Post-Trauma Discharge Instructions: Are We Dropping the Ball?

INTRODUCTION

Complex follow-up plans for polytrauma patients are compiled at the end of hospitalization into discharge instructions. We sought to identify how often patient discharge instructions incorrectly communicated specialist recommendations. We hypothesized that patients with more complex hospitalizations would have more discharge instruction errors (DI-errors).

METHODS

We reviewed adult trauma inpatients (March 2017-March 2018), excluding those who left against medical advice or were expected to follow up outside our system. Complex hospitalizations were represented using injury severity (ISS), hospital length of stay (LOS), intensive care unit length of stay (iLOS), and number of consultants (NC). We recorded the type of consultant (surgical or nonsurgical), and consultant recommendations for follow-up. DI-errors were defined as either follow-up necessary but omitted or follow-up not necessary yet present on the instructions. Patients with DI-errors were compared to patients without DI-errors. Groups were compared using Wilcoxon rank sum or chi-square (alpha <.05).

RESULTS

We included 392 patients (median age 45 [IQR 26-58], ISS 14 [10-21], LOS 6 [3-11]). 55 patients (14%) had DI-errors. Factors associated with DI-errors included the total number of consultants and use of nonsurgical consultants. ISS, LOS, iLOS, were not associated with DI-errors.

CONCLUSION

Common measures of admission complexity were not associated with DI-errors, although the number and type of consultants were associated with DI-errors. Non-surgical specialty consultant recommendations were more likely to be omitted. It is crucial for patients to receive accurate discharge instructions, and systematic processes are needed to improve communication with the patients at discharge.

The Development of a Trauma Resiliency Scale (tRS-18)

Resiliency consists of three core components, which include presence of adversity, protective factors to overcome adversity, and positive outcomes or growth. Therefore, resiliency aligns with the trauma recovery process. This paper describes development of the Trauma Resiliency Scale (tRS) to quantify the resiliency of trauma patients upon presentation and during recovery. Scale items were proposed and reviewed by an expert panel. Group construct validity testing was performed using both individual and focus group feedback with item analysis. Reliability was measured with test-retest administered 14-days apart and evaluated with intraclass correlation coefficient. 123-items were initially proposed. Following item categorizing, a preliminary 17-item questionnaire was created. The questionnaire was administered to 40 individual participants and a trauma survivor focus group to evaluate construct validity. Following group construct testing, an 18-item Trauma Resiliency Scale (tRS-18) was proposed. 24 participants were given the tRS-18 twice, 14 days apart to establish test-retest. Sixteen of the eighteen questions had an intraclass correlation > 0.7 (0.793-0.949). The remaining two questions underperformed based on the ICC (0.592 and 0.493) and were manually evaluated for inclusion. The final tRS-18 is a brief, self-administered measure of resiliency designed specifically for trauma patients. Sound psychometric properties including face validity, construct validity, and reliability of the instrument have been demonstrated. The tRS-18 may quantify resiliency at any time point with potential to be predictive of progress during recovery. Level of Evidence III, prognostic This article is protected by copyright. All rights reserved.

Utility of an integrated health system specialty pharmacy in provision of extended-release buprenorphine for patients with opioid use disorder

PURPOSE

Extended-release (ER) monthly injectable buprenorphine offers an alternative to daily sublingual (SL) dosing for treatment of opioid use disorder (OUD) that may be attractive to several patient populations, including those with barriers to adherence and the frequent follow-up that are necessary for traditional SL buprenorphine. Despite the potential benefits of ER-buprenorphine, there are significant barriers to healthcare provider adoption that may prevent utilization in the populations that would benefit.

SUMMARY

Our health system began providing clinic-administered ER-buprenorphine as treatment for OUD in May 2018 at a single clinic. Expansion was limited due to difficulties with delayed and inaccurate medication delivery and heavy administrative burden. To facilitate uptake of ER-buprenorphine for patients who could benefit, our integrated health-system specialty pharmacy (HSSP) assumed responsibility for medication distribution and administrative management beginning in October 2019. The HSSP provided accurate medication delivery, alleviated administrative burdens of benefits investigation and Risk Evaluation and Mitigation Strategy compliance, and decreased medication wastage by implementing a medication return process. Subsequently, ER-buprenorphine services were expanded to 4 additional sites, allowing 244 more patients to receive treatment.

CONCLUSION

HSSP support can provide significant benefit to patients and the health system through coordinating ER-buprenorphine dispensing and delivery.

Trauma-informed care: recognizing and resisting re-traumatization in health care

Trauma is often viewed as an individual or interpersonal issue. This paper expands the definition of trauma to include the impact collective and structural elements on health and well-being. The need for a trauma-informed response is demonstrated, with instruction as to how to implement this type of care in order to resist re-traumatization. Three examples from healthcare settings across the nation are provided, to demonstrate the ways in which organizations are bringing forward this patient-centered, trauma-informed approach to care.

Sequence Variant in the TRIM39-RPP21 Gene Readthrough is Shared Across a Cohort of Arabian Foals Diagnosed with Juvenile Idiopathic Epilepsy

Juvenile idiopathic epilepsy (JIE) is a self-limiting neurological disorder with a suspected genetic predisposition affecting young Arabian foals of the Egyptian lineage. The condition is characterized by tonic-clonic seizures with intermittent post-ictal blindness, in which most incidents are sporadic and unrecognized. This study aimed to identify genetic components shared across a local cohort of Arabian foals diagnosed with JIE via a combined whole genome and targeted resequencing approach: Initial whole genome comparisons between a small cohort of nine diagnosed foals (cases) and 27 controls from other horse breeds identified variants uniquely shared amongst the case cohort. Further validation via targeted resequencing of these variants, that pertain to non-intergenic regions, on additional eleven case individuals revealed a single 19bp deletion coupled with a triple-C insertion (Δ19InsCCC) within the TRIM39-RPP21 gene readthrough that was uniquely shared across all case individuals, and absent from three additional Arabian controls. Furthermore, we have confirmed recent findings refuting potential linkage between JIE and other inherited diseases in the Arabian lineage, and refuted the potential linkage between JIE and genes predisposing a similar disorder in human newborns. This is the first study to report a genetic variant to be shared in a sub-population cohort of Arabian foals diagnosed with JIE. Further evaluation of the sensitivity and specificity of the Δ19InsCCC allele within additional cohorts of the Arabian horse is warranted in order to validate its credibility as a marker for JIE, and to ascertain whether it has been introduced into other horse breeds by Arabian ancestry.

Higher severe acute respiratory syndrome coronavirus 2 infection rate in pregnant patients

BACKGROUND

During the early months of the coronavirus disease 2019 pandemic, risks associated with severe acute respiratory syndrome coronavirus 2 in pregnancy were uncertain. Pregnant patients can serve as a model for the success of clinical and public health responses during public health emergencies as they are typically in frequent contact with the medical system. Population-based estimates of severe acute respiratory syndrome coronavirus 2 infections in pregnancy are unknown because of incomplete ascertainment of pregnancy status or inclusion of only single centers or hospitalized cases. Whether pregnant women were protected by the public health response or through their interactions with obstetrical providers in the early months of pandemic is not clearly understood.

OBJECTIVE

This study aimed to estimate the severe acute respiratory syndrome coronavirus 2 infection rate in pregnancy and to examine the disparities by race and ethnicity and English language proficiency in Washington State.

STUDY DESIGN

Pregnant patients with a polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection diagnosed between March 1, 2020, and June 30, 2020 were identified within 35 hospitals and clinics, capturing 61% of annual deliveries in Washington State. Infection rates in pregnancy were estimated overall and by Washington State Accountable Community of Health region and cross-sectionally compared with severe acute respiratory syndrome coronavirus 2 infection rates in similarly aged adults in Washington State. Race and ethnicity and language used for medical care of pregnant patients were compared with recent data from Washington State.

RESULTS

A total of 240 pregnant patients with severe acute respiratory syndrome coronavirus 2 infections were identified during the study period with 70.7% from minority racial and ethnic groups. The principal findings in our study were as follows: (1) the severe acute respiratory syndrome coronavirus 2 infection rate was 13.9 per 1000 deliveries in pregnant patients (95% confidence interval, 8.3-23.2) compared with 7.3 per 1000 (95% confidence interval, 7.2-7.4) in adults aged 20 to 39 years in Washington State (rate ratio, 1.7; 95% confidence interval, 1.3-2.3); (2) the severe acute respiratory syndrome coronavirus 2 infection rate reduced to 11.3 per 1000 deliveries (95% confidence interval, 6.3-20.3) when excluding 45 cases of severe acute respiratory syndrome coronavirus disease 2 detected through asymptomatic screening (rate ratio, 1.3; 95% confidence interval, 0.96-1.9); (3) the proportion of pregnant patients in non-White racial and ethnic groups with severe acute respiratory syndrome coronavirus disease 2 infection was 2- to 4-fold higher than the race and ethnicity distribution of women in Washington State who delivered live births in 2018; and (4) the proportion of pregnant patients with severe acute respiratory syndrome coronavirus 2 infection receiving medical care in a non-English language was higher than estimates of pregnant patients receiving care with limited English proficiency in Washington State (30.4% vs 7.6%).

CONCLUSION

The severe acute respiratory syndrome coronavirus 2 infection rate in pregnant people was 70% higher than similarly aged adults in Washington State, which could not be completely explained by universal screening at delivery. Pregnant patients from nearly all racial and ethnic minority groups and patients receiving medical care in a non-English language were overrepresented. Pregnant women were not protected from severe acute respiratory syndrome coronavirus 2 infection in the early months of the pandemic. Moreover, the greatest burden of infections occurred in nearly all racial and ethnic minority groups. These data coupled with a broader recognition that pregnancy is a risk factor for severe illness and maternal mortality strongly suggested that pregnant people should be broadly prioritized for coronavirus disease 2019 vaccine allocation in the United States similar to some states.

Disease severity, pregnancy outcomes, and maternal deaths among pregnant patients with severe acute respiratory syndrome coronavirus 2 infection in Washington State

BACKGROUND

Evidence is accumulating that coronavirus disease 2019 increases the risk of hospitalization and mechanical ventilation in pregnant patients and for preterm delivery. However, the impact on maternal mortality and whether morbidity is differentially affected by disease severity at delivery and trimester of infection are unknown.

OBJECTIVE

This study aimed to describe disease severity and outcomes of severe acute respiratory syndrome coronavirus 2 infections in pregnancy across the Washington State, including pregnancy complications and outcomes, hospitalization, and case fatality.

STUDY DESIGN

Pregnant patients with a polymerase chain reaction-confirmed severe acute respiratory syndrome coronavirus 2 infection between March 1, 2020, and June 30, 2020, were identified in a multicenter retrospective cohort study from 35 sites in Washington State. Sites captured 61% of annual state deliveries. Case-fatality rates in pregnancy were compared with coronavirus disease 2019 fatality rates in similarly aged adults in Washington State using rate ratios and rate differences. Maternal and neonatal outcomes were compared by trimester of infection and disease severity at the time of delivery.

RESULTS

The principal study findings were as follows: (1) among 240 pregnant patients in Washington State with severe acute respiratory syndrome coronavirus 2 infections, 1 in 11 developed severe or critical disease, 1 in 10 were hospitalized for coronavirus disease 2019, and 1 in 80 died; (2) the coronavirus disease 2019-associated hospitalization rate was 3.5-fold higher than in similarly aged adults in Washington State (10.0% vs 2.8%; rate ratio, 3.5; 95% confidence interval, 2.3-5.3); (3) pregnant patients hospitalized for a respiratory concern were more likely to have a comorbidity or underlying conditions including asthma, hypertension, type 2 diabetes mellitus, autoimmune disease, and class III obesity; (4) 3 maternal deaths (1.3%) were attributed to coronavirus disease 2019 for a maternal mortality rate of 1250 of 100,000 pregnancies (95% confidence interval, 257-3653); (5) the coronavirus disease 2019 case fatality in pregnancy was a significant 13.6-fold (95% confidence interval, 2.7-43.6) higher in pregnant patients than in similarly aged individuals in Washington State with an absolute difference in mortality rate of 1.2% (95% confidence interval, -0.3 to 2.6); and (6) preterm birth was significantly higher among women with severe or critical coronavirus disease 2019 at delivery than for women who had recovered from coronavirus disease 2019 (45.4% severe or critical coronavirus disease 2019 vs 5.2% mild coronavirus disease 2019; P<.001).

CONCLUSION

Coronavirus disease 2019 hospitalization and case-fatality rates in pregnant patients were significantly higher than in similarly aged adults in Washington State. These data indicate that pregnant patients are at risk of severe or critical disease and mortality compared to nonpregnant adults, and also at risk for preterm birth.

Factors Influencing Nonadherence to Recommended Postdischarge Follow-Up After Trauma

INTRODUCTION

Historically, trauma patients have low adherence to recommended outpatient follow-up plans, which is crucial for improved long-term clinical outcomes. We sought to identify characteristics associated with nonadherence to recommended outpatient follow-up visits.

METHODS

This is a single-center retrospective examination of inpatient trauma survivors admitted to a level 1 trauma center (March 2017-March 2018). Patients with known alternative follow-up were excluded. All outpatient visits within 1 y from the index admission were identified. The primary outcome was nonadherence, which was noted if a patient failed to follow-up for any specialty recommended in the discharge instructions. Factors for nonadherence studied included age, injury severity score, mechanism, length of stay, number of referrals made, and involvement with a Trauma Recovery Services program. Bivariate and logistic regression analyses were performed.

RESULTS

A total of498 patients were identified (69% men, median age 43 y [range, 26-58 y], median injury severity score 14 [range, 9-19]). Among them, 240 (47%) were nonadherent. The most common specialties recommended were orthopedic surgery (56% referred, 19% nonadherent), trauma (54% referred, 35% nonadherent), and neurosurgery (127 referred, 35% nonadherent). Lowest levels of follow-up were seen for nonsurgical referrals. In adjusted analysis, a higher number of referrals made (odds ratio [OR], 2.45; 95% confidence interval [CI], 1.95-3.05) and older age (OR, 1.01; 95% CI, 1.00-1.02) were associated with nonadherence. Trauma Recovery Service participants and penetrating trauma patients were more likely to be adherent (OR, 0.60; 95% CI, 0.37-0.97).

CONCLUSIONS

The largest contributor to nonadherence was the number of referrals made; patients who were referred to multiple specialists were more likely to be nonadherent. Peer support services may lower barriers to follow-up.

An Improvement Effort to Optimize Electronically Generated Hospital Discharge Instructions

OBJECTIVES

The purpose of hospital discharge instructions (HDIs) is to facilitate safe patient transitions home, but electronic health records can generate lengthy documents filled with irrelevant information. When our institution changed electronic health records, a cumbersome electronic discharge workflow produced low-value HDI and contributed to a spike in discharge delays. Our aim was to decrease these delays while improving family and provider satisfaction with HDI.

METHODS

We used quality improvement methodology to redesign the electronic discharge navigator and HDI to address the following issues: (1) difficulty preparing discharge instructions before time of discharge, (2) suboptimal formatting of HDI, (3) lack of standard templates and language within HDI, and (4) difficulties translating HDI into non-English languages. Discharge delays due to HDI were tracked before and after the launch of our new discharge workflow. Parents and providers evaluated HDI and the electronic discharge workflow, respectively, before and after our intervention. Providers audited HDI for content.

RESULTS

Discharge delays due to HDI errors decreased from a mean of 3.4 to 0.5 per month after our intervention. Parents' ratings of how understandable our HDIs were improved from 2.35 to 2.74 postintervention (P = .05). Pediatric resident agreement that the electronic discharge process was easy to use increased from 9% to 67% after the intervention (P < .001).

CONCLUSIONS

Through multidisciplinary collaboration we facilitated advance preparation of more standardized HDI and decreased related discharge delays from the acute care units at a large tertiary care hospital.

Association Between 6-Week Postdischarge Risk Classification and 12-Month Outcomes After Orthopedic Trauma

Importance

Numerous studies have demonstrated that long-term outcomes after orthopedic trauma are associated with psychosocial and behavioral health factors evident early in the patient's recovery. Little is known about how to identify clinically actionable subgroups within this population.

Objectives

To examine whether risk and protective factors measured at 6 weeks after injury could classify individuals into risk clusters and evaluate whether these clusters explain variations in 12-month outcomes.

Design, Setting, and Participants

A prospective observational study was conducted between July 16, 2013, and January 15, 2016, among 352 patients with severe orthopedic injuries at 6 US level I trauma centers. Statistical analysis was conducted from October 9, 2017, to July 13, 2018.

Main Outcomes and Measures

At 6 weeks after discharge, patients completed standardized measures for 5 risk factors (pain intensity, depression, posttraumatic stress disorder, alcohol abuse, and tobacco use) and 4 protective factors (resilience, social support, self-efficacy for return to usual activity, and self-efficacy for managing the financial demands of recovery). Latent class analysis was used to classify participants into clusters, which were evaluated against measures of function, depression, posttraumatic stress disorder, and self-rated health collected at 12 months.

Results

Among the 352 patients (121 women and 231 men; mean [SD] age, 37.6 [12.5] years), latent class analysis identified 6 distinct patient clusters as the optimal solution. For clinical use, these clusters can be collapsed into 4 groups, sorted from low risk and high protection (best) to high risk and low protection (worst). All outcomes worsened across the 4 clinical groupings. Bayesian analysis shows that the mean Short Musculoskeletal Function Assessment dysfunction scores at 12 months differed by 7.8 points (95% CI, 3.0-12.6) between the best and second groups, by 10.3 points (95% CI, 1.6-20.2) between the second and third groups, and by 18.4 points (95% CI, 7.7-28.0) between the third and worst groups.

Conclusions and Relevance

This study demonstrates that during early recovery, patients with orthopedic trauma can be classified into risk and protective clusters that account for a substantial amount of the variance in 12-month functional and health outcomes. Early screening and classification may allow a personalized approach to postsurgical care that conserves resources and targets appropriate levels of care to more patients.

Necrotising fasciitis caused by metastatic endometrial cancer: a rare cause of a life-threatening condition

We report a case of necrotising fasciitis caused by metastatic endometrial adenocarcinoma. Metastases to the lumbar spine with local invasion to the iliopsoas muscle led to an iliopsoas abscess, which subsequently progressed to necrotising fasciitis of the flank. This patient lacked common risk factors for necrotising fasciitis. There are no previous reports in the literature of necrotising fasciitis with this aetiology. We discuss the available evidence for aetiology of and risk factors for necrotising fasciitis, and the relation of time to surgery with prognosis.

Phylogeny and phylogeography of functional genes shared among seven terrestrial subsurface metagenomes reveal N-cycling and microbial evolutionary relationships

Comparative studies on community phylogenetics and phylogeography of microorganisms living in extreme environments are rare. Terrestrial subsurface habitats are valuable for studying microbial biogeographical patterns due to their isolation and the restricted dispersal mechanisms. Since the taxonomic identity of a microorganism does not always correspond well with its functional role in a particular community, the use of taxonomic assignments or patterns may give limited inference on how microbial functions are affected by historical, geographical and environmental factors. With seven metagenomic libraries generated from fracture water samples collected from five South African mines, this study was carried out to (1) screen for ubiquitous functions or pathways of biogeochemical cycling of CH₄, S, and N; (2) to characterize the biodiversity represented by the common functional genes; (3) to investigate the subsurface biogeography as revealed by this subset of genes; and (4) to explore the possibility of using metagenomic data for evolutionary study. The ubiquitous functional genes are NarV, NPD, PAPS reductase, NifH, NifD, NifK, NifE, and NifN genes. Although these eight common functional genes were taxonomically and phylogenetically diverse and distinct from each other, the dissimilarity between samples did not correlate strongly with geographical or environmental parameters or residence time of the water. Por genes homologous to those of Thermodesulfovibrio yellowstonii detected in all metagenomes were deep lineages of Nitrospirae, suggesting that subsurface habitats have preserved ancestral genetic signatures that inform the study of the origin and evolution of prokaryotes.

Hemodynamics in a lethal basilar artery aneurysm just before its rupture

BACKGROUND AND PURPOSE

Hemodynamics is thought to play an important role in the mechanisms of cerebral aneurysm initiation, progression, and rupture. The purpose of this study was to present a hemodynamic study of a cerebral aneurysm immediately before its rupture to assess whether previously identified hemodynamic characteristics would classify this aneurysm in the high-risk category.

MATERIALS AND METHODS

A patient-specific computational fluid dynamics model was constructed from 3D rotational angiographic images acquired just hours before the aneurysm had ruptured. A pulsatile flow simulation was carried out, and the hemodynamics characterized by the concentration of the inflow jet, the size of the flow impingement region, and the complexity and stability of the flow pattern.

RESULTS

We found that the aneurysm had a concentrated inflow jet that impacted onto a small region of the dome of the aneurysm and created a complex, unstable flow pattern.

CONCLUSIONS

This study supports the proposition that hemodynamic characteristics derived from image-based computational models can be used to identify cerebral aneurysms at high risk for rupture.

Building materials used in construction can affect indoor fungal levels greatly

This article summarizes the results of a fungal investigation of a new, seven-story, 170-room hotel. The owners of the building were refused an occupancy permit by local building officials because of concerns about fungal contamination. This article discusses the processes that were used to investigate and abate the fungal concerns in this building. This investigation involved comparing fungal infestation levels in various building materials, including two different types of gypsum wallboard. During initial testing the indoor air concentrations of problematic fungi were up to 50 times higher than outdoor levels. After the removal of the fungal-infested materials and the replacement with more acceptable materials, the indoor air concentration of problematic fungi dropped to less than one-fourth of outdoor levels.

Strain specific effects of cytomegalovirus on endothelial cells: implications for investigating the relationship between CMV and cardiac allograft vasculopathy

BACKGROUND

Cytomegalovirus (CMV) has been associated with the development of chronic allograft rejection. Attempts to delineate pathogenetic mechanisms for this association have characteristically used well-established laboratory strains for in vitro investigation and rodent strains for in vivo studies. There is substantial genetic heterogeneity not only among different laboratory strains, but also between laboratory strains and clinical isolates, and genetic differences between human and animal strains are profound. Given these genetic differences, one would anticipate differences in biological activity between strains.

METHODS

Vascular endothelial cells were infected with two laboratory strains of CMV (Towne and AD-169) as well as two individual clinical CMV isolates, after genetic typing with six segments of the genome (including early and late genes). mRNA expression coding for a panel of mesenchymal growth factors was studied using quantitative reverse transcription, polymerase chain reaction. Major histocompatibility complex (MHC) expression was investigated using flow cytometry.

RESULTS

There was substantial genetic variability between clinical and laboratory isolates. There did not appear to be differences in overall infectivity by the different strains as determined by expression of immediate-early antigen at 24 hours (5-10% of endothelial cells positive for immediate-early. Two growth factors, platelet-derived growth factor-A and basic fibroblast growth factor were augmented by one of the two clinical strains of CMV (Clin 2) (P=0.0091 and P=0.0018, respectively). Transforming growth factor -alpha and insulin-like growth factor expression were significantly reduced by both clinical strains and AD-169. Two other growth factors, heparin-binding epidermal growth factor and transforming growth factor-beta were not altered by infection with any strain. No strain altered MHC class II expression. MHC class I expression was increased with one of the two clinical strains (Clin 1, P=0.0006) and decreased by AD-169 (P=0.0016). Clin 2 and Towne had no effect on MHC class I expression.

CONCLUSIONS

These data demonstrate that the genetic heterogeneity of CMV is associated with differences in transplant-relevant biologic activity even among clinical isolates. The relationship between CMV and chronic rejection may be difficult to determine given the heterogeneous nature of this complex virus.

Adenovirus-mediated gene transfer of the beta2-adrenergic receptor to donor hearts enhances cardiac function

Gene transfer to modify donor heart function during transplantation has significant therapeutic implications. Recent studies by our laboratory in transgenic mice have shown that overexpression of beta2-adrenergic receptors (beta2-ARs) leads to significantly enhanced cardiac function. Thus, we investigated the functional consequences of adenovirus-mediated gene transfer of the human beta2-AR in a rat heterotopic heart transplant model. Donor hearts received 1 ml of solution containing 1 x 1010 p.f.u. of adenovirus encoding the beta2-AR or an empty adenovirus as a control. Five days after transplantation, basal left ventricular (LV) pressure was measured using an isolated, isovolumic heart perfusion apparatus. A subset of hearts was stimulated with the beta2-AR agonist, zinterol. Treatment with the beta2-AR virus resulted in global myocardial gene transfer with a six-fold increase in mean beta-AR density which corresponded to a significant increase in basal contractility (LV + dP/dtmax, control: 3152.1 +/- 286 versus beta2-AR, 6250.6* +/- 432.5 mmHg/s; n = 10, *P < 0.02). beta2-AR overexpressing hearts also had higher contractility after zinterol administration compared with control hearts. Our results indicate that myocardial function of the transplanted heart can be enhanced by the adenovirus-mediated delivery of beta2-ARs. Thus, genetic manipulation may offer a novel therapeutic strategy to improve donor heart function in the post- operative setting.

Malignant granular cell tumors: report of a case and review of the literature

BACKGROUND

Granular cell tumors are uncommon soft tissue tumors and are more commonly benign. Malignant granular cell tumors are extremely rare, may be confused with other soft tissue sarcomas, and can be diagnosed only when metastatic disease that has the same histologic features as the primary tumor has been identified. Metastases are more commonly seen in lymph nodes and lungs; however, often the metastatic disease is not identified at the time of initial diagnosis and presents anywhere from 3 to 37 months after initial treatment. Certain findings, such as histologic appearance and size, may suggest that a granular cell tumor has uncertain malignant potential.

METHODS

We evaluated a patient with a granular cell tumor of uncertain malignant potential of the left chest wall and no evidence of metastatic disease on physical examination with a preoperative work-up to identify sites of occult disease.

RESULTS

The patient was found to have suspicious ipsilateral axillary adenopathy on magnetic resonance imaging and computed tomography scan. No other regional or distant disease was identified. The patient underwent an en bloc wide excision and axillary lymph node dissection. Metastatic disease was identified in nine of 23 lymph nodes.

CONCLUSIONS

Patients who are diagnosed with a granular cell tumor of uncertain malignant potential may benefit from preoperative radiologic evaluation because occult metastatic disease may be identified, alter the surgical approach, and possibly affect the long-term outcome.

Basic fibroblast growth factor expression is required for clonogenic growth of human glioma cells

Basic fibroblast growth factor (bFGF) is a heparin-binding protein, expressing potent mitogenic and angiogenic properties. Elevated levels of bFGF have been identified in human gliomas and glioma cell lines, suggesting that bFGF expression is involved in the aberrant growth patterns associated with these tumors. In the present study, the influence of bFGF on additional parameters of glioma cell malignancy was evaluated utilizing three distinct methods to suppress bFGF expression or activity including antisense oligonucleotide primers, a neutralizing monoclonal antibody or an inhibitor of the agonist action of bFGF: (1) The addition of 30 microM bFGF-specific antisense oligonucleotide primer to the human glioma cell line SNB-19 resulted in a 55% inhibition in colony formation in soft agar. This effect was dose-dependent and specific, as sense strand primer was ineffective in suppressing growth. In addition to exhibiting fewer colonies, antisense treatment significantly altered colony morphology. (2) SNB-19 cell growth in culture was suppressed in the presence of a neutralizing bFGF-specific monoclonal antibody. (3) Inositolhexakisphosphate, a newly identified antagonist of FGF binding and activity, suppressed SNB-19 cell growth in soft agar culture. These results demonstrate that bFGF may regulate glioma growth and progression independent of its role in tumor angiogenesis and that bFGF release or secretion may be required for these actions.

Family visits and different cultures

Family visits to hospitalized patients provide a form of social support. Social support is known to buffer the effects of stress which may occur with an illness, hospitalization or treatment. The cultural background of any patient is an important variable as well as expectations and results of the hospitalization and treatment. The authors studied the effects of family visits upon physiological parameters of critically ill neuro patients. They will discuss the findings of their research which included patients of several cultures such as Native Americans, Hispanics, and Anglo American families in the samples used. As returned Peace Corps nurses, the presenters will discuss their experiences in different cultures and the role of the family with neuro patients in the areas. Cultures that will be discussed include those of Native Americans, Malaysians and Columbians. Implications for practice include transcultural nursing assessment. Factors to be included are values, beliefs, customs and social structure. This information should be utilized to provide optimal nursing care individualized to each patient and family with reference to their culture.

Evidence for highly stable nuclear poly(A) in cultured mammalian cells

The kinetics of turnover of nuclear poly(A) were determined under conditions which facilitated the detection of relatively stable classes of the molecule. Growing 3T6 or HeLa cells were labeled with [3H]adenosine for several hours. The turnover of nuclear poly(A) was then followed over long time intervals using a variety of chase conditions. When a cordycepin chase was employed, a class of nuclear poly(A) with a half life of 2.5 h was observed. When the chase was effected by allowing the intracellular ATP pool specific activity to decay as a result of normal metabolic processes, a more stable class of nuclear poly(A) was detected (half life = 8--12 h). These results indicate that a significant portion of poly(A)-hnRNA has a long half-life.

Oxygen uptake, glucose utilization, lactate release and adenine nucleotide content of sheep ovarian follicles in culture: effect of human chorionic gonadotrophin

A study has been made of the oxygen uptake, glucose utilization, lactate release and cellular content of adenine nucleotides of isolated sheep ovarian follicles (4-6 min in diameter) maintained in organ culture, and of the effects on these parameters of the addition of human chorionic gonadotrophin (hCG). The mean oxygen consumption of the entire follicles when freshly isolated and of the theca and membrana components was 0-56, 1-08 and 0-05 mumol per milligram wet weight of tissue per hour respectively. About 8 mumol of glucose was taken up and 16 mumol of lactate released per milligram wet weight of follicular tissue per hour during the first 24-h period of culture. This rate reduced by about 30% for each subsequent day of culture, but was significantly increased by the addition of hCG. The mean ATP content of theca and granulosa tissues was 4-6 and 2-8 nmol/mg wet weight of tissue respectively. There was no discernable change in tissue adenine nucleotide content or energy charge ratio during the 3-day culture period, and prolonged exposure to hCG was without effect. Untreated follicles produced both oestrogen and androgens throughout the culture period. The addition of hCG resulted in a transitory stimulation in oestrogen secretion, inhibition of androgen secretion, and a marked and sustained rise in progestin secretion. It is proposed that the increase in glycolytic activity following exposure to hCG may relate to the activation of the granulosa cells coincident with a transference of steroid synthetic capacity from theca interna to membrana granulosa.