown in a rich medium (L broth), mutation frequencies were similar in both aerobic and anaerobic conditions. In contrast, when grown in a minimal medium, mutT anaerobic mutation frequencies were reduced dramatically compared with aerobic values, which were similar to L broth frequencies. L broth mutT cultures treated with a commercial enzyme complex that reduces free oxygen in the medium also showed strongly reduced anaerobic mutation frequencies. These results indicate that the biological role of the MutT protein is to prevent oxidative damage from becoming mutagenic.