Decisions near the end of life.

Designing behavior change programs and evaluating their effects on patient care has been a persistent challenge in research on continuing medical education. The challenge becomes even more complex when we aim to change behaviors that are interactive and highly influenced by the formal and informal institutional context. The authors describe an interdisciplinary continuing education program in bioethics that is designed to effect just such behaviors. The program aims to help hospital and long-term care facilities improve their ability to resolve the ethical dilemmas inherent in terminal care decisions. Targeted to interdisciplinary groups of physicians, nurses, social workers, pastoral counselors, and administrators, Decisions Near the End of Life will provide strategies and tools for examining institutional policies and team practices as well as more traditional information, education, and skill building. The authors describe the program's rationale and design, and raise questions about the potential for developing interdisciplinary, action-oriented CME on other topics.     

EXTERNAL CEPHALIC VERSION

External cephalic version has been used periodically for centuries to manage breech presentations. As cesarean section rates have escalated in the last two decades, ways to curb this rise have been evaluated. By reducing the number of infants that arrive in labor in a representation, it is possible to impact the overall cesarean section rate. External cephalic version is a safe, effective method when used in appropriate cases of breech presentation. A forward or backward roll can be accomplished in women at term with singleton gestations, adequate amniotic fluid, and reactive nonstress tests. Parity, fetal and placental position, and descent of the presenting part may all influence the success rate of the version.     

Shoot First,Draw Later Peroneal Nerve Palsy: A Sonographic Study

A 32–year–old man had an unusual gunshot wound to the leg, causing a peroneal nerve palsy. Sonography provided useful complementary findings to the electrodiagnostic localization of the injury.     

Insertion of Hickman central venous catheters by using angiographic techniques in patients with hematologic disorders.

During a 9-month period, 69 Hickman catheters were successfully inserted by using angiographic techniques in 59 patients with hematologic disorders. A pneumothorax, which did not require drainage, developed in one patient. No other significant complications occurred at the time of insertion. Eighteen catheters were removed electively, 15 are still in situ, six were removed for thrombosis, and five were accidentally removed. Infection precipitated removal in six subjects. Ten patients died with the catheter in place. Five catheters were removed in patients with refractory septicemia of unknown origin. One catheter burst during an injection and had to be removed. Three patients were lost to follow-up. There were 3.24 infectious episodes per 1000 days of catheterization, more than twice the rate found in some other series. The results of this study are compatible with the growing body of evidence in favor of the angiographic insertion of Hickman catheters. The apparently high rate of infection is ascribed to factors other than insertion in the angiography suite, including the high proportion of bone marrow transplantation patients.     

Pretransplant Exposure to Donor HLA-DR Antigen in Random Transfusion Units and the Development of Donor Antigen-Specific Hyporeactivity

Our previous studies have shown that the in vitro assay of donor antigen-specific hyporeactivity is a useful marker for identifying solid organ transplant recipients (kidney, lung and heart) at low risk for immunologic complications (i.e., late acute rejection episodes and chronic rejection). Donor antigen-specific hyporeactivity is defined as a significantly decreased post- vs. pretransplant proliferative response to donor antigens while response to third-party controls remains unchanged. We analyzed whether exposure to the same HLA-DR antigen pretransplant via random blood transfusion and posttransplant via the transplanted organ influenced the development of hyporeactivity. Thirty previously nontransfused recipients, each receiving two 150 ml pretransplant random blood transfusions, were assessed for hyporeactivity at 1 year posttransplant. Of the 12 recipients with pretransplant exposure to kidney HLA-DR via transfusions, 6 (50%) developed hyporesponsiveness; in contrast, of the 18 recipients who were not preexposed, only 3 (15%) exhibited this form of immunomodulation. Of interest, 2 of the 3 hyporesponsive recipients who were not preexposed, received units containing HLA-DR antigens previously shown to share crossreactive epitopes with the kidney HLA-DR. In conclusion, these results suggest a increased incidence in the development of hyporeactivity in patients receiving pretransplant transfusions which share an HLA-DR antigen with the transplanted kidney.     

Addiction.: By David Marteau. Quay Books Division, Mark Allen Publishing, Ltd, London. 2001, 168pp., {pound}14.99. ISBN: 1-85642-189-9.

Addiction was written by David Marteau, a nurse and former headof treatment at Clouds House. It is a short book offering comprehensivecoverage of the causes, nature and treatment of     

INVOLVEMENT OF NON-NMDA AND NMDA RECEPTORS IN GLUTAMATE-INDUCED PRESSOR OR DEPRESSOR RESPONSES OF THE PONS AND MEDULLA

1. Fifty-five intact and six baroreceptor denervated and vagotomized cats of either sex were anaesthetized intraperito-neally with urethane (400 mg/kg) and a-chloralose (40 mg/kg). Responses of the systemic arterial pressure (SAP), mean SAP (MSAP) and sympathetic vertebral nerve (VNA) and renal nerve activities (RNA) were recorded. 2. In intact animals, monosodium L-glutamate (Glu, 0.1 mol/L, 50 nL) was microinjected into pressor areas of the locus coeruleus (LC), gigantocellular tegmental field (GTF), rostral ventrolateral medulla (RVLM) and dorsomedial medulla (DM), and the depressor areas of caudal ventrolateral medulla (CVLM). The induced actions were compared before and after microinjection of either glutamate antagonists, glutamate diethylester (GDEE, 0.5 mol/L, 50–100nL), a competitive AMPA receptor blocker, or 2-amino-5-phosphonovaleric acid (D-AP5, 0.025 mol/L, 50–100 nL), a competitive N-methyl-D-aspartate (NMDA) receptor blocker. GDEE completely blocked the increases of SAP and VNA elicited from all pressor areas. D-AP5 only partially blocked the pressor but slightly blocked VNA and RNA responses from LC, GTF and DM, particularly those from RVLM. Neither GDEE nor D-AP5 blocked the depressor responses of SAP and two nerve activities elicited from CVLM. 3. In baroreceptor denervated animals, NMDA (2 mmol/L, 50–100 nL) and AMPA (0.2 mmol/L, 50–100 nL) were micro-injected into the same pressor areas of GTF, RVLM and DM and the depressor area of CVLM responsive to Glu activation (0.1 mol/L, 30 nL). In RVLM, DM and CVLM, the results of either NMDA or AMPA were similar to those induced by Glu. However, in GTF, microinjection of either NMDA or AMPA did not induce similar responses to Glu. This suggests that the nature of GTF may differ from RVLM and DM. 4. The above results suggest that the Glu-induced pressor responses from LC, GTF, DM and especially RVLM, are primarily mediated through AMPA receptors. The Glu-induced depressor responses from CVLM may not be predominantly mediated by either AMPA or NMDA receptors. 5. In both baroreceptor-intact and -denervated cats stimulation of the pressor areas often produced an increase of VNA and a decrease of RNA, while in the depressor CVLM decreased both VNA and RNA. The VNA, but not RNA were positively correlated with the pressor responses, while both VNA and RNA were positively correlated with the depressor responses. This may suggest that neurons of the sympathetic vertebral and renal nerves are topographically organized in the brain.