Protocolised approach to end-of-life care in the ICU--the ICU PALCare Pilot Project.

International literature on end-of-life care in intensive care units (ICUs) supports the use of 'protocol bundles', which is not common practice in our 18-bed adult general ICU in Sydney, New South Wales. We conducted a prospective observational study to identify problems related to end-of-life care practices and to determine whether there was a need to develop protocol bundles. Any ICU patient who had 'withdrawal' of life-sustaining treatment to facilitate a comfortable death was eligible. Exclusion criteria included organ donors, unsuitable family dynamics and lack of availability of research staff to obtain family consent. Process-of-care measures were collected using a standardised form. Satisfaction ratings were obtained using de-identified questionnaire surveys given to the healthcare staff shortly after the withdrawal of therapy and to the families 30 days later. Twenty-three patients were enrolled between June 2011 and July 2012. Survey questionnaires were given to 25 family members and 30 healthcare staff, with a high completion rate (24 family members [96%] and 28 staff [93.3%]). Problems identified included poor documentation of family meetings (39%) and symptom management. Emotional/spiritual support was not offered to families (39.1%) or ICU staff (0%). The overall level of end-of-life care was good. The overwhelming majority of families and healthcare staff were highly satisfied with the care provided. Problems identified related to communication documentation and lack of spiritual/emotional support. To address these problems, targeted measures would be more useful than the adoption of protocol bundles. Alternate models of satisfaction surveys may be needed.

Relative Importance of the Arcuate and Anteroventral Periventricular Kisspeptin Neurons in Control of Puberty and Reproductive Function in Female Rats.

Kisspeptin plays a critical role in pubertal timing and reproductive function. In rodents, kisspeptin perikarya within the hypothalamic arcuate (ARC) and anteroventral periventricular (AVPV) nuclei are thought to be involved in LH pulse and surge generation, respectively. Using bilateral microinjections of recombinant adeno-associated virus encoding kisspeptin antisense into the ARC or AVPV of female rats at postnatal day 10, we investigated the relative importance of these two kisspeptin populations in the control of pubertal timing, estrous cyclicity, and LH surge and pulse generation. A 37% knockdown of kisspeptin in the AVPV resulted in a significant delay in vaginal opening and first vaginal estrous, abnormal estrous cyclicity, and reduction in the occurrence of spontaneous LH surges, although these retained normal amplitude. This AVPV knockdown had no effect on LH pulse frequency, measured after ovariectomy. A 32% reduction of kisspeptin in the ARC had no effect on the onset of puberty but resulted in abnormal estrous cyclicity and decreased LH pulse frequency. Additionally, the knockdown of kisspeptin in the ARC decreased the amplitude but not the incidence of LH surges. These results might suggest that the role of AVPV kisspeptin in the control of pubertal timing is particularly sensitive to perturbation. In accordance with our previous studies, ARC kisspeptin signaling was critical for normal pulsatile LH secretion in female rats. Despite the widely reported role of AVPV kisspeptin neurons in LH surge generation, this study suggests that both AVPV and ARC populations are essential for normal LH surges and estrous cyclicity.

Implications of compensating property owners for geologic sequestration of CO2.

Geologic sequestration (GS) of carbon dioxide (CO2) is contingent upon securing the legal right to use deep subsurface pore space. Under the assumption that compensation might be required to use pore space for GS, we examine the cost of acquiring the rights to sequester 160-million metric tons of CO2 (the 30-year emissions output for an 800 megawatt power plant operating with a 60% capacity factor and at 90% capture efficiency) using a probabilistic model to simulate the temporal-spatial distribution of subsurface CO2 plumes in several brine-filled sandstones in Pennsylvania and Ohio. For comparison, the Frio Sandstone in the Texas Gulf Coast and the Mt. Simon Sandstone in Illinois were also analyzed. The predicted median values of CO2 plume footprints range from 4500 km(2) to 11,000 km(2) for the Ohio and Pennsylvania sandstones compared to 320 km(2) and 300 km(2) for the thicker Frio and Mt. Simon Sandstones, respectively. We use these footprints to bound the cost to use pore space in Pennsylvania and Ohio and, alternatively, the cost of piping CO2 from Pennsylvania and Ohio to the Mt. Simon or Frio Sandstones for sequestration. The results suggest that pore space acquisition costs could be significant and that using thin local formations for sequestration may be more expensive than piping CO2 to thicker formations at distant sites.

Does EMS belong in the fire service?

For years, EMS was treated as public safety's neglected stepchild. But as fire-suppression responses decrease, EMS is now a hot property--and everyone seems to want a piece of the action. Can EMS flourish under the auspices of the fire service, or are private and third-service systems the way to go? EMS provides a comprehensive report on the current national mind-sets.

Going ... going ... gone? Federal Emergency Management Agency.

Bashing the Federal Emergency Management Agency (FEMA) has become routine among EMS providers. The time has come for the agency's day of reckoning. Here's a look at the Congressional bills designed to build a better FEMA.

Firestorm. The Waco tragedy.

When the Feds stormed Branch Davidian cult leader David Koresh's Waco compound in April after a 51-day stalemate, EMTs were prepared for the worst--and that's what they got.