Communicating With Unconscious Patients: An Overview.

BACKGROUND: Nurses are told to speak to their unconscious patients because hearing is said to be the last sense to depart. There was little reliable evidence before the 1990s that patients in an unconscious state could hear and understand what was being said. That led to reluctance on the part of health professionals to communicate with these unresponsive patients. OBJECTIVE: This historical overview aims to present researched evidence from the 1990s to the present detailing awareness that occurs in unconscious patients, when that awareness increases, and how to detect that awareness. It also includes research about the benefits of communicating with unconscious patients and descriptions of how registered nurses and other health care professionals, from a postsurvey after a continuing education course on experiences of unconscious patients, plan to communicate with unconscious patients. METHODS: A literature search was conducted, which included more than 150 articles and books about experiences of unconscious patients in several electronic databases, including PubMed, CINAHL, and the British Nursing Index. In addition, an analysis of 105 postcourse responses by registered nurses (89%) and other health professionals (11%), licensed practical nurses, emergency medical technicians, and cardiac technicians after taking a continuing education course on experiences of previously unconscious patients were analyzed. RESULTS: The Glasgow Coma Scale and the Full Outline of Unresponsiveness scale are helpful behavioral tools to identify levels of coma but miss detecting awareness in patients who can hear and understand but cannot move. The estimates are that 25% to 40% (J Trauma. 1975;15:94-98; J Neurosci Nurs. 1988;20:223-228; J Neurosci Nurs. 1990;22(1):52-53; Am J Crit Care. 1995;3:227-232) of patients diagnosed with a disorder of consciousness can hear and understand what is being said in their environment. Substantial evidence supports that isolation and loneliness, such as experienced by some patients perceived to be unaware, can be physically and psychologically harmful. CONCLUSIONS: Strong evidence shows that some patients diagnosed as being in a vegetative state can hear and understand what is being said in their environment. Interviews with previously unconscious patients and electrophysiological methods show that awareness can be detected in patients perceived to be unconscious. There is documented evidence that patients experience awareness when going into unconsciousness, even when they appear unaware and when moved. To our knowledge, these times have not been researched using electrophysiological devices but established from interviews.

Accessibility of cysteines in the native bovine rod cGMP-gated channel.

Cyclic nucleotide-gated channels of photoreceptors and olfactory sensory neurons are tetramers consisting of A and B subunits. Here, the accessibility of the cysteines of the bovine rod cyclic nucleotide-gated channel is examined as a function of ligand binding. N-Ethylmaleimide-modified cysteines of both subunits were identified by mass spectrometry after trypsin digestion. In the absence of ligand, the intracellular carboxy-terminal cysteines of both subunits were accessible to N-ethylmaleimide. Activation of the channel abolished the accessibility of Cys505 of the A subunit and Cys1104 of the B subunit, with both being conserved cysteines of the cyclic nucleotide-binding sites. The cysteine of the pore loop of the B subunit was also found to be modified by this reagent in the absence of ligand. The total number of accessible cysteines of each subunit was determined by mass shifting upon modification with polyethylene glycol maleimide. In the absence of cyclic nucleotides, this hydrophilic reagent only weakly labeled cysteines of the A subunit but readily labeled at least three cysteines of the B subunit. Ligand binding exposed two cysteines of the A subunit and one cysteine of the B subunit to chemical modification. Double-modification experiments suggest that some of these cysteines are in or close to membrane-spanning domains. However, these cysteines could not yet be identified. Together, the cysteine accessibility of the native rod cyclic nucleotide-gated channel varies markedly upon ligand binding, thus indicating major structural rearrangements, which are of functional importance for channel activation.

The Ca-activated Cl channel and its control in rat olfactory receptor neurons.

Odorants activate sensory transduction in olfactory receptor neurons (ORNs) via a cAMP-signaling cascade, which results in the opening of nonselective, cyclic nucleotide-gated (CNG) channels. The consequent Ca2+ influx through CNG channels activates Cl channels, which serve to amplify the transduction signal. We investigate here some general properties of this Ca-activated Cl channel in rat, as well as its functional interplay with the CNG channel, by using inside-out membrane patches excised from ORN dendritic knobs/cilia. At physiological concentrations of external divalent cations, the maximally activated Cl current was approximately 30 times as large as the CNG current. The Cl channels on an excised patch could be activated by Ca2+ flux through the CNG channels opened by cAMP. The magnitude of the Cl current depended on the strength of Ca buffering in the bath solution, suggesting that the CNG and Cl channels were probably not organized as constituents of a local transducisome complex. Likewise, Cl channels and the Na/Ca exchanger, which extrudes Ca2+, appear to be spatially segregated. Based on the theory of buffered Ca2+ diffusion, we determined the Ca2+ diffusion coefficient and calculated that the CNG and Cl channel densities on the membrane were approximately 8 and 62 micro m-2, respectively. These densities, together with the Ca2+ diffusion coefficient, demonstrate that a given Cl channel is activated by Ca2+ originating from multiple CNG channels, thus allowing low-noise amplification of the olfactory receptor current.

Assembly of retinal rod or cone Na(+)/Ca(2+)-K(+) exchanger oligomers with cGMP-gated channel subunits as probed with heterologously expressed cDNAs.

Proper control of intracellular free Ca(2+) is thought to involve subsets of proteins that co-localize to mediate coordinated Ca(2+) entry and Ca(2+) extrusion. The outer segments of vertebrate rod and cone photoreceptors present one example: Ca(2+) influx is exclusively mediated via cGMP-gated channels (CNG), whereas the Na(+)/Ca(2+)-K(+) exchanger (NCKX) is the only Ca(2+) extrusion protein present. In situ, a rod NCKX homodimer and a CNG heterotetramer are thought to be part of a single protein complex. However, NCKX-NCKX and NCKX-CNG interactions have been described so far only in bovine rod outer segment membranes. We have used thiol-specific cross-linking and co-immunoprecipitation to examine NCKX self-assembly and CNG-NCKX co-assembly after heterologous expression of either the rod or cone NCKX/CNG isoforms. Co-immunoprecipitation clearly demonstrated both NCKX homooligomerization and interactions between NCKX and CNG. The NCKX-NCKX and NCKX-CNG interactions were observed for both the rod and the cone isoforms. Thiol-specific cross-linking led to rod NCKX1 dimers and to cone NCKX2 adducts of an apparent molecular weight higher than that predicted for a NCKX2 dimer. The mass of the cross-link product critically depended on the location of the particular cysteine residue used by the cross-linker, and we cannot exclude that NCKX forms a higher oligomer. The NCKX-NCKX and NCKX-CNG interactions were not isoform-specific (i.e., rod NCKX could interact with cone NCKX, rod NCKX could interact with cone CNGA, and vice versa). Deletion of the two large hydrophilic loops from the NCKX protein did not abolish the NCKX oligomerization, suggesting that it is mediated by the highly conserved transmembrane spanning segments.

Binding of the retinal rod Na+/Ca2+-K+ exchanger to the cGMP-gated channel indicates local Ca(2+)-signaling in vertebrate photoreceptors.

Ca(2+) ions enter the outer segment of rod or cone photoreceptors exclusively through the cGMP-gated channel and are extruded by the Na(+)/Ca(2+)-K(+) exchanger. Recent evidence indicates that in the plasma membrane, the Na(+)/Ca(2+)-K(+) exchanger is associated with the cGMP-gated channel. In this contribution, the possible physiologic significance of this protein complex is considered. Based on recent experimental evidence, the possibility of a direct functional interaction between the cGMP-gated channel and the Na(+)/Ca(2+)-K(+) exchanger is discussed. Furthermore, a quantitative estimation of the cytoplasmic Ca(2+) diffusion at the cGMP-gated channel indicates that Ca(2+) diffusion is largely confined to the complex of the cGMP-gated channel and the associated Na(+)/Ca(2+)-K(+) exchanger molecules.

Subunit stoichiometry of the CNG channel of rod photoreceptors.

Cyclic nucleotide-gated (CNG) channels play a central role in the conversion of sensory stimuli into electrical signals. CNG channels form heterooligomeric complexes built of A and B subunits. Here, we study the subunit stoichiometry of the native rod CNG channel by chemical crosslinking. The apparent molecular weight (M(w)) of each crosslink product was determined by SDS-PAGE, and its composition was analyzed by Western blotting using antibodies specific for the A1 or B1 subunit. The number of crosslink products and their M(w) as well as the immunological identification of A1 and B1 subunits in the crosslink products led us to conclude that the native rod CNG channel is a tetramer composed of three A1 and one B1 subunit. This is an example of violation of symmetry in tetrameric channels.

Mutual inhibition of the dimerized Na/Ca-K exchanger in rod photoreceptors.

In the dark, rod photoreceptors sustain a continuous influx of Na and Ca ions through the cGMP-gated channels of the rod outer segments (ROS). Whereas Na ions are extruded in the inner segment by the Na-pump, Ca ions are extruded already in the ROS by Na/Ca-K exchange. Our previous findings indicate that in the ROS plasma membrane, exchanger and channel form a complex of two exchangers associated per channel. Here, we report evidence of a novel regulatory mechanism of the dimerized exchanger, based on the following findings: (1), thiol-specific cross-linking with dimaleimides resulted in an increase of the Na/Ca-K exchange activity which correlated with the size of the cross-linking reagent, i.e., with increasing separation of the monomers in a dimerized exchanger; (2), partial proteolysis of the exchanger also increased the exchange rate by about a factor of two; (3), disintegration of the channel-exchanger complex by solubilization of the ROS membranes and preparation of proteoliposomes resulted in a twofold enhancement of the exchange rate; however (4), partial proteolysis of proteoliposomes, in which the exchanger molecules exist as monomers, did not result in any enhancement of the exchange rate. These findings suggest an inhibitory protein domain at the contact site of the dimerized exchanger. The physiological implication of this inference will be discussed in terms of a potential allosteric regulation of the exchanger in the channel-exchanger complex.

The complex of cGMP-gated channel and Na+/Ca2+, K+ exchanger in rod photoreceptors.

Ca2+ is an important signal ion in photoreceptors for recovery after excitation and light adaptation. It enters the outer segment as a minor fraction of the dark current through cGMP-gated channels and is extruded in the same cell compartment by Na+/Ca2+, K+ exchange. Channel and exchanger are located exclusively in the plasma membrane, but not in the cytoplasmic membrane stack, the discs, which contain the visual pigment rhodopsin. The channel consists presumably of two alpha-subunits and two beta-subunits, whereas the exchanger is a monomeric protein. Recently, considerable evidence has been accumulated indicating that both proteins form a complex which is bound to peripherin/rds, an integral protein of the disc rim. This review focuses on the complex of cGMP-gated channel and Na+/Ca2+, K+ exchanger. The possibility of direct functional interaction between channel and exchanger is discussed. Furthermore, the consequences of different subunit arrangements of the channel for the channel-exchanger complex are considered. Finally, a Ca2+ diffusion model is presented which examines the possibility that Ca2+ currents are locally restricted to the close vicinity of the channel.

BUMBLEBEE POLLINATION RELATIONSHIPS ON THE BEARTOOTH PLATEAU TUNDRA OF SOUTHERN MONTANA.

The coadaptive, dynamic relationship between the members of a floral community and their respective bumblebee pollinators was studied on the alpine-tundra of the Beartooth Plateau in southern Montana. A total of ten species of Bombus was observed foraging for pollen and/or nectar on Castilleja pulchella, Delphinium bicolor, Lupinus monticola, Mertensia ciliata, Oxytropis campestris, Penstemon procerus, and Trifolium dasyphyllum. The number of Bombus species per plant species ranged from 1 to 9. Based on relative percentage of pollen types in corbicular loads, monolectic foragers comprised 53.5% and polylectic foragers 46.5% of the bumblebees. Examinations of relative length of nectariferous corolla-tubes, tongue-length of pollinators, foraging frequency of pollinators, phenology of floral anthesis, and stature of plants did not indicate specific resource partitioning. Non-tundra-nesting bumblebees from lower elevations preferred adventive or typically non-tundra plants. Examination of perianth colors in visible light by reflectance spectrophotometry and in long-wave (360 nm) ultraviolet light by photography disclosed well-defined visible light reflectance spectra in all species but ultraviolet reflectance patterns only in D. bicolor. Insect collections and exclosure studies indicated all plant species except D. bicolor and P. procerus are highly reliant on bumblebee pollinators.