Palliative care aspects of wound healing in complex patients: a case report.

DECLARATION OF INTEREST: The authors have no conflicts of interest to declare.

Evaluation of the Pronouncement of Death Policy Implementation and Outcomes: Implications for Advanced Practice Nursing.

In 2011, the Veterans Health Administration mandated that Veterans Affairs (VA) Medical Centers develop and implement a policy that allowed registered nurses (RNs) and advanced practice registered nurses (APRNs) to pronounce the death of residents who die in Veterans Affairs community living centers, previously known as nursing homes, provided that there is a written do-not-resuscitate order in their medical record. The purpose of this quality improvement project was to determine the extent to which the implementation of the RN/APRN death pronouncement policy affected death pronouncement time for residents who die after 5 PM and before 7:30 AM, on weekends and holidays. This project is significant because the previous physician-only death pronouncement policy was found to cause unnecessary delays in death pronouncement. A chart review of the medical records of all veterans' deaths pronounced by physicians 3 years before the implementation of the policy and 4 years after the RN/APRN policy was reviewed and implemented. The data analysis was conducted using descriptive analysis. A significant difference was found in the results (P < .05). The maximum for prepolicy deaths was 125 minutes. The maximum for postpolicy deaths was 7 minutes. The results supported the assumption that RN/APRN pronounced death without delay.

Bioaccessibility and speciation of arsenic in country foods from contaminated sites in Canada.

Arsenic in foods obtained through foraging or hunting (country foods) in contaminated areas has not been reported; moreover the chemical form (arsenic speciation) is not known. Bioaccessibility extractions can be used to extract the arsenic from samples, giving information about the arsenic that is available for absorption into humans. Bioaccessibility of arsenic was measured in country foods (berries, other plants, mushrooms and hares) collected from contaminated sites in Canada. Arsenic speciation in the bioaccessibility extracts was also determined. Arsenic concentrations in berries ranged from 0.06 to 21 mg/kg, and Labrador tea contained 1.9 mg/kg of arsenic (all wet weight). Arsenic concentrations (wet weight) ranged up to 46 mg/kg in mushrooms, but they were much lower in hare muscle tissue (0.007 to 0.6 mg/kg). Percent bioaccessibility was lowest in berries and plants (means of 12-45%), where the arsenic species were mostly toxic inorganic arsenic. Bioaccessibility was higher in mushrooms and hare meat (means of 22-76%), where along with toxic inorganic arsenic, substantial proportions of less toxic organoarsenic species were measured, including non-toxic arsenobetaine. The speciation patterns were highly variable in both mushrooms and hare meat. Toxic forms of arsenic are present in country foods collected from contaminated areas, but the amounts vary according to and within each sample type. Therefore testing should ideally be carried out for new sample types and locations to estimate exposures to humans.

Bioaccessibility of lead and arsenic in traditional Indian medicines.

Arsenic and lead have been found in a number of traditional Ayurvedic medicines, and the practice of Rasa Shastra (combining herbs with metals, minerals and gems), or plant ingredients that contain these elements, may be possible sources. To obtain an estimate of arsenic and lead solubility in the human gastrointestinal tract, bioaccessibility of the two elements was measured in 42 medicines, using a physiologically-based extraction test. The test consisted of a gastric phase at pH 1.8 containing organic acids, pepsin and salt, followed by an intestinal phase, at pH 7 and containing bile and pancreatin. Arsenic speciation was measured in a subset of samples that had sufficiently high arsenic concentrations for the X-ray absorption near edge structure analysis used. Bioaccessible lead was found in 76% of samples, with a large range of bioaccessibility results, but only 29% of samples had bioaccessible arsenic. Lead bioaccessibility was high (close to 100%) in a medicine (Mahayograj Guggulu) that had been compounded with bhasmas (calcined minerals), including naga (lead) bhasma. For the samples in which arsenic speciation was measured, bioaccessible arsenic was correlated with the sum of As(V)-O and As(III)-O and negatively correlated with As-S. These results suggest that the bioaccessible species in the samples had been oxidized from assumed As-S raw medicinal ingredients (realgar, As(4)S(4), added to naga (lead) bhasma and As(III)-S species in plants). Consumption at recommended doses of all medicines with bioaccessibile lead or arsenic would lead to the exceedance of at least one standard for acceptable daily intake of toxic elements.