An integrated care pathway for the last two days of life: Wales-wide benchmarking in palliative care

Functional benchmarking assesses performance and practice across a broad range of settings and carries the potential to effect change in practice. An integrated care pathway (ICP) can assist in the benchmarking process, defining desired outcomes for specific patient groups over a designated time frame. Any variations to the agreed course of care are documented using the 'variance sheet'. This article describes the Wales-wide implementation of an ICP for the last two days of life. The project has enabled an ongoing centralized collection and analysis of variance sheets, which reflect the care of the dying patient in four different care settings crossing the voluntary and statutory sectors. Initial analysis of the first 500 variance sheets to be generated by the ICP for the last two days of life indicates that the management of pain, agitation, excess respiratory secretions and mouth care may be problematic. The same problems were experienced across acute, hospice, specialist inpatient units and community care. Closing the audit cycle involves incorporating the information from the variance analysis into clinical practice.     

Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Tangential views or computed tomography in suspected depressed skull fracture

A short cut review was carried out to establish whether CT scans are better than tangential skull radiographs at detecting depressed skull fractures. No papers answering this question were found using the reported search.     

Endoscopic management of milk of calcium-filled ureterocele stump

A 38-year-old woman with a duplicated right collecting system and a history of right upper-pole heminephrectomy was referred for persistent dysuria and right lower-quadrant abdominal discomfort. Imaging identified a remnant ureter and a ureterocele filled with what appeared to be a large homogenous stone. At cystoscopy, the ureterocele was incised with a holmium:YAG laser, releasing a large quantity of white milky fluid (milk of calcium). There was no evidence of any solid material. Endoscopic evaluation should be the first step in patients with stones in a ureteral stump because milk of calcium may be the etiology of what appears to be a large stone burden in an obstructed system.     

Characterization of biophysical and metabolic properties of cells labeled with superparamagnetic iron oxide nanoparticles and transfection agent for cellular MR imaging

PURPOSE: To evaluate the effect of using the ferumoxides-poly-l-lysine (PLL) complex for magnetic cell labeling on the long-term viability, function, metabolism, and iron utilization of mammalian cells. MATERIALS AND METHODS: PLL was incubated with ferumoxides for 60 minutes, incompletely coating the superparamagnetic iron oxide (SPIO) through electrostatic interactions. Cells were coincubated overnight with the ferumoxides-PLL complex, and iron uptake, cell viability, apoptosis indexes, and reactive oxygen species formation were evaluated. The disappearance or the life span of the detectable iron nanoparticles in cells was also evaluated. The iron concentrations in the media also were assessed at different time points. Data were expressed as the mean +/- 1 SD, and one-way analysis of variance and the unpaired Student t test were used to test for significant differences. RESULTS: Intracytoplasmic nanoparticles were stained with Prussian blue when the ferumoxides-PLL complex had magnetically labeled the human mesenchymal stem and HeLa cells. The long-term viability, growth rate, and apoptotic indexes of the labeled cells were unaffected by the endosomal incorporation of SPIO, as compared with these characteristics of the nonlabeled cells. In nondividing human mesenchymal stem cells, endosomal iron nanoparticles could be detected after 7 weeks; however, in rapidly dividing cells, intracellular iron had disappeared by five to eight divisions. A nonsignificant transient increase in reactive oxygen species production was seen in the human mesenchymal stem and HeLa cell lines. Labeled human mesenchymal stem cells did not differentiate to other lineage. A significant increase in iron concentration was observed in both the human mesenchymal stem and HeLa cell media at day 7. CONCLUSION: Magnetic cellular labeling with the ferumoxides-PLL complex had no short- or long-term toxic effects on tumor or stem cells.