Abstract WMP19: When Minutes Count: Addition Of Stroke Transfer Coordinator

The treatment of hyper acute ischemic stroke is time critical, requiring a coordinated team response. It is common among primary and comprehensive stroke centers to have a “stroke alert” process, activating physicians, laboratory, radiology, and nursing support. In our center, the stroke alert included activation of a stroke program coordinator during day hours to assist with data gathering and time tracking. A clinical nurse expert would attend stroke alerts as able to on nightshift. At times, there were gaps when no personnel were available, and data was backtracked. In 2021, the use of Viz.AI was implemented. The Viz app allows streamlined communication amongst the treatment team (MD, ED Charge, Bed Capacity, etc.). Information including COVID status, time of Contrast given, imaging studies, and family contact information are exchanged prior to the patient’s arrival. Six Stroke Transfer Coordinators (STC) were hired, whose primary focus was attending stroke alerts, monitoring CT scans through the Viz app, and facilitating the transfer of patients with Large Vessel Occlusion (LVO) for thrombectomy treatment.

Methods: This is a single center retrospective cohort study. Basic demographic data, presence of LVO, time of last known well, time of imaging, time of transfer acceptance, NIHSS, and thrombolysis prior to transfer were recorded. Door-in-door out, door-to-angiogram, and door-to-groin puncture times were also collected. We compared and analyzed data from 12 months prior to implementation of the STC (August 2020-July 2021) to the 12 months post-implementation (August 2021 to July 2022).

Results: Total number of Stroke Alerts (SA) in the pre-STC time period was 1479, with 136 thrombectomy alert. Post-TSC the total number of SA was 1306, with 179 thrombectomy alerts. The mean door-to-intervention time pre-STC was 24 minutes (median=25 minutes). Post implementation of the STC, the mean door-to-intervention time was 17 minutes (median= 12 minutes).

Conclusions: STC’s improved the door-to-intervention time by mean of 7 minutes (median= 13 minutes). When every minute counts in re-establishing brain perfusion, this improvement may lead to better patient outcomes. Further study is necessary.

Abstract P865: Pediatric Stroke Algorithm Revision: Focus on Education Process

Background: While the incidence of Pediatric stroke is low at 2.3 to 13 per 100,000 children, our institution saw a need for a pediatric stroke algorithm to provide guidance when children present with stroke symptoms. The process began with development and release of a pediatric stroke guideline in 2017. After initiation of the guideline, mock stroke alerts periodically were performed with feedback provided by staff. After several reviews and revisions, the paradigm of a guideline was discarded in favor of an algorithm, a more accurate reflection of the necessity for clinical judgement rather than a series of predetermined steps. In June 2020, the Pediatric Stroke Algorithm was revised to incorporate one algorithm for both Emergency Room (ER) and inpatient areas after a recent mock stroke alert in the Pediatric Intensive Care Unit (PICU) and following feedback. The purpose behind our process improvement project was to provide education regarding the updated Pediatric Stroke Algorithm to all relevant clinical areas.

Methods: The first step was to identify the staff in patient care areas that would need education on the updated Pediatric Stroke Algorithm. Next, we identified the methods of communication that would be utilized to ensure all staff received proper education.

Results: In 2020, the updated Pediatric Stroke Algorithm document was placed on the UK HealthCare Care Web page (Clinical Web Page). Information on the location of the document was sent to the key stakeholders for nursing, physician, and appropriate ancillary staff in the ER and PICU for further distribution. The algorithm was presented in various stroke committee meetings and sent by email to team members of these committees to share with their staff. The algorithm was further presented at the PICU Collaborative Practice Meeting and posted on the PICU share point site, in the ER, and PICU areas.

Conclusions: A comprehensive educational process of the revised Pediatric Stroke Algorithm was successfully completed with all the appropriate staff.

Marine debris is selected as nesting material by the brown booby (Sula leucogaster) within the Swain Reefs, Great Barrier Reef, Australia

Many seabirds are impacted by marine debris through its presence in foraging and nesting areas. To determine the extent of this problem, marine debris use in nest material of the brown booby (Sula leucogaster) in the Great Barrier Reef, Australia, was investigated. Nine cays were examined using beach and nest surveys. On average, four marine debris items were found per nest (n=96) with 58.3% of surveyed nests containing marine debris. The source of marine debris in nests and transects were primarily oceanic. Hard plastic items dominated both nest (56.8%) and surveyed beaches (72.8%), however only two item types were significantly correlated between these surveys. Nest surveys indicated higher levels of black and green items compared to beach transects. This selectivity for colours and items suggest these nests are not good indicators of environmental loads. This is the first study to examine S. leucogaster nests for marine debris in this location.

Ingestion of marine debris plastic by the wedge-tailed shearwater Ardenna pacifica in the Great Barrier Reef, Australia

We present the first evidence of ingestion of plastic by seabirds from the southern Great Barrier Reef (GBR), Australia. The occurrence of marine debris ingestion in the wedge-tailed shearwater, Ardenna pacifica, on Heron Island was the focus of this preliminary research. Our findings indicate that 21% of surveyed chicks are fed plastic fragments by their parents, having ingested 3.2 fragments on average. The most common colours of ingested plastic fragments were off/white (37.5%) and green (31.3%). Ingested fragments had a mean size of 10.17±4.55 mm and a mean weight of 0.056±0.051 g. Our results indicate that further research is critical to understanding the extent of ingestion, colour preferences, and what impacts ingestion may have on these and other seabird populations in the GBR.

Pharmacologic options for the treatment of obesity

Past and current drug therapies for weight loss are discussed. More than 50% of Americans can be categorized as overweight or obese. Obesity is associated with increased mortality and with comorbidities such as hypertension, hyperglycemia, dyslipidemia, coronary artery disease, and certain cancers. According to guidelines for identification, evaluation, and treatment of obesity, patients with a body mass index (BMI) of > or = 30 kg/m2 should attempt to lose weight. Patients with a BMI of > or = 25 kg/m2 plus two or more risk factors or patients with an excessive waist circumference plus two or more risk factors should also attempt to lose weight. The initial goal is a 10% weight reduction in six months achieved through lifestyle changes. If lifestyle changes alone are not effective, then drug therapy may be indicated. Pharmacotherapeutic options for obesity have decreased over the past few years. Fenfluramine, dexfenfluramine, and phenylpropanolamine have been withdrawn because of severe adverse effects, leaving only sympathomimetics, sibutramine, and orlistat as anorectics with FDA-approved labeling. Phentermine has been shown to cause a 5-15% weight loss if given daily or intermittently. Compared with sibutramine and orlistat, phentermine is cheaper, and specific formulations allow once-daily administration. However, phentermine is indicated only for short-term treatment, and tolerance often develops. Common adverse effects associated with phentermine are dry mouth, insomnia, increased blood pressure, and constipation. Sibutramine increases norepinephrine and serotonin levels in the CNS and should not be taken with many antidepressants because of the risk of increased norepinephrine and serotonin levels. Its use is also contraindicated in patients with cardiovascular disease. Orlistat is not systemically absorbed; therefore, it does not cause the systemic adverse effects or drug interactions of phentermine and sibutramine. Orlistat has a cholesterol-lowering effect not seen with other diet medications. However, the three-times-daily administration and frequent gastrointestinal effects limit its use. Sibutramine, phentermine, and orlistat have both positive and negative properties. Choosing among the medications will depend on concurrent disease states and medications, ease of administration, and cost.

The synthesis of phosphopeptides

Phosphorylation and dephosphorylation are key events in protein expression and regulation and in signal transduction. Phosphopeptides are very useful reagents for the study of these processes, and have been used to great advantage in the study of phosphatase substrate specificity, SH2 domain ligand specificity, and protein-protein interactions. Furthermore, the advent of cell-permeable peptide carriers, such as those from the antennapedia homeodomain and the HIV TAT transcription factor, has allowed the study of intracellular events, thus underscoring the utility of these reagents. In this paper we review methods for the synthesis of phosphopeptides with the emphasis on the preparation of phosphoamino acid building blocks.

Secondary health conditions among middle-aged individuals with chronic physical disabilities: implications for unmet needs for services

Data from the Aging with Disability (AwD) Study are used to examine variations in the types and frequency of secondary conditions experienced by 301 middle-aged individuals living with the effects of three disabling conditions: polio (n = 124), rheumatoid arthritis (RA) (n = 103), and stroke (n = 75). All respondents were randomly selected from a county rehabilitation hospital or a community-based subject pool. Secondary conditions are operationalized as (1) the number of new health problems diagnosed or treated since the onset of the primary disability and (2) the amount of change/decline in basic and instrumental daily activities since a previous reference period in the disability trajectory. Also analyzed are changes in use of assistive devices and unmet needs for services. Differences in secondary conditions are examined within the AwD sample by impairment group and between samples by comparing AwD rates to national estimates for the same cohort. Results reveal significant differences in the types of new health problems reported by persons living with polio, RA, and stroke and document marked disparities, or accelerated aging, between disabled and nondisabled adults. Findings are discussed in terms of the changing health care needs of persons aging with disability and the importance of improving access to preventive services, ongoing rehabilitation, and assistive technology.

Construction of a BAC contig map of chromosome 16q by two-dimensional overgo hybridization

We have used sequence-based markers from an integrated YAC STS-content/somatic cell hybrid breakpoint physical map and radiation hybrid maps of human chromosome 16 to construct a new sequence-ready BAC map of the long arm of this chromosome. The integrated physical map was generated previously in our laboratory and contains 1150 STSs, providing a marker on average every 78 kb on the euchromatic arms of chromosome 16. The other two maps used for this effort were the radiation hybrid maps of chromosome 16 from Whitehead Institute and Stanford University. To create large sequenceable targets of this chromosome, we used a systematic approach to screen high-density BAC filters with probes generated from overlapping oligonucleotides (overgos). We first identified all available sequences in the three maps. These include sequences from genes, ESTs, STSs, and cosmid end sequences. We then used BLASTto identify 36-bp unique fragments of DNA for overgo probes. A total of 906 overgos were selected from the long arm of chromosome 16. Hybridizations occurred in three stages: (1) superpool hybridizations against the 12x coverage human BAC library (RPCI-11); (2) two-dimensional hybridizations against rearrayed positive BACs identified in the superpool hybridizations; and (3) pooled tertiary hybridizations for those overgos that had ambiguous positives remaining after the two-dimensional hybridization. For the superpool hybridizations, up to 236 overgos have been pooled in a single hybridization against the 12x BAC library. A total of 5187 positive BACs from chromosome 16q were identified as a result of five superpool hybridizations. These positive clones were rearrayed on membranes and hybridized with 161 two-dimensional subpools of overgos to determine which BAC clones were positive for individual overgos. An additional 46 tertiary hybridizations were required to resolve ambiguous overgo-BAC relationships. Thus, after a total of 212 hybridizations, we have constructed an initial probe-content BAC map of chromosome 16q consisting of 828 overgo markers and 3363 BACs providing >85% coverage of the long arm of this chromosome. The map has been confirmed by the fingerprinting data and BAC end PCR screening.

Patient responses during rapid terminal weaning from mechanical ventilation: a prospective study

OBJECTIVE

To describe and analyze patient responses to rapid terminal weaning from mechanical ventilation.

DESIGN

A prospective, descriptive, correlational study.

SETTING

An urban, university-affiliated, trauma/emergency hospital.

PATIENTS

A convenience sample of 31 adult patients experiencing withdrawal of mechanical ventilation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Physiologic (peripheral oxygen saturation, end-tidal CO2, heart rate, and respiratory rate) and comfort (electroencephalogram [EEG], Bizek Agitation Scale, and the COMFORT scale) measures were collected at baseline, during, and after the terminal weaning procedure. Clinical status was measured using the Acute Physiology and Chronic Health Evaluation score, Glasgow Coma Scale, and PaO2/F(IO2). Duration of survival after the wean inversely correlated with illness severity but did not correlate with consciousness, use of analgesia/sedation, or pulmonary function. Respiratory rate and oxygen saturation changed significantly during the wean but not end-tidal CO2. Patients remained comfortable with little or no analgesia/sedation, in a predominantly comatose sample. Subjective measures of comfort strongly correlated with objective data from bispectral analysis of EEG.

CONCLUSIONS

Patients with altered consciousness or coma can be kept comfortable during a rapid terminal weaning procedure with morphine and benzodiazepines in low doses. Comfort can be reliably evaluated using subjective scales.

Spatial and temporal expression of AP-1 responsive rod photoreceptor genes and bZIP transcription factors during development of the rat retina

PURPOSE

The promoter region of the rod-specific beta subunit of cGMP PDE (beta-PDE) and opsin genes contains highly conserved cis-acting elements, which include an AP-1 and/or Nrl response element (NRE: An extended AP-1 like sequence). Transactivation of AP-1 or NRE appears necessary to drive expression of these rod-specific genes during adulthood, however, their role during development is relatively unknown. Therefore, we determined the spatial and temporal relationships between rod morphological and functional development, rod-specific gene expression, and expression of the bZIP transcription factors c-fos, junD and Nrl.

METHODS

Retinas from 0-45 day old (PN0-45) dark- and light-adapted Long-Evans rats were used. Morphological development was monitored by light and electron microscopy. Whole retinal trypsin-activated cGMP-PDE activity and rhodopsin content were measured biochemically. The expression of opsin, beta-PDE, c-fos, junD and Nrl mRNAs were determined by Northern blot analysis. The cellular localization of Nrl was examined with in situ hybridization.

RESULTS

The mRNAs for opsin, beta-PDE and c-fos were observed at PN0-2, while cGMP-PDE activity and rhodopsin were detected first at PN5: coincident with rod outer segment development. The developmental pattern of cGMP-PDE activity and rhodopsin accumulation paralleled the expression of beta-PDE and opsin mRNA and all reached their maximal levels by PN45. Nrl expression, for all three transcripts found in the rat retina, was low on PN2 and reached its maximal level at PN14. The c-fos and Nrl expression preceded beta-PDE and opsin mRNA expression by 1-2 days. Nrl expression was detected first in the distal post-mitotic retina at PN5 and then in all nuclear layers during retinal development. Maximal expression shifted from the ganglion cells to the outer nuclear layer as the neural retina matured. In contrast, junD expression was highest at PN0 and declined to a stable level by PN10.

CONCLUSIONS

Colocalization of Nrl and c-Fos suggests that expression of rod-specific genes, which utilize AP-1 or NRE sites in their promoter, could be regulated through the formation of Nrl-Fos dimers. We hypothesize that Nrl and c-Fos play a fundamental role in the initiation and regulation of the rod-specific gene expression in developing and adult rod photoreceptors.

A survey of hantavirus antibody in small-mammal populations in selected United States National Parks

Hantavirus activity in 39 National Parks in the eastern and central United States was surveyed by testing 1,815 small mammals of 38 species for antibody reactive to Sin Nombre virus. Antibody-positive rodents were found throughout the area sampled, and in most biotic communities. Antibody was detected in 7% of 647 deer mice (Peromyscus maniculatus), 2% of 590 white-footed mice (P. leucopus), 17% of 12 rice rats (Oryzomys palustris), 3% of 31 cotton rats (Sigmodon hispidus), and 33% of 18 western harvest mice (Reithrodontomys megalotis). Antibody was also found in three of six species of voles, and in one of 33 chipmunks (Tamias minimus). Prevalence among Peromyscus was highest in the northeast. Although few cases of hantavirus pulmonary syndrome have been identified from the eastern and central regions, widespread infection in reservoir populations indicates that potential exists for human infection throughout much of the United States.

Integrating technology with compassionate care: withdrawal of ventilation in a conscious patient with apnea

This case was atypical because the patient was conscious and apneic. The usual responses that indicate a patient's distress during terminal weaning would not have been evident in this patient. Introducing noninvasive monitoring of end-tidal CO2 and SpO2 and using BIS allowed the weaning to progress with confidence that the patient was as comfortable as possible. We think we kept our commitment to HD to honor his wishes by using the most humane method we could devise, and to address his family's needs at the same time.

Integrating technology with compassionate care: withdrawal of ventilation in a conscious patient with apnea

This case was atypical because the patient was conscious and apneic. The usual responses that indicate a patient's distress during terminal weaning would not have been evident in this patient. Introducing noninvasive monitoring of end-tidal CO2 and SpO2 and using BIS allowed the weaning to progress with confidence that the patient was as comfortable as possible. We think we kept our commitment to HD to honor his wishes by using the most humane method we could devise, and to address his family's needs at the same time.

Small mammal survival and trapability in mark-recapture monitoring programs for hantavirus

Following the 1993 hantavirus pulmonary syndrome (HPS) epidemic in the south-western United States, mammalogists and epidemiologists instituted long-term studies to monitor population density and prevalence of infection in rodents which constitute the reservoir for Sin Nombre virus (SNV). In this study, field techniques used in sampling small mammals for SNV infection were evaluated to determine if trapping and handling protocols were having significant effects on future trapability or mortality of animals. We compared rodent mark-recapture control plots, on which all rodents were simply measured, marked, and released on site, with experimental plots on which all animals were anesthetized with methoxyflurane, sampled for blood and saliva, measured, marked, and released. Blood samples were obtained from anesthetized animals on the experimental plots via a retro-orbital sinus puncture using a heparinized capillary tube. Dacron tipped oral swabs were used to collect buccal cells and saliva from the rodent's oral cavity. Field data were collected monthly from August 1994 to August 1996 at two sites in New Mexico (USA). Analyses were based on 3,661 captures of 1,513 individuals representing 21 species from three rodent families (Rodentia: Muridae, Heteromyidae, Sciuridae) and two species of rabbits (Lagomorpha: Leporidae). Overall, for most murid rodents (including five Peromyscus spp., Neotoma albigula, and Onychomys leucogaster) and one rabbit species (Sylvilagus floridanus), the handling/bleeding procedures had no significant effects on recapture rates or mortality. In contrast, several species of heteromyids (Dipodomys ordii and Perognathus flavus), one murid (Reithrodontomys megalotis) and one leporid (S. auduboni) suffered higher mortality rates, and heteromyid kangaroo rats (D. ordii and D. merriami) exhibited lower trapability as a result of the anesthesia and sampling procedures. In view of the overall non-significant influence of the sampling procedures on murid rodents, the anesthesia and blood/saliva sampling protocols described herein appear to be appropriate for hantavirus research, and may serve as a model for environmental monitoring of other zoonotic agents and their reservoirs.

Functional alterations and apoptotic cell death in the retina following developmental or adult lead exposure

Long-term visual system deficits occur in man and animals following developmental and occupational lead exposure. Recent experimental data suggests that the adult brain is not altered following lead exposure. Therefore, the aim of these studies was to use the retina as a CNS model to examine and compare the morphological, biochemical and electroretinographic (ERG) changes occurring in rats exposed to low or moderate levels of lead during development (0-21 days of age) with those occurring in adult rats with equivalent blood and retinal levels of lead for three or six weeks. Five main results were obtained. First, developmental and adult lead exposure for six weeks produced age- and dose-dependent retinal degeneration such that rods and bipolar cells were selectively lost. At the ultrastructural level, all dying cells exhibited the classical morphological features of apoptotic cell death. Second, in the lead-exposed groups, the decrease in the number of rods was correlated with the loss of rhodopsin content per eye confirming that rods were directly affected by lead. Third, single-flash rod ERGs and cone ERGs obtained from developmentally and adult lead-exposed rats demonstrated that there were age- and dose-dependent decreases in the rod a-wave and b-wave sensitivity and maximum amplitudes without any effect on cones. In adult rats exposed to lead for three weeks, qualitatively similar ERG changes occurred in the absence of cell loss or decrease in rhodopsin content. Fourth, developmental and adult lead exposure for three and six weeks produced age- and dose-dependent decreases in retinal cGMP phosphodiesterase (PDE) activity resulting in increased cGMP levels. Fifth, picomolar to micromolar concentration of free lead directly inhibited rat retinal and purified bovine rod cGMP PDE. In summary, there are three main conclusions. First, the retinas of developing and adult rats exposed to lead exhibit qualitatively similar rod-mediated ERG alterations as well as rod and bipolar apoptotic cell death. Thus, developing and mature retinas are both sensitive to the adverse effects of lead: albeit to significantly different extents. Second, a similar biochemical mechanism such as the inhibition of rod and bipolar cell cGMP PDE, varying only in degree and duration, underlies both the lead-induced ERG rod-mediated deficits and the rod and bipolar apoptotic cell death. Third, the composite results from our experiments and those of others suggest that the developing retina might be more sensitive to preweaning lead exposure than the hippocampus and thus may serve as a good model for studying the cellular and molecular mechanisms underlying developmental and adult lead neurotoxicity.

The contemporary food supply of three northern Manitoba Cree communities

A complex set of social, economic, cultural and environmental circumstances affecting native Canadians in northern regions has resulted in the dietary replacement of indigenous foods with marketed products not always of equivalent nutritional value. This article examines the current food supply in three northern Manitoba Cree communities by looking at the availability and preservation of traditional foods, the price of marketed foods and perceptions of the food supply. Data were obtained by questionnaire from older adults (over 55 years) and younger women (16-45 years) in each community. The food supply comprised a mix of traditional and marketed foods, with limited use of traditional methods of food preservation. Marketed food prices were high in communities without all-weather road access. Respondents expressed a desire for more traditional food. Promotion of traditional foods could increase nutrient intake, decrease food costs and contribute to a revival of interest in Cree culture.

The contemporary food supply of three northern Manitoba Cree communities

A complex set of social, economic, cultural and environmental circumstances affecting native Canadians in northern regions has resulted in the dietary replacement of indigenous foods with marketed products not always of equivalent nutritional value. This article examines the current food supply in three northern Manitoba Cree communities by looking at the availability and preservation of traditional foods, the price of marketed foods and perceptions of the food supply. Data were obtained by questionnaire from older adults (over 55 years) and younger women (16-45 years) in each community. The food supply comprised a mix of traditional and marketed foods, with limited use of traditional methods of food preservation. Marketed food prices were high in communities without all-weather road access. Respondents expressed a desire for more traditional food. Promotion of traditional foods could increase nutrient intake, decrease food costs and contribute to a revival of interest in Cree culture.

Depression and life satisfaction in aging polio survivors versus age-matched controls: relation to postpolio syndrome, family functioning, and attitude toward disability

OBJECTIVE

To compare depressive symptoms and life satisfaction in aging polio survivors with age-matched controls and to relate these outcomes to scores to psychosocial and disability-related variables.

DESIGN

A planned medical, functional, and psychosocial study with multivariate analyses.

SETTING

A large, urban rehabilitation center.

PARTICIPANTS

A volunteer sample of 121 polio survivors and an age-matched control group of 60 people with similar sociodemographic backgrounds.

MAIN OUTCOMES

Depression as measured by the Geriatric Depression Scale and an 11-item life satisfaction scale.

RESULTS

The prevalence of depressive disorders was not significantly different in the two groups, although the postpolio group tended to have more symptomatology and an overall depressive disorder prevalence of 28%. Some life satisfaction scale scores were significantly lower in the postpolio group, especially those concerned with health. People with postpolio syndrome scored significantly higher on depression scales and lower on some life satisfaction scales than people with a history of polio but without postpolio syndrome. Several psychosocial variables, most notably family functioning and attitude toward disability, helped to mediate this effect. Among people with significant depression, there was little, evidence of adequate treatment in the community.

CONCLUSIONS

Postpolio by itself does not relate to higher depression scores or lower life satisfaction. Postpolio syndrome has some relation to depression, but family functioning and attitude toward disability are more important. There is a need for better community-based psychological services.

Experience with an end-of-life practice at a university hospital

OBJECTIVE

To describe a 10-yr experience with an end-of-life practice in a hospital.

DESIGN

A nonexperimental, prospective, descriptive design was used to record variables from a convenience sample of patients transferred to the Comprehensive Supportive Care Team.

SETTING

Detroit Receiving Hospital is an urban, university-affiliated, Level I trauma/emergency hospital.

PATIENTS

Patients who are not expected to survive hospitalization, and for whom a decision has been made to focus care on palliative interventions, are candidates for care by this practice.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patient demographics, including the following information: age, gender; diagnoses; illness severity; mortality rate; and disposition. Measures of resource utilization included: referral sources; Therapeutic intervention Scoring System values; bed costs; and length of hospital stay. Satisfactory patient/family care with a measurable reeducation in the use of resources can be achieved in the hospital setting.

CONCLUSIONS

A hands-on approach to the care of dying patients by this specialty, palliative care service has provided patients, families, and clinicians with the type of support needed for satisfactory end-of-life care. A summary of our experience may be useful to others.

Collection of surgical specimens in total joint arthroplasty. Is routine pathology cost effective?

A retrospective review of 715 consecutive cases of total joint arthroplasty (283 hips, 432 knees), performed for a variety of indications during 1992 and 1993, was undertaken to assess the cost effectiveness of routine pathologic examination. The charts were reviewed for preoperative, operative, and pathologic diagnosis, and any discrepancies in diagnosis were noted. Particular attention was paid to pathologic findings suggestive of neoplasia or rheumatoid arthritis that were not noted in the preoperative or operative diagnoses. Six of the 715 cases fit into this category, but all failed to have any clinical significance. No alteration in patient care resulted from routine pathologic examination. This paper questions the necessity of routinely submitting pathologic specimens in uncomplicated total hip and knee arthroplasty.

Impact of patient consciousness on the intensity of the do-not-resuscitate therapeutic plan

BACKGROUND: The nature and intensity of a do-not-resuscitate therapeutic plan varies by patient. Some do-not-resuscitate therapeutic plans may include interventions directed at the withdrawal of life-sustaining therapy. OBJECTIVE: The purpose of this study was to examine the impact of patient consciousness on the nature and intensity of the do-not-resuscitate plan, and on the decision to withdraw life-sustaining therapy. METHODS: This study represents a secondary analysis of data obtained in a previous study to evaluate patient care requirements under varying intensities of do-not-resuscitate plans. Data were collected retrospectively through record review. Patients were grouped as follows, according to the intensity of the do-not-resuscitate plan: (1) all but cardiopulmonary resuscitation, (2) conservative care without cardiopulmonary resuscitation, (3) comfort only, and (4) withdrawal of life-sustaining therapy. In addition to demographic data, consciousness and illness severity were measured. Data were analyzed using descriptive statistics. RESULTS: There was a significant decrease in consciousness from admission in all groups except conservative care. The withdrawal group had the lowest average Glasgow Coma Scale scores at the time of the do-not-resuscitate designation. Multiple regression analysis was used to demonstrate a significant impact of consciousness on type of do-not-resuscitate decision, but no significant impact from age or illness severity. CONCLUSIONS: These results support previous observations that decisions to withdraw life-sustaining therapy are prompted by diminished consciousness. These results may stimulate caregivers to offer withdrawal of life-sustaining therapy as an option in patients with severely decreased consciousness and a poor prognosis for functional recovery.

Impact of patient consciousness on the intensity of the do-not-resuscitate therapeutic plan

BACKGROUND

The nature and intensity of a do-not-resuscitate therapeutic plan varies by patient. Some do-not-resuscitate therapeutic plans may include interventions directed at the withdrawal of life-sustaining therapy.

OBJECTIVE

The purpose of this study was to examine the impact of patient consciousness on the nature and intensity of the do-not-resuscitate plan, and on the decision to withdraw life-sustaining therapy.

METHODS

This study represents a secondary analysis of data obtained in a previous study to evaluate patient care requirements under varying intensities of do-not-resuscitate plans. Data were collected retrospectively through record review. Patients were grouped as follows, according to the intensity of the do-not-resuscitate plan: (1) all but cardiopulmonary resuscitation, (2) conservative care without cardiopulmonary resuscitation, (3) comfort only, and (4) withdrawal of life-sustaining therapy. In addition to demographic data, consciousness and illness severity were measured. Data were analyzed using descriptive statistics.

RESULTS

There was a significant decrease in consciousness from admission in all groups except conservative care. The withdrawal group had the lowest average Glasgow Coma Scale scores at the time of the do-not-resuscitate designation. Multiple regression analysis was used to demonstrate a significant impact of consciousness on type of do-not-resuscitate decision, but no significant impact from age or illness severity.

CONCLUSIONS

These results support previous observations that decisions to withdraw life-sustaining therapy are prompted by diminished consciousness. These results may stimulate caregivers to offer withdrawal of life-sustaining therapy as an option in patients with severely decreased consciousness and a poor prognosis for functional recovery.

Medical futility and life-sustaining treatment decisions

By focusing our attention on the questions of "what are we trying to achieve" and "are we able to do it", the discussion of medical futility has contributed an important dimension to the ethics of treatment decision making near the end of life. It is not simply enough to ask and answer the question of what the patient wants. Healthcare professionals have a responsibility to offer only those life-sustaining efforts that have a reasonable chance of being beneficial. Futility policies should permit treatment-limiting decisions to be made without the agreement of the patient or surrogate at times, but such policies should also provide opportunities to challenge a judgement of futility. Above all, such policies should not be used as a reason to avoid communication. Patients or surrogates need to be informed about what treatments are options and what are not. The futility criterion for limiting treatment should be recognized as a means of contributing to communication and discussion regarding benefits, harms and medical goals. It should not be permitted to bypass such discussions. The recognition of the significance of the concept of futility means that discussion needs to continue at another level as well. The questions of "what are we trying to achieve" and "are we able to do it" are not easily answered. It is especially important, we think, that those who are experienced in working with patients with neurological impairments contribute to the on-going reflection on what constitutes benefit or what is the appropriate use of life-sustaining interventions for such patients.

Program assessment through outcomes analysis: efficacy of a comprehensive supportive care team for end-of-life care

Addressing end-of-life care issues is difficult in our death-denying society, particularly in the hospital environment, which is characterized by a proliferation of life-sustaining therapy. A hospital model for end-of-life care has been in practice at an urban university hospital since late 1985. Outcomes analysis at the micro-level permitted a demonstration of the practice's effectiveness over time.

Managing terminal dyspnea: caring for the patient who refuses intubation or ventilation

Dyspnea in a dying patient is one of the most distressing symptoms challenging a critical care nurse. A humane response to terminal dyspnea, which may result when the patient chooses to forego life-sustaining intubation and ventilation, is expected by the patient. The author presents strategies for reducing the distress of dyspnea for patients who are dying when intubation and ventilation are being withheld.

Chronic steroid-responsive encephalitis without autoantibodies to glutamate receptor GluR3

Autoantibodies to GluR3, an AMPA glutamate receptor subtype, may be a cause of chronic unilateral encephalitis (Rasmussen's syndrome). We report a woman with chronic left hemisphere encephalitis whose partial seizures, aphasia, and motor weakness are highly responsive to intermittent steroids and cyclophosphamide. Her serum and CSF were negative for antibodies to GluR3 by both immunoblot and immunocytochemical analysis of cells transfected with GluR3 cDNA, indicating that separate immune-mediated processes may be involved in some cases of chronic encephalitis.

Interpretation of an ambiguous advance directive

Advance directives are statements made by a person who is capable of making decisions regarding health care choices that need to be applied at a future time when the person may no longer be capable of decision making. A patient may present a life-threatening condition with an ambiguous advance directive, and a delay in decision making could compromise the patient outcome. This article describes a case and includes an analysis of a situation where there is an ambiguous advance directive. Suggestions to the critical care nurse are provided.

Combination adriamycin and suramin induces apoptosis in bcl-2 expressing prostate carcinoma cells

Bcl-2 expression has been associated with progression of prostate cancer from androgen-dependence to androgen-independence and may contribute to the relative drug-resistant phenotype typically observed in androgen-independent prostate cancer. Dunning-G rat prostate cancer cells transfected with a bcl-2 expression vector demonstrated resistance to apoptosis induced by adriamycin and, to a lesser extent, suramin. Use of adriamycin and suramin in combination, however, circumvents this bcl-2 associated drug resistance. Our findings indicate that combination drug actions may induce apoptosis in resistant malignant cell types with defective apoptotic pathways.

An advanced practice model: inpatient collaborative practices

Advanced practice nurses play a key role in optimal patient care. In primary care, their functions include history taking, physical examination, development of a plan of care, instruction and counseling, use of laboratory data, diagnosis of routine illness, prescription of medications or other therapies as allowed by state laws, coordination of services, and referral when necessary. These nursing services may be provided independently or in collaboration with physician providers. Nurse-physician collaborative practices generally occur in the ambulatory care setting. The purpose of this article is to illustrate inpatient collaborative practices with CNSs and staff physicians in an urban, medical-center hospital.

Procuring organs from a non-heart-beating cadaver: commentary on a case report

Procurement of organs from non-heart-beating cadaver donors raises concerns. Standards for optimal patient care during withdrawal of life-sustaining therapy are evolving and continue to be debated and studied. Consensus on specific procedures and methods has not been attained, however, and protocols for the procurement of organs from patients following the withdrawal of life-sustaining therapies may compromise the evolving standards and harm the patient and the attendant family. In addition, there is little evidence to suggest that such protocols will significantly increase the number of organs procured. "Non-heart-beating cadaver" protocols that do not give comprehensive attention to optimal patient/family care at the time of withdrawal of life-sustaining therapy ought not to be endorsed.

Impact of the DNR therapeutic plan on patient care requirements

BACKGROUND. The intensity and nature of a patient therapeutic plan should depend upon the specific therapeutic goals. When the therapeutic plan includes a do-not-resuscitate order, the intensity of the plan may be high or low. OBJECTIVE. To examine the differences in patient care requirements and hospital outcomes in patients with a do-not-resuscitate status to determine the most appropriate care setting, eg, intensive vs nonintensive care. METHOD. Data from a prospective sample of 100 patients were analyzed. Patients were grouped according to the intensity of the therapeutic plan: (1) all-but-CPR: all support except cardiopulmonary resuscitation, (2) conservative-care: medical management without the addition of life-sustaining measures, (3) comfort-only, and (4) withdrawal of life-sustaining therapy. RESULTS. Patient mortality was high for all groups except the conservative-care group. Patient care requirements remained high in the all-but-CPR group, necessitating continued intensive care. Patient care requirements decreased significantly in the comfort-only and withdrawal groups, illustrating the ability to manage these patients in a nonintensive care setting.

Impact of the DNR therapeutic plan on patient care requirements

BACKGROUND

The intensity and nature of a patient therapeutic plan should depend upon the specific therapeutic goals. When the therapeutic plan includes a do-not-resuscitate order, the intensity of the plan may be high or low.

OBJECTIVE

To examine the differences in patient care requirements and hospital outcomes in patients with a do-not-resuscitate status to determine the most appropriate care setting, eg, intensive vs nonintensive care.

METHOD

Data from a prospective sample of 100 patients were analyzed. Patients were grouped according to the intensity of the therapeutic plan: (1) all-but-CPR: all support except cardiopulmonary resuscitation, (2) conservative-care: medical management without the addition of life-sustaining measures, (3) comfort-only, and (4) withdrawal of life-sustaining therapy.

RESULTS

Patient mortality was high for all groups except the conservative-care group. Patient care requirements remained high in the all-but-CPR group, necessitating continued intensive care. Patient care requirements decreased significantly in the comfort-only and withdrawal groups, illustrating the ability to manage these patients in a nonintensive care setting.

The bcl-2 oncogene: apoptosis and neoplasia

Cloning of the t(14;18) translocation breakpoint resulted in the identification of a new putative oncogene, which mapped to 18q21, termed bcl-2. The t(14;18) resulted in inappropriately high levels of bcl-2 expression in follicular lymphoma. Prospective studies using mice transgenic for a human bcl-2-immunoglobulin minigene, intended to recreate the molecular features of the t(14;18), demonstrated that bcl-2 gene deregulation was oncogenic. Interestingly, overexpression of bcl-2 showed no demonstrable influence on rates of cellular proliferation. Rather, bcl-2 was found to extend cellular viability by blocking apoptosis. Recent studies with other oncogenes and tumor suppressor genes, such as c-myc and p53, have demonstrated that the deregulation of apoptosis may be of general significance in the development of multiple types of cancer and appears to be a critical event during multistep carcinogenesis. The selective induction of apoptosis in tumor cell populations is now being considered in the design of novel therapeutic interventions.

Case studies in terminal weaning from mechanical ventilation

Terminal weaning, withdrawal of mechanical ventilation when the patient is not expected to survive the process, must not be burdensome to the patient or significant others. The healthcare team must individualize the weaning process, considering the physiologic comfort of the patient and the psychoemotional comfort of both the patient and family. The following case studies illustrate variations in a method for terminal weaning that are patient-specific and are based on the experience of a supportive care team.

Case studies in terminal weaning from mechanical ventilation

Terminal weaning, withdrawal of mechanical ventilation when the patient is not expected to survive the process, must not be burdensome to the patient or significant others. The healthcare team must individualize the weaning process, considering the physiologic comfort of the patient and the psychoemotional comfort of both the patient and family. The following case studies illustrate variations in a method for terminal weaning that are patient-specific and are based on the experience of a supportive care team.