The CASH assessment tool: A window into existential suffering.

Spiritual beliefs and practices have long served as a critical component of treating or managing serious illness. There is evidence to suggest that patients would like healthcare professionals to address their existential and spiritual needs. The CASH Assessment Tool focuses on four key areas of spiritual concern: Care, Assistance/Help, Stress, and Hopes/Fears. In this QI Project, a palliative care team within an urban, safety net, tertiary-care, and academic healthcare setting sought to elicit themes from the CASH assessment used by chaplains caring for patients with serious illnesses. Thirty patients were included in the pilot. Themes identified included knowing the patient as a person, concern about loved ones, concern about pain, and fear of death. We found that the CASH Assessment Tool was able to demonstrate the existential concerns of patients and serve as a framework for discussion about concerns and hopes of patients with serious illness.

Comparative evaluation of lateral flow immunoassays, LAMP, and quantitative PCR for diagnosis of fire blight in apple orchards.

Fire blight remains a serious threat to commercial apple production in the USA and worldwide. Other diseases and spray damage can result in fire blight-like symptoms that can lead to misdiagnosis and affect disease management strategies. Accurate and timely detection of the fire blight pathogen, Erwinia amylovora, is extremely important to deploy appropriate and timely measures to reduce fire blight epidemics in commercial apple orchards. We tested two commercial lateral flow immunoassays (AgriStrip®, and Pocket Diagnostics kit), Loop mediated isothermal amplification (LAMP), and quantitative PCR (qPCR) to diagnose E. amylovora infected samples in lab and field settings. The AgriStrip® and Pocket Diagnostics kits were able to detect actively growing bacteria up to ×106 cfu/ml bacterial concentration. Pocket Diagnostics kit had less specificity and showed positive tests for E. pyrifolia in addition to E. amylovora. The LAMP assay showed high specificity for E. amylovora and was able to detect up to ×103 cfu/ml bacterial concentrations. The qPCR assay was also able to detect bacterial cells up to ×10-3 cfu/ml bacterial concentration with highly specific E. amylovora detection. Grower surveys and comparative cost-benefit analysis indicated that immunoassay kits are less expensive, easier to use, and require less technical expertise for on-site fire blight diagnosis than LAMP and qPCR. However, the choice of a specific diagnostic assay depends on the time, sensitivity, and specificity required for the detection of fire blight and its management.

A Novel Use of Topical Ketamine for the Treatment of Oral Pemphigus: A Case Report.

BACKGROUND: Paraneoplastic pemphigus (PNP) is a rare autoimmune blistering disease often associated with lymphoproliferative disorders. PNP causes hemorrhagic stomatitis of the lips, tongue, and cheeks which can be painful and difficult to treat. CASE HISTORY: A 54-year-old man was referred to our hospital for treatment of Stage IV lymphoma and paraneoplastic pemphigus. Due to pain from oral stomatitis, he required a gastrostomy tube for delivery of nutritional tube feeds. He was placed on steroids and received both lidocaine mouthwash and opioids, but his pain persisted. CASE MANAGEMENT AND OUTCOME: A palliative care consult was obtained for management of his pain. The palliative team recommended topical ketamine for the treatment of the painful lip lesions. The patient felt immediate relief with the application of ketamine and his pain level was reduced to a 5/10. The following day, his pain was 0/10. Five days later, the opioids were discontinued and the pain relief continued. CONCLUSION: Painful stomatitis from PNP may be refractory to standard treatment. We found that the application of topical ketamine was very effective in this patient with hemorrhagic stomatitis from PNP.

Top Ten Tips Palliative Care Clinicians Should Know About Teaching Trainees How to Conduct a Family Meeting.

The family meeting is an essential component of effective palliative care (PC); however, medical students and junior doctors-in-training often consider leading a family meeting to be a daunting task. The old "see one, do one, teach one" axiom should not apply in preparing trainees to conduct a family meeting. After a review of the literature on established PC curricula, trainee perceptions of their PC educational experiences, and documented educational interventions in preparing trainees to conduct a family meeting, we have compiled a list of 10 tips for clinical educators to consider in assisting their students to feel better equipped to conduct productive family meetings.

Nebulized fentanyl for refractory dyspnea secondary to chronic obstructive pulmonary disease (COPD): A case report.

We present a case where we evaluated the effectiveness of nebulized fentanyl in the treatment of refractive dyspnea in a patient with chronic obstructive pulmonary disease (COPD) with major complications and comorbidities. Nebulized fentanyl was used to successfully decrease the subjective symptoms of refractory dyspnea in this given patient. Nebulized fentanyl appears to be a cost-effective treatment option in patients that experience episodes of severe shortness of breath (SOB).

Nebulized Fentanyl for Dyspnea: A Retrospective Chart Review.

Nebulized fentanyl is well established for analgesia but its use for dyspnea requires further investigation. The aim of our study was to determine the effectiveness of nebulized fentanyl in treating patients with dyspnea and to determine if there were harmful side effects described by patients or their providers. We used a convenience sample of patients from July 1 2014 to July 1 2018 and performed a retrospective chart review. We found that 360 doses of nebulized fentanyl were given to 73 patients during that time period. Of the 73 patients evaluated, 32 patients (43.8%) were female and forty-one were male (56.1%). The median age was 67 and the median length of stay was 9 days. There were no documented findings of bronchospasm, hypotension, or allergic reaction in any of the medical records reviewed. Patients treated with nebulized fentanyl for dyspnea showed a mean decreased respiratory rate of 4.3 breaths/min and a mean increased oxygen saturation of 2.3%. Also, 71% of patients with documented responses experienced an improvement in their dyspnea. Our preliminary data suggest that nebulized fentanyl has limited side effects and may have a role in the treatment of dyspnea. Further research is necessary to determine its efficacy.

A Treatment for Refractory High Ileostomy Output.

We present a case where the glucagon-like peptide 2 (GLP-2) analog teduglutide was used successfully to decrease high ostomy output due to short bowel syndrome in a patient not entirely dependent on parenteral nutrition. Short bowel syndrome is known to decrease quality of life and is associated with high health care costs. Although use has been limited by cost, teduglutide appears to be a treatment option for palliative care practice if patients suffer from short bowel syndrome.

Do audition electives impact match success?

PURPOSE: The authors sought to determine the value of the audition elective to the overall success of medical students in the match. METHOD: The authors surveyed 1,335 fourth-year medical students at 10 medical schools in 2013. The study took place over a 2-month period immediately following the match. Medical students were emailed a 14-question survey and asked about audition electives, rank order, and cost of 'away' rotations. RESULTS: One hundred percent of students wishing to match in otolaryngology, neurosurgery, plastic surgery, radiation oncology, and urology took the audition electives. The difference by specialty in the proportion of students who took an audition was statistically significant (p<0.001). Of the students who auditioned, 71% matched at one of their top three choices compared with 84% of non-auditioners who matched to one of their top three choices (p<0.01). CONCLUSIONS: Students performed a large number of 'away' rotations as 'auditions' in order to improve their chances in the match. For certain competitive specialties, virtually all students auditioned. Overall, students who did not audition were just as successful as or more successful than students who did audition.

Permanent Peripheral Neuropathy: A Case Report on a Rare but Serious Debilitating Side-Effect of Fluoroquinolone Administration.

The health risks and side effects of fluoroquinolone use include the risk of tendon rupture and myasthenia gravis exacerbation, and on August 15, 2013, the Food and Drug Administration updated its warning to include the risk of permanent peripheral neuropathy. We present a case of fluoroquinolone-induced peripheral neuropathy in a patient treated for clinically diagnosed urinary tract infection with ciprofloxacin antibiotic.

Carbohydrate analysis throughout the development of a protein therapeutic.

This review discusses the challenges involved in the characterization of the glycosylation of therapeutic glycoproteins. The focus is on methods that are most commonly used in regulatory filings and lot release testing of therapeutic glycoproteins. The different types of assays for carbohydrate analysis are reviewed, including the distinction between assays appropriate for lot release or better suited to testing during early drug development or in-depth characterization of the glycosylation. Characteristics of the glycoprotein and production process that should be considered when determining the amount of testing, the number of different methods to employ and when the testing should be performed during development of protein therapeutics is also discussed.

Effect of genetic background on glycosylation heterogeneity in human antithrombin produced in the mammary gland of transgenic goats.

Glycosylation is involved in the correct folding, targeting, bioactivity and clearance of therapeutic glycoproteins. With the development of transgenic animals as expression systems it is important to understand the impact of different genetic backgrounds and lactations on glycosylation. We have evaluated the glycosylation of recombinant antithrombin produced in several transgenic goat lines, from cloned animals and from different types of lactation including induced lactations. Our results show glycosylation patterns from the protein expressed in animals, derived from the same founder goat, are mostly comparable. Furthermore, the protein expressed in two cloned goats had highly consistent oligosaccharide profiles and similar carbohydrate composition. However, there were significantly different oligosaccharide profiles from the proteins derived from different founder goats. Artificial induction of lactation did not have significant effects on overall carbohydrate structures when compared to natural lactation. The only major difference was that recombinant antithrombin from induced lactations contained a slightly higher ratio of N-acetylneuraminic acid to N-glycolylneuraminic acid and less amount of oligosaccharides containing N-glycolylneuraminic acid. The oligosaccharides from all animals were a mixture of high mannose-, hybrid- and complex-type oligosaccharides. Sialic acid was present as alpha-2,6-linkage and no alpha-1,3-linked galactose was observed. These results indicate that transgenic animals with closely related genetic backgrounds express recombinant protein with comparable glycosylation.

N-linked oligosaccharide analysis of glycoprotein bands from isoelectric focusing gels.

Glycoproteins often display a complex isoelectric focusing profile because of the presence of negatively charged carbohydrates, such as sialic acid, phosphorylated mannose, and sulfated GalNAc. Until now, understanding the role of these charged carbohydrates in determining the isoelectric focusing profile has been limited to observing pattern shifts following complete removal of the sugars in question. We have developed a simple and sensitive method for analyzing N-linked oligosaccharides from the individual isoelectric focusing bands of a glycoprotein using recombinant human thyroid-stimulating hormone as a model system. N-linked oligosaccharides were released and profiled from individual bands following electroblotting of isoelectric focusing gels. As might be predicted, high-pH anion-exchange chromatography-pulsed amperometric detection and matrix-assisted laser desorption/ionization-time of flight analyses indicated that the bands that migrated closer to the positive electrode contained more sialylated N-linked oligosaccharides. The sialic acid content of these bands correlated with that predicted from the corresponding oligosaccharide analyses.

Mannose 6-phosphate quantitation in glycoproteins using high-pH anion-exchange chromatography with pulsed amperometric detection.

An assay has been developed to quantitate the amount of mannose 6-phosphate in glycoproteins using high-pH anion-exchange chromatography with pulsed amperometric detection (HPAEC-PAD). The method was tested on a recombinant lysosomal enzyme, human alpha-galactosidase A, that contains mannose 6-phosphate. The assay includes two steps: hydrolysis of the glycoprotein in 6.75 M trifluoroacetic acid to release mannose 6-phosphate and quantitation of the released mannose 6-phosphate using HPAEC with PAD. There is a linear relationship between the amount of mannose 6-phosphate measured and the amount of alpha-galactosidase hydrolyzed. The assay is also sensitive for as little as 2.5 microg alpha-galactosidase, which contains 117 pmol mannose 6-phosphate. Further, the assay has been shown to have good day-to-day and operator-to-operator consistency. In order to evaluate the assay for glycoprotein in crude extract, the glycoprotein was separated by SDS-PAGE and transferred to polyvinylidene difluoride membrane. The amount of mannose 6-phosphate in the electroblots following hydrolysis was determined using HPAEC-PAD. The assay was also linear when measuring mannose 6-phosphate on electroblots. Therefore, this assay has been shown to be specific, sensitive, and reproducible.