Concerns about analgesics among patients and family caregivers in a hospice setting

Patients receiving curative treatment for cancer have concerns about reporting pain and using analgesics. These concerns are associated with underutilization of analgesics. To extend knowledge about such concerns to the context of palliative care, the concerns of hospice patients and family caregivers were compared. Within 5 days of admission to hospice, 35 patients with cancer and their caregivers each completed a measure of eight concerns such as fear of addiction, worry about tolerance, and worry about side effects. There was no correlation between caregiver and patient concerns and means for the two groups were similar, indicating that within a given dyad either the patient or the caregiver may have greater concerns. The findings highlight the need for patient and caregiver education about reporting pain and using analgesics. © 1996 John Wiley & Sons, Inc.     

Generation of an atlas of the proximal femur and its application to trabecular bone analysis

Automatic placement of anatomically corresponding volumes of interest and comparison of parameters against a standard of reference are essential components in studies of trabecular bone. Only recently, in vivo MR images of the proximal femur, an important fracture site, could be acquired with high‐spatial resolution. The purpose of this MRI trabecular bone study was two‐fold: (1) to generate an atlas of the proximal femur to automatically place anatomically corresponding volumes of interest in a population study and (2) to demonstrate how mean models of geodesic topological analysis parameters can be generated to be used as potential standard of reference. Ten females were used to generate the atlas and geodesic topological analysis models, and 10 females were used to demonstrate the atlas‐based trabecular bone analysis. All alignments were based on three‐dimensional (3D) multiresolution affine transformations followed by 3D multiresolution free‐form deformations. Mean distances less than 1 mm between aligned femora, and sharp edges in the atlas and in fused gray‐level images of registered femora indicated that the anatomical variability was well accommodated and explained by the free‐form deformations. Magn Reson Med, 2011. © 2011 Wiley‐Liss, Inc.     

The aged rat model of ovarian hormone deficiency bone loss

Three studies were carried out. First, the effects of aging on the maturation of the female skeleton were assessed. Second, the hypothesis that has linked ovarian hormone deficiency bone loss to hypercalcemic suppression of the parathyroids leading to a decrease in 1,25-dihydroxyvitamin D synthesis and gut absorption of calcium was examined. Third, the effects of ovariectomy and a combination of ovarian hormone deficiency and low dietary calcium on bone and the calcium-regulating hormones were evaluated. After 6 months, ovariectomy and a low calcium diet independently decreased the density of the ilium, the femur, and the fourth lumbar vertebra as well as the calcium content of the latter two. The effects of the two treatment regimens were additive and more marked in the vertebral bone. Ovariectomy lowered serum calcitonin only in animals fed a normal diet and had no effect on serum PTH and vitamin D metabolites, while a low calcium diet caused a significant increase in serum 1,25-dihydroxyvitamin D. In both dietary regimens ovariectomy resulted in about a 30% decrease in intestinal calcium absorption. A low calcium diet increased morphometric indices of bone formation and bone resorption as did ovariectomy, with resorption exceeding formation. The discussion of our findings led to the conclusion that the aged rat model of ovarian hormone deficiency bone loss qualifies for serious consideration as a practical convenient cost-effective animal model for exploring aspects of the pathogenesis and treatment of postmenopausal bone loss.     

Resolution of vitamin D insufficiency in osteopenic patients results in rapid recovery of bone mineral density.

Vitamin D insufficiency is characterized biochemically by the presence of secondary hyperparathyroidism, which can contribute to bone loss in osteopenic patients. Over a 2-yr period of evaluation of 118 consecutive, free living patients with osteopenia or osteoporosis, we identified 18 subjects with depressed serum 25-hydroxyvitamin D (250HD; < or = 14 ng/mL). Twelve of these subjects harbored a low 25OHD level and consented to undergo replacement with 50,000 IU vitamin D2 twice weekly for 5 weeks. Five hundred thousand units of oral vitamin D2 resulted in significant increases in 25OHD (+24.3+/-16.9 ng/mL; P < 0.001) and the fasting urinary calcium/creatinine excretion ratio (+0.06+/-0.004; P = 0.01) and significant decreases in the serum concentration of PTH (-32.9+/-36.9 pg/mL; P < 0.001) and osteocalcin (-4.9+/-2.4 ng/mL; P < 0.001). Vitamin D repletion was associated with a significant 4-5% annualized increase in bone mineral density at both the lumbar spine (P < 0.001) and the femoral neck (P = 0.03), indicating that resolution of vitamin D insufficiency in a population of patients with low bone mass results in a rapid rebound increase in bone mineral density.     

Practice guidelines and performance measures in emergency medical services for children

Practice guidelines and performance measures are critical elements of an effective quality improvement process for emergency medical services for children (EMSC). Practice guidelines address the clinical management of individual patients, and performance measures assess the quality of care delivered to a population. The public and private sectors have invested considerable resources in developing practice guidelines and performance measures to improve the quality of health care services. As organizations continue development efforts, health care professionals who are actively involved in emergency care must collaborate to develop guidelines that address the unique physiologic, psychologic, and cultural needs of children. The Emergency Medical Services for Children Managed Care Task Force recommended the development of a series of white papers to focus on issues related to practice guidelines and performance measures in EMSC. The Maternal and Child Health Bureau, Health Resources and Services Administration, the National Highway Traffic Safety Administration, and the Robert Wood Johnson Foundation jointly sponsored the project. The paper was developed by a panel selected from a pool of experts in managed care, quality improvement, and emergency medical services. After a review of the literature, the panelists met to discuss critical issues related to practice guidelines and performance measures in EMSC. The panelists developed recommendations that can serve as resources for managed care organizations, health care providers, professional associations, and governmental policy makers. The panel recognized the lack of nationally recognized pediatric emergency care guidelines and performance measures and called for immediate action in these areas.     

Microcirculation of the sternum following harvesting of the left internal mammary artery

BACKGROUND: Internal thoracic arterial grafts (ITA) in coronary artery bypass surgery provide excellent long-term patency results. Due to the elevated incidence of sternal infections following pedicled ITA harvesting, blood supply to the sternum has gained the focus of attention. This study sought to evaluate real time parameters of sternal microcirculation prior and immediately after harvesting of the ITA by a novel laser Doppler flowmetry and remission spectroscopy system (Oxygen-To-See (O2C), LEA Medizintechnik, Giessen). METHODS: 21 patients (16 males, age 63 + 4 years, mean NYHA 2.3 +/- 0.3) scheduled for coronary artery bypass grafting (CABG) were enrolled into the study. After median sternotomy, the probe was placed sequentially pre- and retrosternally for measurements of tissue oxygen saturation (sO2), hemoglobin concentration (rHb), superficial (2 mm) und deep (8 mm) blood flow. Measurements were performed and analyzed before and after surgical harvesting of the ITA with a pedicle. RESULTS: Baseline pre- and retrosternal tissue oxygen saturation (sO2) were 90 +/- 3 % and 87 + 4 %, respectively (n. s.). After left ITA harvesting, presternal sO2 remained unchanged (90 + 4 %, n. s.), whereas retrosternal sO2 decreased significantly (54 + 4 %, p < 0.001). Simultaneously, retrosternal post-capillary venous filling (rHb) increased significantly after ITA harvesting (86 +/- 2 vs. 93 + 2, p < 0.05), whereas presternal rHb remained unchanged. Retrosternal superficial and deep blood flow also decreased significantly (75 +/- 5 vs. 41 +/- 4, and 94 +/- 5 vs. 52 +/- 6) in contrast to comparable presternal blood flow before and after ITA harvesting. There were neither superficial nor deep sternal wound infections occurred in the studied patient population. CONCLUSIONS: The pedicled harvesting of ITA leads to a significant decrease of microcirculatory blood flow, retrosternal tissue oxygen saturation, and an increase in post-capillary venous filling. Parameters of microcirculation in the presternal area after ITA harvesting remained unchanged compared to baseline values. Hence, the incidence of sternal infections after ITA harvesting in coronary surgery may well be explained by a significant decrease of sternal blood supply in the retrosternal area. Further prospective randomized studies are needed to elucidate the potential role of skeletonized ITA preparation in sternal microcirculation.     

A small molecule accelerates neuronal differentiation in the adult rat

Adult neurogenesis occurs in mammals and provides a mechanism for continuous neural plasticity in the brain. However, little is known about the molecular mechanisms regulating hippocampal neural progenitor cells (NPCs) and whether their fate can be pharmacologically modulated to improve neural plasticity and regeneration. Here, we report the characterization of a small molecule (KHS101) that selectively induces a neuronal differentiation phenotype. Mechanism of action studies revealed a link of KHS101 to cell cycle exit and specific binding to the TACC3 protein, whose knockdown in NPCs recapitulates the KHS101-induced phenotype. Upon systemic administration, KHS101 distributed to the brain and resulted in a significant increase in neuronal differentiation in vivo. Our findings indicate that KHS101 accelerates neuronal differentiation by interaction with TACC3 and may provide a basis for pharmacological intervention directed at endogenous NPCs.     

Vitamin D deficiency in the spontaneously hypertensive heart failure [SHHF] prone rat

Background and aimsVitamin D deficiency has been associated with the etiology and pathogenesis of heart disease including congestive heart failure. We previously observed cardiac hypertrophy in vitamin D deficient rats and vitamin D receptor knockout mice. These studies indicate that the absence of vitamin D-mediated signal transduction and genomic activation results in increased sensitivity of the heart to ionotropic stimuli and cardiomyocyte hypertrophy. This study's aim is to investigate the relationship between vitamin D status and the heart failure phenotype in the rat.Methods and resultsVitamin D status was assessed by measuring 25-hydroxyvitamin D levels and related to heart weight in young, middle-aged and aging spontaneously hypertensive, heart failure (SHHF) prone rats. We also measured the effects of the vitamin D hormone,1,25(OH)₂D₃, on cardiac function in SHHF rats. Cardiac hypertrophy in this model of the failing heart increased with age and related to decreasing vitamin D status. Vitamin D deficiency presented after cardiac hypertrophy was first observed. Additionally, we found that 1,25(OH)₂D₃ treatment between 4.0 and 7.0 months of age prevented cardiac hypertrophy and permits decreased workload for the heart while allowing adequate blood perfusion and pressure, resulting in reduced cardiac index.ConclusionsOur findings suggest that low vitamin D status is associated with the progression and final terminal phase of the heart failure phenotype and not with initial heart hypertrophy. Also, we report that in the vitamin D sufficient SHHF rat, 1,25(OH)₂D₃ treatment provided protection against the progression of the heart failure phenotype.