Outcomes of long-term ventilator patients: a descriptive study

BACKGROUND

Long-term ICU patients who require prolonged mechanical ventilation are a growing segment of the in-hospital population. Despite recognition that this population is costly to care for no systematic research has been done on the characteristics, outcomes, and disposition of these patients after they leave the hospital.

OBJECTIVE

To describe clinical and sociodemographic characteristics and outcomes of ICU patients who require long-term (5 days or more) mechanical ventilation while in the hospital.

METHODS

A prospective, longitudinal descriptive design was used to study 57 ICU patients who required 5 days or more of continuous mechanical ventilation while in the hospital. Clinical and sociodemographic data were collected at the time of enrollment. Patients were followed up for up to 6 months after discharge from the hospital to ascertain disposition and morality.

RESULTS

On average, patients had a hospital stay of almost 6 weeks and required mechanical ventilation for approximately 4 weeks; 43.9% of the patients died in the hospital. None of the patients discharged from the hospital were able to return home initially without assistance. By 6 months after discharge, more than 50% of the original sample and died, 9% resided in an institution, and 33% were living at home.

CONCLUSIONS

A large percentage of ICU patients who require 5 days or more of mechanical ventilation die in the hospital, and many of those who live spend considerable time in an extended-care facility before they are discharged to their homes. These likely outcomes of patients who require long-term ventilation should be discussed with patients and their families to assist them in making informed decisions.

Outcomes of long-term ventilator patients: a descriptive study

BACKGROUND: Long-term ICU patients who require prolonged mechanical ventilation are a growing segment of the in-hospital population. Despite recognition that this population is costly to care for no systematic research has been done on the characteristics, outcomes, and disposition of these patients after they leave the hospital. OBJECTIVE: To describe clinical and sociodemographic characteristics and outcomes of ICU patients who require long-term (5 days or more) mechanical ventilation while in the hospital. METHODS: A prospective, longitudinal descriptive design was used to study 57 ICU patients who required 5 days or more of continuous mechanical ventilation while in the hospital. Clinical and sociodemographic data were collected at the time of enrollment. Patients were followed up for up to 6 months after discharge from the hospital to ascertain disposition and morality. RESULTS: On average, patients had a hospital stay of almost 6 weeks and required mechanical ventilation for approximately 4 weeks; 43.9% of the patients died in the hospital. None of the patients discharged from the hospital were able to return home initially without assistance. By 6 months after discharge, more than 50% of the original sample and died, 9% resided in an institution, and 33% were living at home. CONCLUSIONS: A large percentage of ICU patients who require 5 days or more of mechanical ventilation die in the hospital, and many of those who live spend considerable time in an extended-care facility before they are discharged to their homes. These likely outcomes of patients who require long-term ventilation should be discussed with patients and their families to assist them in making informed decisions.

Merger motorway. Giving staff the tools to reengineer

Mergers and health care agencies' response to mergers dominate current conversations in this evolving managed care environment. Hospitals are rapidly learning to adjust to declining occupancy rates and deceased utilization of resources. A business model to guide mergers was adapted to assist staff with the people, structural, cultural and political issues of organizational change. Creating successful new work environments, moving from a "We-they" mentality to unity and decreasing use of resources are outcomes described in this article.

Effects of farm management practices on cattle grazing behaviour and the potential for transmission of bovine tuberculosis from badgers to cattle

Despite the large body of circumstantial evidence to suggest a link, the means by which bovine tuberculosis is passed from badgers to cattle remains unclear; pasture contamination with the urine, faeces and/or sputum of infectious badgers is believed to be the main route of transmission. Therefore the behaviour of grazing cattle was studied to determine whether they avoided investigating and/or grazing pasture contaminated with badger excreta, and whether different farm management practices enhanced the potential for disease transmission. Active latrines were avoided by most cattle until the sward length in the rest of the field was reduced, after which there was an increasing likelihood that active badger latrines would be grazed. Most of the cattle grazed active badger latrines, but cattle of low rank within the herd grazed latrines more heavily. Farm management practices that reduced the availability of long swards shortened the period of investigative behaviour and greatly enhanced the risk that cattle would graze active badger latrines. Cattle were more likely to graze pasture away from latrines that was contaminated either with badger urine or single faeces. Because bacilli remain viable in the soil for up to 2 years, there is the potential for bacilli to accumulate at active badger latrines, and these could pose a significant risk to cattle, even when the latrine is no longer being used by badgers. Cattle readily grazed the lush sward at disused latrines, during which they could ingest contaminated soil; the amount of soil ingested increases as sward length decreases.

Effects of human tumor cell lines on local new bone formation in vivo

Although some tumors cause osteolytic lesions, there are some that stimulate new bone formation. This is an important phenomenon because the responsible mechanisms probably represent an aberration of normal physiological bone formation, and identifying the factors involved in the process may lead to new therapies for various bone diseases. To clarify our understanding of the potential mechanism responsible, we compared and quantitated the extent of new bone formation stimulated by human tumors (HeLa, Hep-2, AV-3, FL, WISH and KB), some of which have osteogenic activity in vivo [2]. Tumor cells were injected over the calvaria of nude mice to examine formation of new bone. The tumor cells produced three histologically distinct patterns of new bone growth: (1) WISH and KB stimulated appositional bone growth adjacent to periosteal bone surfaces; (2) HeLa and Hep2 induced new bone growth over calvarial surface even when distant from the tumor mass; (3) FL stimulated bone formation adjacent to periosteum as well as ectopic bone formation in sites distant from bone. All tumors except AV3 induced mean new bone thickness >100 microm, and Hep-2 cells produced bone 330 microm thick. PCR and Northern blot analysis of mRNA isolated from cultured tumor cells revealed that all cell lines expressed mRNA for TGFbeta, (fibroblast growth factor) FGF-1, FGF-2, and IGF-I, and most cell lines produced mRNA for PDGF. Only FL expressed large amounts of mRNA for BMP2. In serum-free conditioned media from Hep2 and HeLa cells purified by heparin affinity chromatography, we have identified FGF-I, FGF-2, and PDGF by immunodetection with specific antibodies. Our results show that new bone growth caused by these tumors is likely due to the production of bone growth factors by the tumor cells, and that the overall effects on bone may be due to several factors working in concert.

Transdermal fentanyl administration in children and adolescents with sickle cell pain crisis

PURPOSE

The purpose of this study was to determine the dose-concentration relationship and clinical effect of transdermal fentanyl (TF) in patients with sickle cell pain crisis (SCPC).

PATIENTS AND METHODS

Ten patients aged 9-16 years were studied. Patients initially received a TF dose of 25 (n = 7) or 50 (n = 3) micrograms/h if morphine use was > 2.5 mg/h. Supplemental morphine usage via patient-controlled analgesia (PCA), sedation status, pain status, respiratory rate, pulse rate, oxygen saturation, and blood pressure were monitored.

RESULTS

The average TF dose was 0.77 +/- 0.37 micrograms/kg/h on day 1 and 1.17 +/- 0.46 micrograms/kg/h on day 2. Fentanyl concentrations measured at 24 and 48 h were 0.60 +/- 0.31 and 1.18 +/- 0.44 ng/ml, respectively. A significant relationship existed between TF dose and fentanyl concentration (r2 = 0.56, p < 0.01). There was no difference in any of the clinical monitoring parameters between day 1 and day 2. However, 7 of 10 patients reported subjective improvement in pain control over that achieved with PCA alone. No adverse effects were noted.

CONCLUSIONS

Improved understanding of the dose-effect relationship for TF in children and adolescents is necessary before adequate pain control can be achieved with this delivery system.

Issues concerning patient advocacy: personal experiences

Issues concerning patient advocacy and nursing advocacy are explored in relation to the nurse's role and the UKCC code of conduct. The author's personal experiences of being an advocate are described. Potential conflict between the nurse's role and doctor's role in relation to advocacy is identified. The best person to take on the role of patient advocate is discussed.

Myotonic dystrophy: will the real gene please step forward!

The mutation underlying myotonic dystrophy (DM) was identified at the end of 1991 amidst great rejoicing from the patients supporting the research and, not least, from those who spent so long searching for it. Subsequently, the molecular genetic phenomena associated with DM have been clearly explained by the transmission behaviour of the expanding repeat, which remains the only mutation that has been described in patients. We understand the molecular basis of anticipation, why the severe congenital form is almost exclusively transmitted by affected mothers and we have widely accepted models of the population genetics of DM. Yet, despite all these clearly explained molecular events, we appear to be hardly any closer to understanding the molecular pathology of DM than when the mutation was first identified. To understand the reason for this, we have to look in detail at the mutation itself, and in particular at the locus and its complex nuances. In doing so, we begin to realise that DM is unique amongst the Mendelianly inherited disorders, in that the mutation, because of its location in a very gene-rich region of the genome, probably simultaneously renders several genes dysfunctional. The somatic heterogeneity of the repeat, coupled with the involvement of several genes, accounts for the pleiotropy observed in the phenotype. Added to this complexity is the uncertainty of the level at which gene dysfunction or gain of function is occurring. It is possibly at the level of DNA/chromatin structure and/or RNA regulation/processing, and all of these pathways may, in different tissues, contribute to the final phenotype.

Enoxaparin for thromboembolism prophylaxis in spinal injury: preliminary report on experience with 105 patients

Venous thromboembolism continues to be a major cause of morbidity and mortality in patients with spinal injury (SI). Recently, we reported on the effectiveness and safety of a low molecular weight heparin (LMWH), tinzaparin, in preventing deep vein thrombosis in motor-complete SI patients. Recently, another LMWH, enoxaparin, was approved by the United States Food and Drug Administration for prevention of thromboembolism in hip and knee replacement surgery. Since its approval, we have used 30 mg of enoxaparin subcutaneously every 12 h as routine prophylaxis in all hospitalized SI patients. In this retrospective study, we present an analysis of safety and efficacy of the first six months experience, during which 105 patients received the drug. No patient developed clinical evidence of thromboembolism, and none of the 60 venous ultrasound examinations showed a deep vein thrombus. Eleven patients had evidence of hemorrhage, but the LMWH was considered to have contributed to the bleeding in only three. This additional experience with enoxaparin reinforces our previous conclusion that LMWHs are safe and effective thromboprophylactic agents in SI patients.

Comparison of numerous delivery systems for the induction of cytotoxic T lymphocytes by immunization

A variety of vaccine delivery systems including peptides with various adjuvants, recombinant particles, live recombinant viruses and bacteria and plasmid DNA were tested for their ability to induce CD8+ cytotoxic T lymphocytes (CTL) against a well-defined epitope (amino acids 252-260) from the circumsporozoite (CS) protein of Plasmodium berghei. We compared routes of immunization that would be applicable for the administration of a malaria vaccine in humans. The majority of these vaccines did not induce high CTL responses in the spleens of immunized mice. However, both a yeast-derived Ty virus-like particle expressing the optimal nine-amino acid epitope SYIPSAEKI from the CS protein (CSP-VLP) and a lipid-tailed peptide of this same sequence induced high levels of the major histocompatibility complex (MHC) class I-restricted CTL with one and three subcutaneous immunizations, respectively. Moreover, these CTL were able to recognize naturally processed antigen expressed by a recombinant vaccinia virus. The levels of CTL induced by CSP-VLP could be augmented by co-immunization with certain cytokines. Target cells pulsed with CSP-VLP were recognized and lysed, showing that the particles were effectively processed and presented through MHC class I presentation pathway. The levels of CTL induced using CSP-VLP and lipopeptides are comparable to those observed after immunization with multiple doses of irradiated sporozoites.

Longitudinal study of adrenal steroids in a cohort of HIV-infected patients with hemophilia

The objective of the study was to relate plasma dehydroepiandrosterone sulfate (DHEA-S) concentrations to the progression of HIV infection in individual HIV-infected men with hemophilia and to obtain information on the cause of DH EA-S alterations. Blood samples were obtained from 16 men with hemophilia; in 9 men serial samples were available for up to 11 years after HIV-1 infection. Control samples were obtained from men of comparable ages without hemophilia or HIV infection. Measurements were made of CD4+ cell counts, plasma adrenocorticotropic hormone (ACTH), cortisol, DHEA, DHEA-S, and prolactin. Before HIV infection, men with hemophilia had significantly lower plasma levels of DHEA-S than control men. After infection, 3 of 9 subjects studied serially had little or no change in plasma DHEA-S levels or in CD4+ cell counts over 11 years. Four of the 9 i n whom AIDS developed had progressive decreases in plasma DHEA-S concentrations that, in some cases, preceded a precipitous fall in CD4+ cell counts. Major decreases in plasma DHEA-S levels before falls in CD4+ counts were observed in 2 ot her subjects who had other severe illnesses. None of the decreases in DHEA-S levels were associated with decreased concentrations of plasma cortisol, ACTH, or prolactin. We conclude that plasma DHEA-S is an indicator of general health rather than a specific indicator for progression of HIV. The decrease in plasma DHEA-S is not related to ACTH stimulation of the adrenal gland or to cortisol secretion, but it may be related to cytokines that can inhibit 17-hydroxylation of DH EA-S precursors.

Joint attention and language gains in children with Down syndrome

Joint attention and topic initiation in caregiver-child interactions was explored in relation to children's language gains over 13 months. Caregivers of 28 children with Down syndrome spent more time in joint attention and maintained more attention to caregiver-selected toys than did caregivers of 17 children with typical development. Receptive language gains of children with Down syndrome were associated with caregivers maintaining attention to child-selected toys and with longer lengths of joint attention. Caregivers redirecting attention away from child-selected toys and a greater frequency of joint attention episodes was negatively associated with children's language gains. More time spent in joint attention and caregivers maintaining attention to mother-selected toys was associated with receptive language gains in children who were developing typically.

Splenic marginal zone expansion in B-cell lymphomas of gastrointestinal mucosa-associated lymphoid tissue (MALT) is reactive and does not represent homing of neoplastic lymphocytes

It has been suggested that lymphocytes of mucosa-associated lymphoid tissue (MALT) arise from marginal zone cells and that MALT-derived lymphomas may spread to other extra-nodal sites by homing to marginal zones in different tissues. Marginal zone expansion has been observed in spleens removed during surgery for gastrointestinal MALT lymphoma, which was sufficiently extreme in some cases to suggest neoplastic involvement. To investigate this phenomenon, polymerase chain reaction (PCR) amplification of immunoglobulin heavy chain gene fragments was performed to demonstrate B-cell clonality in gastrointestinal MALT lymphomas and spleens from 11 patients. Monoclonal PCR products were obtained from 9 of the 11 gastrointestinal tumours but from none of the accompanying spleens. One additional spleen, for which the accompanying gastric lymphoma tissue was unavailable for review, yielded a monoclonal product. However, obvious lymphoma deposits were present in this specimen, in addition to marginal zone enlargement. It is concluded that splenic marginal zone expansion accompanying gastrointestinal MALT lymphoma is correctly interpreted as being reactive. Splenic involvement by MALT lymphoma is uncommon and does not show preferential colonization of the marginal zone to suggest homing of MALT-derived cells to this site.

The union movement: legislative and regulatory issues in California

In the late 1980s, hospitals began to identify that patient care services needed to be restructured to deliver services in a more cost-effective and efficient way. As more and more hospitals adopted this philosophy, unions began to take an increasingly aggressive role advocating against the strategies that hospitals employed, which often put unlicensed assistive personnel in a role that more appropriately used the professional training of a registered nurse. The strategies taken by the unions took several forms: regulatory and legislative, which sought to preserve nurses' jobs through mandatory staffing ratios; a public relations campaign aimed at discrediting hospitals that have restructured and informing the public that the changes jeopardize patient welfare; and targeted organizing. This article addresses the impact the union strategies have had on hospitals and the changing health care market.

Dose-response relation between terfenadine (Seldane) and the QTc interval on the scalar electrocardiogram: distinguishing a drug effect from spontaneous variability

The primary goal of this investigation was to describe the effect of terfenadine on the QT interval corrected for heart rate (QTc) of the scalar electrocardiogram (ECG). The design was double-blind, four-period crossover, dose escalation, which involved 28 normal healthy volunteers and 28 patients with stable cardiovascular disease. At baseline, the normal subjects had a mean QTc interval of 407 msec, whereas the patients with cardiovascular disease had a mean QTc interval of 417 msec (p<0.01). The largest increase in mean QTc on terfenadine was 24 msec in a normal subject and 28 msec in a patient with cardiovascular disease. The longest average QTc observed was 449 msec and 501 msec in any normal subject and patient with cardiovascular disease, respectively. Compared to baseline, terfenadine 60 mg twice daily is associated with a QTc increase of 6 msec in normal subjects and a 12 msec increase in patients with cardiovascular disease (p<0.01 vs baseline; p>0.05 when the two populations were compared). Although the QTc increase from baseline are statistically significant, the magnitude of the spontaneous variability in QTc in the same patients is much greater. Because 40 ECGs were obtained while taking placebo in each participant, the spontaneous variability in QTc interval with placebo was also described. Only one of the 28 normal subjects had a mean baseline QTc=440 msec, yet 14 of the 28 normal subjects had at lease one of the 40 placebo ECGs with a QTc=440 msec. The 28 patients with cardiovascular disease had a mean QTc at baseline of 417 msec; yet 20 of 28 had at lease one ECG on placebo with a QTc interval = 440 msec. On the average, the QTc fluctuated 56 msec in each patient during placebo administration. From the observed placebo variability, we calculated that an increase in QTc of=35 msec while receiving drug therapy is likely to represent a drug effect at the 95% confidence interval.

Last-minute preoperative cardiology consultations: epidemiology and impact

To identify clinical predictors of last-minute preoperative cardiology consultations and to evaluate the impact of these consultations on patient care, we performed a retrospective case-control study including all 166 patients who received unscheduled cardiology consultations at the preadmission testing center (PATC) of an urban teaching hospital. Control subjects were 166 patients matched by date and category of surgical procedure. Significant (p < 0.05) independent predictors of last-minute consultations included history of myocardial infarction (odds ratio [OR] = 23.7; 95% confidence interval [CI] = 1.5 to 373), history of chest pain (OR = 15.3; 95% CI = 3.7 to 62.9), history of chronic obstructive lung disease (OR = 5.9; 95% CI = 1.1 to 32.9), prior echocardiography (OR = 3.4; 95% CI = 1.2 to 9.8), and age (OR per decade = 1.1; 95% CI = 1.04 to 1.1). Thus among patients undergoing elective noncardiac surgery, last-minute preoperative consultations are common and are usually precipitated by an abnormal electrocardiogram or history of cardiovascular disease. Last-minute consultations may be preventable if those patients with risk factors for consultation are identified in advance of the preadmission evaluation and referred for elective consultation.

Consumers as community support providers: issues created by role innovation

Using data from a CSP-funded research demonstration project designed to expand vocational services offered by case management teams serving people with serious mental illness, this paper examines the issues created by employing consumers as peer support specialists for the project. Roles and benefits of these positions are analyzed. Challenges experienced by specialists created by serving peers, the structure of the position, the mental health system and the community, and personal issues are analyzed using data from focus groups and the project's management information system. Implications for consumer role definition, supports for role effectiveness, and the structuring of these types of positions are discussed.

Familial deletion of chromosome 18 (p11.2)

Familial transmission of del (18p) syndrome from a mother to her daughter is rare and has been reported only once before. We report a female patient referred to us at age 18 years because of mental retardation associated with short stature. Similar clinical features are also seen in her mother. Chromosome analysis revealed a 46,XX, del (18) (p11.2) karyotype in both the proposita and her mother. Fluorescence in situ hybridization with whole chromosome paint for chromosome 18 showed no evidence of translocation. Because of the familial transmission of del (18p), this case has wider implications in genetic counseling.

Bicistronic vector for the creation of stable mammalian cell lines that predisposes all antibiotic-resistant cells to express recombinant protein

We have developed an improved vector for the stable expression of recombinant protein in mammalian cells. In this vector, designated pCIN, both the recombinant cDNA and the neomycin phosphotransferase selection marker are transcribed from a single promoter element. To facilitate translation of the second open reading frame, the encephalomyocarditis virus internal ribosome entry site has been inserted into the expression cassette immediately before the start codon of this sequence. We report the use of this vector to generate stable cell lines expressing the human 5-HT1Da serotonin receptor and show that following transfection and clonal selection, all ten cell lines characterized express similar and high levels of receptor (1.5-11.9 pmol receptor/mg protein). Use of pCIN should permit the rapid and efficient production of stable mammalian cell lines for the characterization of recombinant protein, as this vector appears to predispose all transfected cells to express such protein.

Randomized controlled trial of cervical cap with intracervical reservoir versus standard intracervical injection to inseminate cryopreserved donor semen

A prospective controlled study of donor insemination without sperm preparation or ovarian stimulation was performed to compare the use of a cervical cap incorporating an intracervical reservoir with a standard intracervical injection technique to inseminate 0.5 ml cryopreserved semen. Treatments were alternated in successive cycles in each patient after initial randomized selection. A total of 198 patients had 635 treatment cycles (median 3, range 1-7), 309 with reservoir and 326 by standard injection. A total of 56 women became pregnant, 24 (7.8% per cycle) with the reservoir and 32 (9.8% per cycle) by injection. There were no significant differences between the pregnancy rates per cycle overall or cycle-specific cumulative rates calculated using the life-table method. There were no significant differences in age, parity, baseline gonadotrophin measurements, mid-luteal serum progesterone concentrations, frequency of adverse fertility factors in the woman or her partner's cause of infertility between women who conceived and those who failed to conceive. We conclude that use of a cervical reservoir and cap for donor insemination does not offer any advantage over standard intracervical insemination.