Heterotopic abdominal heart transplantation: a pilot study

The increasingly severe shortage of donor hearts has prompted a liberalization of what is considered an acceptable donor heart. The use of marginally acceptable organs has increased in recent years. Although these marginal donors have proved effective, there still remains a tremendous shortage of donors to treat the large number of patients who are candidates for cardiac transplantation. Further use of marginal donors is limited by the requirement to assume immediate and full support of the circulation. New strategies are required to increase donor organ use even further. The authors developed a model of heterotopic abdominal heart transplant (HAHT) to investigate the possibility of using marginal donor hearts to expand the donor pool for cardiac transplantation. The authors' goal was to show that HAHT was technically feasible and could potentially function as auxiliary circulatory support in the setting of low cardiac output. The hemodynamic and metabolic consequences of a HAHT were investigated in a pilot study that provides proof of concept and lays the groundwork for future investigations.     

A case study of theory development: moral behavior in nursing

The theoretical considerations, operationalization of the constructs, and measurement issues of an ongoing program of research designed to explain ethical practice in nursing are presented. They illustrate the constant give and take among research, the empirical world, and theory building. This case study depicts the iterative and complex process of developing constructs and relationships, based on research findings, that explain moral behavior in nursing practice.     

Immediate postoperative thrombolytic therapy: an aggressive strategy for neurologic salvage when cerebral thromboembolism complicates carotid endarterectomy

A 42-year-old man with a high-grade left internal carotid artery (ICA) stenosis demonstrated on a duplex scan was referred to us. A cerebral arteriogram confirmed a greater than 90% left internal carotid stenosis, but with the unexpected finding of a moderate amount of thrombus in the proximal ICA. He underwent emergent left carotid endarterectomy, but during the operation, only a small amount of thrombus was identified as adherent to the atherosclerotic plaque. he awakened in the operating room with a dense right hemiplegia and aphasia. Immediate reexploration demonstrated a patent endarterectomy site, a distal thromboembolectomy was performed without extraction of thrombus, and urokinase (250,000 Units) was infused into the distal ICA. He reawakened with an unchanged right hemiplegia and aphasia. The patient then underwent an urgent postoperative carotid and cerebral arteriogram that demonstrated an embolus to the middle cerebral artery. he was treated with the superselective infusion of urokinase (500,000 Units), with almost complete resolution of the clot. Over the course of the next 48 hours, the patient made a nearly complete neurologic recovery, and he was discharged from the hospital with only a slight facial droop. At 2 months' follow-up he was completely neurologically healthy. To our knowledge this is the first reported case of urokinase administered in the immediate postoperative period in the angiography suite to treat a thromboembolus complicating a carotid endarterectomy.     

Anticoagulation for mechanical heart valves: a role for patient based therapy

Anticoagulation management issues following mechanical cardiac valve replacement revolve around target levels for chronic oral anticoagulation. While these levels are important, they are only one aspect of a follow-up process that should be individualized to each patient with a mechanical cardiac valve and coupled with patient education, risk factor modification, and long-term follow-up. It is difficult to separate patient related risk factors, those traditional risk factors that markedly increase the incidence of potential valve related events (i.e., atrial fibrillation), and yet other more subtle non-traditional risk factors for thromboembolism (i.e., smoking and hypertension) that contribute to events. These also require management during the post-operative period and long-term follow-up. There are also different risk factors for anatomic valve position. The aortic valve is the safest of all the anatomic positions regarding valve related events. The mitral valve is at higher risk and the tricuspid valve is the most risky anatomic position. Anticoagulation related hemorrhage is the most dangerous event for mortality and morbidity in the aortic position, thromboembolism in the mitral position, and valve thrombosis in the tricuspid position. Each of these requires different degrees of patient modification and target levels for anticoagulation. Additionally, low risk patients with aortic valve replacement may not require anticoagulant therapy at all. Rather, treatment with modern, highly potent platelet inhibiting drugs may be effective after a period of sewing ring endothelialization under the protection of antithrombotic therapy. Each of these aspects and risk factors is discussed, as well as the call for prospective randomized trials treating low risk patients with anti-platelet drugs versus warfarin anticoagulation.     

Moral competence in nursing practice

This article presents the derivation of moral competence in nursing practice by identifying its attributes founded on Thai culture. In this process moral competence is formed and based on the Thai nursing value system, including personal, social and professional values. It is then defined and its three dimensions (moral perception, judgment and behavior) are also identified. Additionally, eight attributes as indicators of moral competence are identified and selected from three basic values. The eight attributes are loving kindness, compassion, sympathetic joy, equanimity, responsibility, discipline, honesty, and respect for human values, dignity and rights. All attributes are discussed by addressing the three moral dimensions in order to present how to deal with ethical issues in nursing practice. As a summary, a model of moral competence is presented to demonstrate moral competence in nursing practice in Thailand.