The use of crisis medication in the management of terminal haemorrhage due to incurable cancer: a qualitative study.

BACKGROUND: Terminal haemorrhage is a rare but devastating event that may occur in certain advanced cancers. The focus of management involves administration of 'crisis medicine' with the intention of relieving patient distress through sedative doses of anxiolytics or opioids. This practice, whilst widely accepted, is based on limited evidence and has never been formally evaluated. AIM: To evaluate the utility of crisis medication in the management of terminal haemorrhage, through the experiences of nurses who had personally managed such events. METHOD: Semi-structured interviews exploring the experiences of palliative care and head and neck oncology nurses were recorded, transcribed verbatim and analysed using interpretative phenomenological analysis. Saturation of themes occurred after interviewing 11 nurses with cumulative experience of managing 37 terminal haemorrhages. RESULTS: Participants reported crisis medication to have little, if any, role in the management of terminal haemorrhage, which was such a rapid event that patients died before it could be administered. As many events had not been predicted, anticipatory prescribing of crisis medication did not always occur. Staying with and supporting the patient, and using dark-coloured towels to camouflage blood were reported to be of more practical use. A focus on accessing crisis medicines had often been to the detriment of these simple yet beneficial measures. CONCLUSION: Anticipatory prescribing of crisis medication rarely benefits the patient and may unintentionally detract from nursing care. Guidelines on the management of terminal haemorrhage should reconsider the emphasis on crisis medication and focus on non-pharmacological approaches to this invariably fatal event.

Delivery of safe and effective care out of hours: the impact of the shared clinical record on a patient's out-of-hours contact with specialist palliative care.

Access to adequate clinical information is essential for out-of-hours palliative care teams and general practitioners, specific examples to illustrate and justify this need are surprisingly rare in the medical literature. Without access to the full clinical background the patient in this lesson may have been inappropriately admitted to a palliative care unit and delayed investigations would have misguided the admitting doctor's assessment, planned investigations and management.

Minimally Invasive Surgery to the Aortic Arch - Endovascular Repair combined with Ebranching: 4 Case Reports

Traditional repair of aortic arch aneurysms requires cardiopulmonary bypass and a period of profound hypothermia and circulatory arrest - allowing detachment of the head vessels off the aneurysm; and their anastomosis onto the graft. The procedure is safe and reproducible; however morbidity is significant and includes air embolism; stroke; excessive bleeding and acidosis. In addition the procedures are time-consuming; and cardioplegic arrest is also necessary; resulting in the potential for low cardiac output. Aortic arch aneurysms are not typically suitable for With improving techniques of descending aortic repair with stent grafts; hybrid techniques; which involve aortic arch debranching - thereby creating a proximal landing zone of adequate length; followed by stenting over the aortic arch are becoming popular. Methods: Four cases are presented. The technique involves initial sternotomy or upper sternal split; detachment of the innominate and left common carotid arteries; and their reattachment to the ascending aorta by separate grafts (debranching procedure). During this time a side clamp is placed on the ascending aorta. The left subclavian is usually left intact for technical reasons; unless there is a dominant left vertebral artery. This is safe as the shoulder has adequate collateral circulation; and stenting over this vessel is therefore well tolerated. The aortic arch is then completely covered with a stent graft which is inserted via the femoral artery. Arteriography was performed at the end of the procedure to confirm stent graft position and exclusion of the lesion. Results: All surgical transpositions were successful; and the patients recovered without neurologic; bleeding or cardiac complications. Surgical conversion for aortic graft was never required. There were no endoleaks. Mean duration of follow up was 53.5 months (range 21-77). Conclusions: Endovascular repair of the descending thoracic aorta; initially reserved for inoperable patients; is now becoming the accepted initial management. With improved technology and endografts it is now the safest option; especially for traumatic dissection. These techniques have now extended to the aortic arch. Debranching of the aortic avoiding cardiopulmonary bypass and circulatory arrest. Good pre-operative planning is necessary to make the procedure feasible

An observational study of screening for malnutrition in elderly people living in sheltered accommodation.

BACKGROUND: Elderly people are particularly at risk of malnutrition. There is no consensus regarding the optimal malnutrition screening test for elderly people and little is known about the prevalence of malnutrition in elderly people living in sheltered housing. METHOD: An observational study comparing sensitivity, specificity and positive and negative predictive values of the following screening measures in elderly people living in sheltered accommodation: body mass index, mid-arm circumference, albumin, haemoglobin, lymphocyte count, cholesterol and the Malnutrition Universal Screening Tool (MUST) and Mini Nutritional Assessment (MNA). A dietitian assessment was used as the gold standard to establish whether there was a risk of malnutrition. RESULTS: Of 100 people recruited (31 male and 69 female with average age 79.3 years) ten were categorized at risk by the dietitian assessment. The MUST score was the most sensitive and specific screening measure (100% and 98% respectively) with a negative predictive value of 1. The sensitivity and specificity of the other measures were: MNA 80% and 90%, mid-arm circumference 70% and 99%, BMI 60% and 90%, albumin 30% and 77%, haemoglobin 50% and 61%, lymphocyte count 20% and 86%, low cholesterol 30% and 90%. CONCLUSIONS: Ten per cent of elderly people in sheltered housing are at risk of malnutrition. The MUST screening tool is a sensitive and specific method of identifying those requiring further nutritional assessment.

Making do not attempt resuscitation decisions: do doctors follow the guidelines?

When do not attempt resuscitation orders are contemplated, guidelines exist to outline standards for planning patient care and decision making. These guidelines may not always be fully followed as ethical issues arise which may prevent doctors from doing so.

Conserved fragments of transposable elements in intergenic regions: evidence for widespread recruitment of MIR- and L2-derived sequences within the mouse and human genomes.

We analysed the distribution of transposable elements (TEs) in 100 aligned pairs of orthologous intergenic regions from the mouse and human genomes. Within these regions, conserved segments of high similarity between the two species alternate with segments of low similarity. Identifiable TEs comprise 40-60% of segments of low similarity. Within such segments, a particular copy of a TE found in one species has no orthologue in the other. Overall, TEs comprise only approximately 20 % of conserved segments. However, TEs from two families, MIR and L2, are rather common within conserved segments. Statistical analysis of the distributions of TEs suggests that a majority of the MIR and L2 elements present in murine intergenic regions have human orthologues. These elements must have been present in the common ancestor of human and mouse and have remained under substantial negative selection that prevented their divergence beyond recognition. If so, recruitment of MIR- and L2-derived sequences to perform a function that increases host fitness is rather common, with at least two such events per host gene. The central part of the MIR consensus sequence is over-represented in conserved segments given its background frequency in the genome, suggesting that it is under the strongest selective constraint.

Hydatid cyst fistula into the aorta presenting with massive hemoptysis. Case report and literature review.

Hydatid involvement of the aorta is extremely uncommon. We present a case where a hydatid cyst of the lung eroded into the thoracic aorta, causing massive hemoptysis. Successful repair was performed by resection (including left lower lobectomy) and graft interposition.

Myocardial abscess with contained rupture: successful repair.

Spontaneous rupture of the heart from myocardial abscess is a rare occurrence. Most cases of spontaneous cardiac rupture are due to myocardial infarction. We present a case of a contained rupture of the heart in a patient with staphylococcal septicemia. Although cultures from the pericardial space were negative the macroscopic and clinical picture was compatible with an abscess.

Penetrating cardiac injuries--current evaluation and management of the stable patient.

Patients with penetrating cardiac injuries present in a stable or only mildly shocked condition--especially if the laceration has sealed off and the patient has been adequately resuscitated. A large proportion of patients presenting to our unit are in a reasonably stable condition after resuscitation, and rapid diagnosis may be difficult. We present our experience over a 5-year period (191 patients), with particular reference to the stable patient. All patients with penetrating precordial wounds should be assessed for a possible cardiac injury, especially if a period of hypotension has occurred. Clinical signs, central venous pressure, chest radiograph, pericardiocentesis and subxiphoid window are not always helpful in the diagnosis. Cardiac ultrasound is very useful (in the absence of haemothorax), and was performed in 103 of 191 patients, with 8 false-negatives and 3 false-positives. When an unstable patient presents with an obvious diagnosis use of cardiac ultrasound should be restricted. A subxiphoid window has diagnostic value where the cardiac ultrasound is inconclusive.

High-power dual-rod Yb:YAG laser.

We describe a diode-pumped Yb:YAG laser that produces 1080 W of power cw with 27.5% optical optical efficiency and 532 W Q-switched with M(2)=2.2 and 17% optical-optical efficiency. The laser uses two composite Yb:YAG rods separated by a 90 degrees quartz rotator for bifocusing compensation. A microlensed diode array end pumps each rod, using a hollow lens duct for pump delivery. By changing resonator parameters we can adjust the fundamental mode size and the output beam quality. Using a flattened Gaussian intensity profile to calculate the mode-fill efficiency and clipping losses, we compare experimental data with modeled output power versus beam quality.

Surgical management of airway obstruction in primary tuberculosis in children.

BACKGROUND: The role of surgery in the management of airway obstruction from lymphobronchial tuberculosis is discussed in the present article. METHODS: Nine patients were operated on over a 4-year period and are currently presented. The age of the patients ranged between 5 and 28 months and 7 patients were male. Six patients required preoperative ventilation due to respiratory failure and all received standard posterolateral thoracotomies. Partial dissection and enucleation of bulky lymph nodes was performed in all but 1 patient. In that patient, the group of lymph nodes could be removed fully, including the sheath. RESULTS: All patients showed marked improvement and were weaned off the ventilator between 24 and 72 hours postoperatively. Long term follow-up was available in 7 patients and they are all doing well and are free of symptoms. CONCLUSIONS: Enucleation of mediastinal lymph nodes obstructing the airways in young patients with lymphobronchial tuberculosis is safe. It successfully relieves obstruction and is devoid of complication providing that incision, evacuation, and curettage of lymph nodes is performed avoiding overzealous dissection.

Current evaluation of cardiac stab wounds.

BACKGROUND: Patients with penetrating cardiac injuries may be stable or only mildly shocked, especially if the laceration has sealed off and the patient has been aggressively resuscitated. Clinical signs, chest roentgenograms, pericardiocentesis, and subxiphoid window are not always helpful in establishing the diagnosis. We reflect on the current evaluation based on 128 patients. METHODS: There were four groups of patients, ranging from lifeless (group I) to stable (group IV). Patients in groups I and II were prepared immediately for operation. Those in groups III and IV were often investigated further (chest roentgenogram and cardiac ultrasound). RESULTS: Mortality was 8%. Significant findings were a precordial stab, central venous pressure of more than 15 cm of water, one or more clinical signs of tamponade, and initial shock. Cardiac ultrasound was performed in 5 patients in group II (15%), 14 patients in group III (48%), and 37 patients in group IV (86%). There were no false positives, and 6 false negatives (11%). Thirty-one patients (24%) had clotted lacerations. There were no negative sternotomies. CONCLUSIONS: Efficient fluid resuscitation and rapid confirmation of diagnosis with cardiac ultrasound should decrease mortality. Stable patients with a precordial wound should undergo cardiac ultrasound or echocardiogram. Diagnosis may be reliably confirmed in these patients whose clinical signs often fluctuate (or rapidly deteriorate).

The faces of group practice. The transformation and progression of physician organizations.

The future will bring an increase in the economic forces which drive the succession of organizational forms. Migrating to integrated models of medical practice will become a survival technique for more and more physicians. This is a frightening prospect for individuals trained to be independent and self reliant. Fortunately, there are a variety of organizational models through which physicians can progress to ease the transition from solo to larger integrated practice forms. Regardless of the evolutionary course, successful physician organizations of the future will be primary care-based, geographically distributed, meaningfully partnered with hospital entities, equipped to accept risk, and lead by strong, business-savvy physician leaders and administrators. This organization will have the ability to flourish within a radically changing climate and will result in the delivery of measurably superior health care to its community.

Spectra of electron-beam pumped XeF lasers.

An analysis is presented of the lasing spectrum of the rovibronic XeF(B-X) transition as observed in an electron-beam pumped laser. The intricate spin-split rotational and vibrational structure in the 35.1- and 353-nm lasing emission is investigated, and insight is gained on the processes responsible for the vibrational, rotational, and spin inhomogeneities manifested in the spectra. Explanations of the data are developed in terms of near-resonant vibration-rotation energy transfer, rotational relaxation rate differences in the B and X states, rapid dissociation of the rotational resonances near the dissociation limit of the ground state, relatively slow collisional spin relaxation, and optical coupling of spin states. The implications for narrowband extraction in the 351- and 353-nm bands are noted. The rotational relaxation rates of the X and B states of XeF are estimated in the Appendix.

Mechanisms for improved XeF laser performance at elevated temperatures.

Lasing spectra and output efficiency have been measured for four Ne/Xe/NF(3) laser mixtures from 300 to 450 K. These high resolution spectra have been correlated with a theoretical rotational bandhead structure to identify rotational states contributing to two narrowband emissions in the 351-nm band. Rotationalvibrational population shifts appear to be the most important mechanisms responsible for the increase in laser efficiency with temperature. Increased ground-state dissociation and decreased narrowband absorption may not be as important as previously thought.

Lipid and fatty acid composition of testes of quaking mice.

Testes of quaking mice (sterile mutants) and of controls were analyzed for major lipid classes and fatty acid composition. Of the main lipid classes, only cholesterol esters differed significantly in concentration between the two groups (1.01 for quakers vs 0.69 mg/g wet wt of tissue for controls). The concentration of triglycerides was 4.5-5.0 that of total phosphatides 18-19 and that of free cholesterol 1.9-2.0 mg/g for mutants and controls. The concentrations of phosphatidyl ethanolmanine and of sphingomyelin were both lower in quaking than in normal mice, but only the change in the former was statistically significant. Phosphatidyl choline was the major phosphatide (43-45% of total phosphatides) followed by phosphatidyl ethanolamine (24-26%) and sphingomyelin, phosphatidyl serine, and phosphatidyl inositol (all ca. 7% of total phosphatides). Minor differences between the mutants and controls were observed in concentrations of fatty acids of major lipid classes. The mutants, sterile because of faulty spermatid differentiation, had normal quantities of 22:6 w3 and 22:5 w6. These data are consistent with the hypothesis that the 22-carbon polyenes are associated with the formation of spermatids, rather than with their final differentiation into spermatozoa.