Doing the right thing at the right time.

OBJECTIVE: To identify factors that clinicians consider when a patient is dying, enabling implementation of the Liverpool Care Pathway. BACKGROUND: In order to improve the care of the dying patient and their families it is helpful to implement the Liverpool Care Pathway for the dying. It therefore is necessary to identify the dying patient in a timely fashion. METHOD: A phenomenological study using semi-structured interviews (n=five nurses and five doctors) conducted on a hospice inpatient unit. FINDINGS: There was a prominent theme of anxiety about getting the timing of diagnosing dying right, with an emphasis how the dying patient and their families would cope if this were wrong. The main factors identified were: support for decision making, understanding the patient's journey and concern that the care given is appropriate. CONCLUSIONS AND IMPLICATIONS FOR NURSING PRACTICE: All clinicians interviewed for this study had concerns about increasing the patient's/carers' distress if the Liverpool Care Pathway implementation was mistimed. There is a risk that clinicians are avoiding difficult conversations with families and there may be a lack of understanding around the reasons for use of the Liverpool Care Pathway. Specific communications training may help clinicians in this role.

Gracilis or semitendinosus myopathy in 18 dogs.

The clinical findings in 18 dogs with gracilis (n = 17) or semitendinosus (n = 1) myopathy are described. Each dog had a similar hind-limb gait abnormality characterized by a shortened stride with a rapid, elastic medial rotation of the paw, internal rotation of the hock and external rotation of the calcaneus [corrected] and internal rotation of the stifle during the mid-to-late swing phase of the stride. Medical management prior to or in lieu of surgery was attempted (n = 8) with no apparent response. Fifteen dogs had one or multiple surgical procedures. Although transection, partial excision, or complete resection of the affected muscle resulted in resolution of lameness following surgery, lameness recurred six weeks to five months (mean, 2.5 months; median, two months) following surgery. Adjunctive medical treatment did not prevent recurrence. Variable replacement of the affected muscle with fibrous connective tissue (predominantly along the caudolateral border of the muscle) was evident grossly, and replacement of myofibers with fibrous connective tissue was confirmed histologically. A definitive etiology could not be established.

Improving patient satisfaction at all points in the revenue cycle.

A common expectation among consumers, whether in the market for a new automobile, a new home, or healthcare services, is that a certain level of customer service will be provided along with the product or service. And the level of customer service provided substantially influences a consumer's satisfaction with the purchase of a product or service.

Screw fixation of accessory carpal bone fractures in racing Greyhounds: 12 cases (1981-1986).

Fractures of the accessory carpal bone in 12 racing Greyhounds were repaired by use of internal fixation with screws. All dogs had a sprain-avulsion fracture of the distal margin of the articular surface of the accessory carpal bone, where the accessorioulnar ligament inserts (type I). Two dogs had a second avulsion fracture at the proximal margin of the articular surface, where the palmar ulnocarpal ligament inserts (type II), and 2 dogs had a second fracture at the caudal end of the bone at the insertion of the accessoriometacarpal ligaments (type III). Fractures were exposed surgically, using a palmarolateral approach between the fourth and fifth accessoriometacarpal ligaments, and were repaired using 1.5-mm or 2-mm cortical screws. Eight dogs were evaluated radiographically to monitor fracture healing. Union of fractures, with bridging of the fracture gap, usually developed by 5 to 8 weeks after surgery. Follow-up evaluation after surgical repair was possible in 11 dogs; 10 (91%) returned to training or racing, and 5 (45%) of those won 1 or more races.

Fractures of the calcaneus in racing greyhounds.

Fifty-one calcaneus fractures associated with (41) or without (10) central tarsal bone (Tc) fractures in racing greyhounds were evaluated and categorized. All calcaneal fractures with no Tc fractures had a plantar proximal intertarsal subluxation. No subluxations were found in dogs with both calcaneal and central tarsal fractures. The calcaneal fractures were treated either with coaptation splints or surgical repair. Surgical techniques included a Steinmann pin with a figure eight tension band device or screw or plate fixation as primary techniques supplemented by Kirschner wires and cerclage wires. In all calcaneal fractures associated with plantar proximal intertarsal subluxation, an arthrodesis of the calcaneoquartal joint was performed. All 22 surgically repaired fractures in dogs available for physical and radiographic reexamination had healed within 1 to 6 months. Eight dogs with fractures of the calcaneus associated with fractures of Tc returned to a racing career. None of the dogs with plantar proximal intertarsal subluxation raced again. Based on the orientation of the fracture lines and on dissection of two tarsi with calcaneal fractures, a hypothesis on the pathogenesis of calcaneal fractures in racing greyhounds was formulated.

Lateral ligamentous injury to the carpus of a racing greyhound.

The lateral collateral ligament of the ulna and the dorsolateral ligaments of the radiocarpal joint of a racing Greyhound were ruptured, resulting in instability of the carpus when the joint was flexed. This report describes a technique for making a ligament prosthesis, using the ulnaris lateralis tendon. Although the dog did not return to racing, the carpus was stable enough for general activity.

Central tarsal bone fractures in the racing Greyhound: a review of 114 cases.

A total of 114 central tarsal bone (Tc) fractures, including associated secondary fractures, were identified in 114 racing Greyhounds. The fractures were classified according to a previously described scheme. The type IV Tc fracture, dorsal and medial slab fractures, was most common. A Tc fracture alone, or a Tc fracture with associated fractures of the 4th tarsal bone (T4), calcaneus, or T4 and lateral base of the 5th metatarsal bone were the most commonly observed. The prevalence of secondary fractures increased with the severity of the Tc fracture. Management of Tc fractures involved 3 methods: coaptation, single-screw fixation, and 2-screw fixation. Additional repair was performed as indicated by the presence of concurrent secondary fractures. A total of 71% of the dogs returned to competitive racing.

Treatment of central tarsal bone fractures in the racing Greyhound.

Methods of repair of central tarsal bone (Tc) fractures in the racing greyhound can involve coaptation, single-screw fixation, or 2-screw fixation. Successful management, defined as a return to competitive racing, was obtained in 71% of 114 affected dogs treated by these methods. Both 1- and 2-screw fixation, with interfragmentary compression, was used to repair Tc fractures in 81 dogs. It was concluded that satisfactory results can be expected by use of open reduction and screw fixation in all types of Tc fractures except those that are severely comminuted.

Trauma to the carpus, tarsus, and phalanges of dogs and cats.

The methods described are those currently employed by the authors for the injuries described. As surgical results accumulate, we hope to modify and improve our methods. Many injuries to the carpus and tarsus have been omitted. Many questions remain unanswered. How long must external coaptation be applied? When is the optimum time for removal of internal fixation devices? Are sclerosing agents more successful for the management of interphalangeal luxations than primary suturing? Should autogenous cancellous bone be used in all arthrodeses? What is the best method of handling sesamoid fractures, and what is the best postoperative care for these fractures? When should passive joint movement be initiated? What is the owner's optimum role in providing rehabilitative physical therapy? Only be evaluating large numbers of clinical cases or controlling experimental cases can these questions be answered.