Crossing disciplinary boundaries in end-of-life education.

There is a tremendous need to educate professional nurses and other health care providers in the care of the dying person. Both nurses and physicians have begun to recognize the need to cross traditional disciplinary boundaries to provide the complex care required during the last human transition. This article describes the evolution of a unique interdisciplinary graduate course on end-of-life issues at Wayne State University. Using a new model centered on narrative and culture, the course focuses on the synthesis of concepts from many of the stories told by and about dying people, their families and communities, and their various caregivers. The effects of 5 years of experience with the course on students, faculty, and the university community are described, and future directions are suggested.     

A comparative study of the bone-restorative efficacy of anabolic agents in aged ovariectomized rats

Introduction The study was designed to compare the bone anabolic effects of basic fibroblast growth factor (bFGF), a selective agonist for prostaglandin E receptor subtype EP4, and parathyroid hormone (PTH) in aged ovariectomized (OVX) rats with severe cancellous osteopenia. Methods Groups of aged OVX rats were maintained untreated for 1 year postovariectomy (15 months of age) to develop severe tibial cancellous osteopenia. These animals were then treated with bFGF or the EP4 agonist (EP4) for 3 weeks. Other groups of aged OVX rats were treated with EP4 or PTH alone for 11 weeks, or sequentially with bFGF or EP4 for 3 weeks followed by PTH for 8 weeks. Cancellous and cortical bone histomorphometry were performed in the right proximal tibial metaphysis and tibial diaphysis respectively. Results Treatment with bFGF for 3 weeks markedly increased serum osteocalcin, osteoid volume, and osteoblast and osteoid surfaces to a greater extent than EP4. Basic FGF, but not EP4 or PTH, induced formation of osteoid islands within bone marrow. EP4 stimulated cancellous bone turnover, but failed to restore lost cancellous bone in the severely osteopenic proximal tibia after 11 weeks of treatment. In contrast, EP4, much like PTH, increased cortical bone mass in the tibial diaphysis by stimulating both periosteal and endocortical bone formation. Treatment of aged OVX rats with PTH alone tended to partially reverse the severe tibial cancellous osteopenia, whereas sequential treatment with bFGF and PTH increased tibial cancellous bone mass to near the level of vehicle-treated control rats. These findings indicate that bFGF had the strongest stimulatory effect on cancellous bone formation, and was the only anabolic agent to induce formation of osteoid islands within the bone marrow of the severely osteopenic proximal tibia. Therefore, bFGF may be more effective for the reversal of severe cancellous osteopenia. PTH and EP4 increased cortical bone mass to nearly the same extent, but cancellous bone mass was greater by two-fold in PTH-treated OVX rats than in EP4-treated OVX rats. Conclusion These findings in aged OVX rats suggest that PTH is more efficacious than EP4 for augmentation of cancellous bone in the severely osteopenic, estrogen-deplete skeleton.     

Collapsing focal segmental glomerulosclerosis in a liver transplant recipient on alendronate

We describe a case of collapsing focal segmental glomerulosclerosis and severe kidney dysfunction in a liver transplant recipient after the initiation of alendronate for osteopenia. In view of the increasing incidence of chronic kidney disease in long-term liver transplant patients, bisphosphonates need to be used with caution in these patients. The usefulness of bisphosphonates for the prevention of early bone loss after liver transplantation is increasingly reported. However, there is little information on the safety and efficacy of these drugs when used in the later stages of liver transplant, particularly in the presence of chronic kidney disease. Bisphosphonates are excreted unchanged via the kidneys after reaching the systemic circulation. Some cases of severe kidney injury, in particular collapsing focal segmental glomerulosclerosis, have been described that are associated with the use of pamidronate. Alendronate, a widely used bisphosphonate in transplant patients, has not been related to kidney toxicity. We describe a case of collapsing focal segmental glomerulosclerosis and severe kidney dysfunction in a liver transplant recipient soon after the initiation of alendronate for osteopenia. Possible pathogenetic mechanisms are discussed. In view of the increasing incidence of chronic kidney disease in long-term liver transplant patients, bisphosphonate need to be used with caution in patients with a low glomerular filtration rate.     

ECAT ART — a continuously rotating PET camera: Performance characteristics, initial clinical studies, and installation considerations in a nuclear medicine department

Advances in fully three-dimensional (3D) image reconstruction techniques have permitted the development of a commercial, rotating, partial ring, fully 3D positron emission tomographic (PET) scanner, the ECAT ART. The system has less than one-half the number of bismuth germanate detectors compared with a full ring scanner with the equivalent field of view, resulting in reduced capital cost. The performance characteristics, implications for installation in a nuclear medicine department, and clinical utility of the scanner are presented in this report. The sensitivity (20 cm diameter×20 cm long cylindrical phantom, no scatter correction) is 11400 cps·kBq^–1·ml^–1. This compares with 5800 and 40500 cps·kBq^–1·ml^–1 in 2D and 3D respectively for the equivalent full ring scanner (ECAT EXACT). With an energy window of 350–650 keV the maximum noise equivalent count (NEC) rate was 27 kcps at a radioactivity concentration of ~15 kBq·ml^–1 in the cylinder. Spatial resolution is ~6 mm full width at half maximum on axis degrading to just under 8 mm at a distance of 20 cm off axis. Installation and use within the nuclear medicine department does not appreciably increase background levels of radiation on gamma cameras in adjacent rooms and the dose rate to an operator in the same room is 2 µSv·h^–1 for a typical fluorine-18 fluorodeoxyglucose (¹⁸F-FDG) study with an initial injected activity of 370 MBq. The scanner has been used for clinical imaging with¹⁸F-FDG for neurological and oncological applications. Its novel use for imaging iron-52 transferrin for localising erythropoietic activity demonstrates its sensitivity and resolution advantages over a conventional dual-headed gamma camera. The ECAT ART provides a viable alternative to conventional full ring PET scanners without compromising the performance required for clinical PET imaging.     

Langerhans' cell histiocytosis of the frontal bone

Two cases of Langerhans' cell histiocytosis of the frontal bone are presented. This condition was previously known as eosinophilic granuloma and rarely involves the orbit but may be associated with widespread and life-threatening disease. Clinical, radiological and histopathological features are presented. A discussion of the light and electron microscopic appearances, investigation and management follows.     

Heart period variability and psychopathology in urban boys at risk for delinquency

To examine associations between heart period variability (HPV) and psychopathology in young urban boys at risk for delinquency, a series of 69 7–11-year-old younger brothers of adjudicated delinquents received a standardized psychiatric evaluation and an assessment of heart period variability (HPV). Psychiatric symptoms were rated in two domains: externalizing and internalizing psychopathology. Continuous measures of both externalizing and internalizing psychopathology were associated with reductions in HPV components related to parasympathetic activity. These associations could not be explained by a number of potentially confounding variables, such as age, ethnicity, social class, body size, or family history of hypertension. Although familial hypertension predicted reduced HPV and externalizing psychopathology, associations between externalizing psychopathology and HPV were independent of familial hypertension. Psychiatric symptoms are associated with reduced HPV in young urban boys at risk for delinquency.