Education in end-of-life care: bridging disciplinary and institutional boundaries

This paper describes the development of an interdisciplinary, interinstitutional seminar in palliative care for South Dakota students in medicine, nursing, pharmacy, chaplaincy, and social work. Student outcomes from six seminars conducted during 2001-2004 are reported, and recommendations for future educational efforts are outlined.

(-)-Epicatechin inhibits nitration and dimerization of tyrosine in hydrophilic as well as hydrophobic environments

The flavanol (-)-epicatechin is known to protect against peroxynitrite-induced nitration and oxidation reactions. This study investigated the protection afforded by (-)-epicatechin against both these reaction types on one target molecule, the aminoacid tyrosine, in a hydrophilic milieu as well as with a lipophilic tyrosine derivative, N-t-BOC l-tyrosine tert-butyl ester (BTBE), bound to liposomes. The flavanol efficiently attenuated both tyrosine nitration and tyrosine dimerization (which is based on an initial oxidation reaction) and was active in the hydrophilic and hydrophobic systems at similar IC(50) values, approximately 0.02-0.05 mol (-)-epicatechin/mol peroxynitrite. Related procyanidin oligomers of different chain-length (dimer to octamer) were also tested for their protective properties, and exhibited protection that, on a monomer basis, was in the same order of magnitude as those for (-)-epicatechin.

Improving survival of vulnerable infants increases neonatal intensive care unit nosocomial infection rate

OBJECTIVE

To determine the factors associated with an increasing rate of nosocomial infections in infants with very low birth weights.

METHODS

Retrospective review of clinical and nosocomial infection databases for all infants with birth weights of 1500 g or less admitted to an academic neonatal intensive care unit between January 1, 1991, and December 31, 1997 (N = 1184). Two study periods were compared: 1991-1995 and 1996-1997.

RESULTS

Among the 1085 infants who survived beyond 48 hours, the proportion who developed nosocomial infections increased from 22% to 31% (P =.001) and the infection rate increased from 0.5 to 0.8 per 100 patient-days (P<.001) during the period from 1996 to 1997. In that same period, the median duration of indwelling vascular access increased from 10 to 16 days (P<.001), and the median duration of mechanical ventilation increased from 7 to 12 days (P<.001). Although the device-specific rate of bloodstream or respiratory infections did not change, the increase in infections was directly attributable to the increasing proportion of infants who required these devices. In both study periods, the peak incidence of initial infection occurred between 10 and 20 days of age. For the entire sample, proportional hazard models identified birth weight, duration of vascular access, and postnatal corticosteroid exposure as significant contributors to the risk of infection.

CONCLUSIONS

The increasing number of technology-dependent infants was the primary determinant in the increase of nosocomial infections. Because these infections occur in a small proportion of infants, understanding the host factors that contribute to this vulnerability is necessary to decrease nosocomial infections in neonatal intensive care units.

Use of simple and complex in vitro models for multiparameter characterization of human blood-material/device interactions

Medical devices, intended for blood contacting applications, undergo extensive in vitro testing followed by animal and clinical feasibility studies. Besides the use of materials known to be intrinsically blood-compatible, the surface of such devices is often modified with a coating in order to improve the performance characteristics during blood exposure. In vitro evaluation of blood-device interactions accompanies the product development cycle from the early design phase using basic material geometries until final finished-product testing. Specific test strategies can vary significantly depending on the end application, the particular study objectives and variables of interest, and cost. To examine the degree to which findings derived from two different in vitro approaches complement one another, this report contrasts findings from a simple multipass loop model with findings from a simulated cardiopulmonary bypass (CPB) model. The loop model consists of tubular test materials, with and without surface modification, formed into valved Chandler loops. The CPB model has an oxygenator with and without surface modification connected to a reservoir and a blood pump. The surface modifications studied in this report are the Carmeda BioActive Surface and Duraflo II heparin coatings. Common blood parameters in the categories of coagulation, platelets, hematology, and immunology were monitored in each model. Ideal models employ the optimal level of complexity to study the design variables of interest and to meet practical cost considerations. In the case of medical device design studies, such models should also be predictive of performance. In the more complex and realistic simulated CPB model, experimental design and cost factors prevented easy/optimum manipulation of critical variables such as blood donor (use of paired samples) and heparin level. Testing in the simpler loop model, on the other hand, readily offered manipulation of these variables, and produced findings which overlapped with observations from the more complex CPB model. Thus, the models described here complimented one another. Moreover, conclusions from consistent findings, such as favorable responses associated with the heparin coatings, between the two models were considered to be more robust.

Epicatechin selectively prevents nitration but not oxidation reactions of peroxynitrite

The flavanol (-)-epicatechin has been found to protect against damage inflicted by peroxynitrite, an inflammatory intermediate. Here, epicatechin was tested in systems of increasing complexity. The compound efficiently protected against nitration of protein tyrosine residues by peroxynitrite (IC(50) approximately 0.02 mol epicatechin/mol peroxynitrite). However, at epicatechin concentrations completely preventing nitration of tyrosine by peroxynitrite, protection against the oxidative inactivation of glyceraldehyde-3-phosphate dehydrogenase or soybean lipoxygenase-1 was marginal (IC(50) > 1 mol epicatechin/mol peroxynitrite), approximately two orders of magnitude less. Likewise, epicatechin was relatively ineffective against oxidation of thiols in cell lysates, and against the oxidation of 2',7'-dichlorodihydrofluorescein in cultured cells. The activation of the kinases Akt/protein kinase B, ERK1/2 and p38-MAPK by peroxynitrite in murine aorta endothelial cells was not altered by epicatechin, suggesting that activation of these kinases is due to processes other than tyrosine nitration.

[Gastrointestinal stromal tumor: individualized treatment for a special class of tumors]

HISTORY AND ADMISSION FINDINGS

Case 1: A 36-year-old woman was admitted because of dizziness and weakness. Her skin and mucosae were pale. There was rather dark stool on the gloved finger at rectal examination, but the patient had not noticed any tarry stools. Case 2: An 89-year-old man in excellent general condition presented with dyspepsia. Physical examination was unremarkable except for a small epigastric hernia.

INVESTIGATIONS

Endoscopy in Case 1 revealed, at the lesser curvature of the gastric antrum, a submucous tumour covered by a slightly haemorrhagic mucosal erosion. In Case 2 endoscopy similarly revealed an antral submucous tumour. There was no evidence of metastasis in either case.

TREATMENT AND COURSE

Exploratory laparotomy was performed in both patients. A subtotal gastric resection with gastrojejunostomy was undertaken in Case 1, a submucous excision via an anterior gastrostomy in Case 2. In both cases histology showed a gastrointestinal stromal tumour, but its benignity could not be firmly established even after detailed immunohistological examination.

CONCLUSION

Gastrointestinal tumours are rare. Although they have particular immunohistological characteristics their benignity cannot usually be definitively established even on the excised specimen. Because more extensive resection does not increase survival time, a resection margin of 1-2 cm is considered adequate. Neither radio- nor chemotherapy are successful. Life-long follow-up is indicated because the tumor's uncertain benignity.

Reactions of peroxynitrite with cocoa procyanidin oligomers

Peroxynitrite is a mediator molecule in inflammation, and its biological properties are being studied extensively. Flavonoids, which are natural plant constituents, protect against peroxynitrite and thereby could play an anti-inflammatory role. Procyanidin oligomers of different sizes (monomer through nonamer), isolated from the seeds of Theobroma cacao, were recently examined for their ability to protect against peroxynitrite-dependent oxidation of dihydrorhodamine 123 and nitration of tyrosine and were found to be effective in attenuating these reactions. The tetramer was particularly efficient at protecting against oxidation and nitration reactions. Epicatechin oligomers found in cocoa powder and chocolate may be a potent dietary source for defense against peroxynitrite.

[Regional initiative on health care reform in Latin America and the Caribbean]

Many countries throughout Latin America and the Caribbean are introducing reforms that can profoundly influence how health services are provided and who receives them. Governments in the region identified the need for a network to support health reform by building capacity in analysis and training, both at the Summit of the Americas in 1994 and at the Special Meeting on Health Sector Reform, which was convened in 1995 by an interagency committee of the Pan American Health Organization/World Health Organization, the Inter-American Development Bank, the World Bank, and other multilateral and bilateral agencies. In response, in 1997 the Pan American Health Organization and the United States Agency for the International Development launched the Latin America and Caribbean Regional Health Sector Reform Initiative. The Initiative has approximately US$ 10 million in funding through the year 2002 to support activities in Bolivia, Brazil, the Dominican Republic, Ecuador, El Salvador, Guatemala, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Paraguay, and Peru. Now in its third year of implementation, the Initiative supports regional activities seeking to promote more equitable and effective delivery of basic health services.

In vitro modulation of macrophage phenotype and inhibition of polymer degradation by dexamethasone in a human macrophage/Fe/stress system

A new in vitro accelerated biological model, the macrophage-FeCl2-stress system was used for the evaluation of dexamethasone (DEX)-polymer formulations. This model combines the effects of cells (macrophages), transition metal ions (Fe2+), and polymer stress to promote material biodegradation. The cell and material effects of DEX, either in solution or incorporated into a polyetherurethane matrix (DEX/PEU), were monitored. Cell morphology and hydroperoxide formation in the polymer during cell culturing were characterized. After a subsequent treatment with FeCl2 the development of environmental stress cracking in the polymer was evaluated. We attempted to duplicate the biodegradation of PEU in terms of environmental stress cracking (ESC). Our results support the direct involvement of macrophages in polyetherurethane oxidation, probably by inducing hydroperoxide formation in the polymer structure. Under the influence of stress or strain, polymers with sufficient hydroperoxides degrade in the presence of Fe2+ metal ions in a manner that closely resembles the stress cracking that is observed in vivo. By contrast, polymers treated with either agents that inhibit cell activation and/or the oxidative burst, or with cells with no oxidative burst did not show signs of the biodegradative process. We demonstrated a reduction in hydroperoxide formation and no later ESC development in macrophage-cultured PEU in the presence of DEX in solution or in DEX-loaded PEU. We believe the prevention of initial polymer oxidation by reducing the cell's potential to produce oxidative stress at the tissue-biomaterial interface can directly inhibit the ESC degradation of chronically implanted polymers. The in vitro macrophage-Fe-stress system is a valuable tool for reliable assessment and cost-effective evaluation of biomaterials.

Glutamine dipeptides-supplemented parenteral nutrition reverses gut mucosal structure and interleukin-6 release of rat intestinal mononuclear cells after hemorrhagic shock

Glutamine is an essential substrate for gut mucosal structure, but the role for gut immune function is not fully known. To determine the effect on gut cytokine release in relation to bacterial translocation and gut morphology, a nonlethal hemorrhagic shock (30 min, 30 mmHg) was performed in male Wistar rats followed by 4 days of different way of feeding. A conventional total parenteral nutrition (TPN) solution was compared with an isocaloric and isonitrogenous TPN solution supplemented with alanin-L-glutamine and glycyl-L-glutamine. An enteral chow-fed control group was included. Gut mononuclear cells and splenic macrophages were obtained and endotoxin-induced supernatant tumor necrosis factor-alpha (TNF) and interleukin-6 (IL-6) bioactivity was measured. Histological specimen of the small bowel were taken and mesenteric lymph nodes (MLN) were separated. Enteral feeding following hemorrhagic shock was accompanied by a normal mucosal structure and no bacterial translocation could be detected. TPN was characterized by suppression of cytokine release in gut mononuclear cells and splenic macrophages compared with the enteral-fed control (p < .05). Decreased TNF and IL-6 release was associated with a significantly increased mucosal injury score (p < .05) and a high incidence of bacterial translocation to MLN (66%, p < .05 vs. control). Supplementation of glutamine-dipeptides did not prevent TPN-induced bacterial translocation to MLN (p < .05 vs. control) but significantly improved mucosal injury (p < .05 vs. TPN). Down-regulation of TNF release in TPN-fed rats could not be reversed by glutamine dipeptides while IL-6 release was significantly increased compared with TPN-fed animals (p < .05), and no difference to enteral-fed controls could be found. Enteral nutrition following hemorrhagic shock is superior to parenteral nutrition with regard to mucosal structure, cytokine release, and bacterial translocation. Supplementation of TPN with glutamine dipeptides could reverse TPN-induced suppression of IL-6 release and improved mucosal structure, which may be beneficial in various disease conditions in which TPN is an integrated part of patients management.

[Distal femoro-popliteal bypass using Esmarch tourniquet ischemia]

The Esmarch bandage is an effective substitute for vascular clamps in distal femoro-popliteal or tibial bypass surgery. Intimal trauma caused by clamping is avoided, vasa vasorum are preserved due to only semicircumferential dissection of vessels. This method is particularly suitable for heavy calcified rigid vessel walls. We demonstrate this technique, which was employed in 8 patients (10 bypasses). The use of this technique requires neither a longer operation- nor clamping time. The postoperative course of all but one patients develops normally and the technique does not provoke any pathological results in the area of operation. Advantages of the procedure compared to conventional techniques will be discussed.

[Severe obstipation in the mentally ill and disabled]

Severe constipation is a well recognized symptom amongst disabled or mentally ill patients. Characteristically, these patients live without bowel movements for days and present themselves with abdominal distension and fecal impaction. Inpatient treatment is necessary frequently. Due to intestinal obstruction, diagnostic approaches are often delayed because of lack of cooperation. Data of 94 disabled patients with severe obstipation are presented. 54 patients were admitted to inpatient treatment of constipation or bowel obstruction, 40 were treated for another diagnosis but had severe constipation which required intervention. Ileus or conservatively untreatable constipation led to 16 operations in 14 patients (polypectomy 2, rectopexy 1, cecostoma 5, left hemicolectomy 3, subtotal colectomy 5). Cecostomata are considered not to be effective as definite treatment whereas colonic resection resulted in daily bowel movements.

The future of the quality professional in health care

Radical changes in health care, organizations, and the quality science have converged, radically altering the role of many, including the quality professional. The very existence of this role remains in question. Should it continue, radical changes are in store for its conduct. It is critical that quality professionals today remain aware of the issues, and strategically move forward to chart a quality direction for both their organizations and their own careers.

[Transcutaneous or transconjunctival peribulbar anesthesia?]

BACKGROUND

Transconjunctival peribulbar anesthesia is reported to permit better identification of the bulbar limits because of a better view into the fornix; it is also said to be less painful compared to transcutaneous peribulbar anesthesia. The aim of our study was to compare the two injection techniques.

PATIENTS AND METHODS

This study comprised 46 patients undergoing eye operations under local anesthesia. They were allocated randomly in a prospective and simple masked study. Twenty-three patients received transconjunctival injections and 23 patients transcutaneous peribulbar injections. Before injection, all patients received Oxybuprocain eyedrops for anesthesia of the conjunctiva. In all cases no separate injections for lid akinesia were performed. Before and 20 min after the injection, the following parameters were assessed: pain score (visual analog scale), frequency of conjunctival chemosis and the necessity for supplemental anesthesia. For identification of the bulbar limits we checked if it was possible to see the caudal and the cranial fornix.

RESULTS

The transconjunctival injection was significantly (P = 0.05) more painful (5.6 +/- 2.4) than the transcutaneous injection (4.2 +/- 2.4). Among the patients with transconjunctival injection, in 66.6% the cranial fornix could not or was only poorly seen.

CONCLUSIONS

Transconjunctival peribulbar anesthesia appears not to be more advantageous than transcutaneous peribulbar anesthesia.