Improving ICU-Based Palliative Care Delivery: A Multicenter, Multidisciplinary Survey of Critical Care Clinician Attitudes and Beliefs.

OBJECTIVE: Addressing the quality gap in ICU-based palliative care is limited by uncertainty about acceptable models of collaborative specialist and generalist care. Therefore, we characterized the attitudes of physicians and nurses about palliative care delivery in an ICU environment. DESIGN: Mixed-methods study. SETTING: Medical and surgical ICUs at three large academic hospitals. PARTICIPANTS: Three hundred three nurses, intensivists, and advanced practice providers. MEASUREMENTS AND MAIN RESULTS: Clinicians completed written surveys that assessed attitudes about specialist palliative care presence and integration into the ICU setting, as well as acceptability of 23 published palliative care prompts (triggers) for specialist consultation. Most (n = 225; 75%) reported that palliative care consultation was underutilized. Prompting consideration of eligibility for specialist consultation by electronic health record searches for triggers was most preferred (n = 123; 41%); only 17 of them (6%) felt current processes were adequate. The most acceptable specialist triggers were metastatic malignancy, unrealistic goals of care, end of life decision making, and persistent organ failure. Advanced age, length of stay, and duration of life support were the least acceptable. Screening led by either specialists or ICU teams was equally preferred. Central themes derived from qualitative analysis of 65 written responses to open-ended items included concerns about the roles of physicians and nurses, implementation, and impact on ICU team-family relationships. CONCLUSIONS: Integration of palliative care specialists in the ICU is broadly acceptable and desired. However, the most commonly used current triggers for prompting specialist consultation were among the least well accepted, while more favorable triggers are difficult to abstract from electronic health record systems. There is also disagreement about the role of ICU nurses in palliative care delivery. These findings provide important guidance to the development of collaborative care models for the ICU setting.

Cell Salvage in Obstetrics.

Intraoperative cell salvage is a strategy to decrease the need for allogeneic blood transfusion. Traditionally, cell salvage has been avoided in the obstetric population because of the perceived risk of amniotic fluid embolism or induction of maternal alloimmunization. With advances in cell salvage technology, the risks of cell salvage in the obstetric population parallel those in the general population. Levels of fetal squamous cells in salvaged blood are comparable to those in maternal venous blood at the time of placental separation. No definite cases of amniotic fluid embolism have been reported and appear unlikely with modern equipment. Cell salvage is cost-effective in patients with predictably high rates of transfusion, such as parturients with abnormal placentation.

Readability, Content, and Quality Assessment of Web-Based Patient Education Materials Addressing Neuraxial Labor Analgesia.

BACKGROUND: Studies in a variety of disciplines have shown that the readability of Web-based patient education materials is above that of the sixth grade reading level recommended by the U.S. Department of Health and Human Services. The aim of this study was to evaluate the readability, content, and quality of English- and Spanish-language patient education materials addressing neuraxial labor analgesia. METHODS: The websites of 122 U.S. academic medical centers with obstetric anesthesia divisions were searched for English- and Spanish-language patient education materials. Readability of English-language patient education materials was assessed with 3 validated indices: Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook, and Gunning Frequency of Gobbledygook. Readability of Spanish-language patient education materials was assessed using the Spanish Lexile Measure. A 1-sample t test was used to evaluate the mean readability level against the recommended sixth grade reading level. A scoring matrix was developed to evaluate the content of patient education materials. Website quality was assessed using the Patient Education Materials Assessment Tool for Print. RESULTS: We identified 72 English-language and 29 Spanish-language patient education materials. The mean readability levels of all patient education materials were higher than the recommended sixth grade reading level using all indices (Flesch-Kincaid Grade Level: 9.1 ± 1.9, Simple Measure of Gobbledygook: 8.6 ± 1.4, Gunning Frequency of Gobbledygook: 11.8 ± 2.1; P < 0.001 for all). All patient education materials discussed the benefits of neuraxial analgesia. However, only 14% (upper 95% confidence interval: 24%) discussed contraindications to neuraxial anesthesia. Postdural puncture headache and hypotension were the most commonly addressed complications (92%). All other complications were addressed by less than half of patient education materials. Patient Education Materials Assessment Tool for Print scores were consistent with poor website understandability (median score, 64%; interquartile range, 64-73). CONCLUSIONS: The mean readability of Web-based patient education materials addressing neuraxial labor analgesia was above the recommended sixth grade reading level. Although most patient education materials explained the benefits of neuraxial analgesia, possible contraindications and complications were not consistently presented. The content, readability, and quality of patient education materials are poor and should be improved to help patients make more informed decisions about analgesic options during labor and delivery.

The incidence of methicillin-resistant Staphylococcus aureus in pressure ulcers.

Colonization of chronic wounds with methicillin-resistant Staphylococcus aureus continues to be an important healthcare concern. Aside from the morbidity associated with infections, colonization alone can contribute to outbreaks at long-term-care facilities and within hospitals. Despite the prevalence of pressure ulcers, the incidence of S aureus in these chronic wounds is unknown.

Age-Dependent Impact of Fluoroscopic Radiation on the Gender of Off-Spring: An International Survey of Cardiologists.

Background: Fluoroscopic radiation has been implicated in reducing the sex ratio (M:F) by potentially damaging the Y chromosome. We examined the effects of exposure to fluoroscopic radiation on gender of offspring of cardiologists across the world. Methods: An internet based survey was e-mailed worldwide to 8000 physicians who practice invasive electrophysiology and/or interventional cardiology. Survey questions included age, race, sub-specialty, hours of exposure to radiation, number of children, gender of off-spring, miscarriages and mutations and exposure to radiation prior to conception of each child. Logistic regression analyses were performed on years of exposure and gender of offspring born post radiation exposure. Results: Responses of 377 cardiologists (84% male and 16% female) were reviewed. With a total of 398 males and 402 females born to 377 cardiologists, although reduced, the overall sex ratio (0.99) was not significantly different from that observed in the general population (1.05). Univariate logistic regression analysis identified higher male births with increasing hours of radiation exposure (OR 1.034, CI 1.003-1.067 p=0.03) and increasing paternal age (OR 1.05, CI 1.01-1.08, p=0.002). Subgroup analysis of children of male cardiologists revealed higher incidence of male births with increasing age and radiation exposure and multivariate analysis only identified paternal age as predictor of higher incidence of male births (OR 1.05, CI 1.01-1.089, p=0.0027). Conclusion: Exposure to ionizing radiation leads to a decrease in the sex ratio (M/F) in younger male cardiologists, while this effect is reversed with greater number of male births in older male cardiologists.

Characterization of the core elements of the NF-κB signaling pathway of the sea anemone Nematostella vectensis.

The sea anemone Nematostella vectensis is the leading developmental and genomic model for the phylum Cnidaria, which includes anemones, hydras, jellyfish, and corals. In insects and vertebrates, the NF-κB pathway is required for cellular and organismal responses to various stresses, including pathogens and chemicals, as well as for several developmental processes. Herein, we have characterized proteins that comprise the core NF-κB pathway in Nematostella, including homologs of NF-κB, IκB, Bcl-3, and IκB kinase (IKK). We show that N. vectensis NF-κB (Nv-NF-κB) can bind to κB sites and activate transcription of reporter genes containing multimeric κB sites or the Nv-IκB promoter. Both Nv-IκB and Nv-Bcl-3 interact with Nv-NF-κB and block its ability to activate reporter gene expression. Nv-IKK is most similar to human IKKε/TBK kinases and, in vitro, can phosphorylate Ser47 of Nv-IκB. Nv-NF-κB is expressed in a subset of ectodermal cells in juvenile and adult Nematostella anemones. A bioinformatic analysis suggests that homologs of many mammalian NF-κB target genes are targets for Nv-NF-κB, including genes involved in apoptosis and responses to organic compounds and endogenous stimuli. These results indicate that NF-κB pathway proteins in Nematostella are similar to their vertebrate homologs, and these results also provide a framework for understanding the evolutionary origins of NF-κB signaling.