Practical Considerations in Providing End-of-Life Care for Dying Patients and Their Family in the Era of COVID-19 / 한국호스피스완화의료학회지

In the era of coronavirus disease 2019 (COVID-19), social distancing and strict visitation policies at hospitals have made it difficult for medical staff to provide high-quality endof-life (EOL) care to dying patients and their families. There are various issues related to EOL care, including psychological problems of patients and their families, difficulties in EOL decision-making, the complicated grief of the bereaved family, moral distress, and exhaustion of medical staff. In relation to these issues, we aimed to discuss practical considerations in providing high-quality EOL care in the COVID-19 pandemic. First, medical staff should discuss advance care planning as early as possible and use the parallel planning strategy. Second, medical staff should play a role in facilitating patient-family communication. Third, medical staff should actively and proactively evaluate and alleviate dying patients’ symptoms using non-verbal communication. Lastly, medical staff should provide care for family members of the dying patient, who may be particularly vulnerable to postbereavement problems in the COVID-19 era. Establishing a system of screening highrisk individuals for complicated grief and connecting them to bereavement support services might be considered. Despite the challenging and limited environment, providing EOL care is essential for patients to die with dignity in peace and for the remaining family to return to life after the loved one’s death. Efforts considering the practical issues faced by all medical staff and healthcare institutions caring for dying patients should be made.

Practical Considerations in Providing End-of-Life Care for Dying Patients and Their Family in the Era of COVID-19 / 한국호스피스완화의료학회지

In the era of coronavirus disease 2019 (COVID-19), social distancing and strict visitation policies at hospitals have made it difficult for medical staff to provide high-quality endof-life (EOL) care to dying patients and their families. There are various issues related to EOL care, including psychological problems of patients and their families, difficulties in EOL decision-making, the complicated grief of the bereaved family, moral distress, and exhaustion of medical staff. In relation to these issues, we aimed to discuss practical considerations in providing high-quality EOL care in the COVID-19 pandemic. First, medical staff should discuss advance care planning as early as possible and use the parallel planning strategy. Second, medical staff should play a role in facilitating patient-family communication. Third, medical staff should actively and proactively evaluate and alleviate dying patients’ symptoms using non-verbal communication. Lastly, medical staff should provide care for family members of the dying patient, who may be particularly vulnerable to postbereavement problems in the COVID-19 era. Establishing a system of screening highrisk individuals for complicated grief and connecting them to bereavement support services might be considered. Despite the challenging and limited environment, providing EOL care is essential for patients to die with dignity in peace and for the remaining family to return to life after the loved one’s death. Efforts considering the practical issues faced by all medical staff and healthcare institutions caring for dying patients should be made.

Vascular Endothelial Dysfunction in Cerebral Leukoaraiosis

BACKGROUND: Chronic subclinical ischemia has been considered as one of major causes of leukoaraiosis, although its trigger is unknown. The vascular endothelium plays a major role in maintaining cerebral perfusion through autoregulation. In this study we evaluated the endothelial bioavailability of nitric oxide (NO) in patients with leukoaraiosis. METHODS: We enrolled consecutive patients with lacunar syndrome or transient ischemic attack; the control group comprised age- and sex-matched patients with hypertension but with no neurological abnormality. All participants underwent flow-mediated dilatation of the brachial artery (FMD) to evaluate endothelial function. Leukoaraiosis was defined as ill-defined patches with high signal intensities on FLAIR and low signal intensities on T1-weighted images. Patients were defined as having ischemic leukoaraiosis if they presented with leukoaraiosis and lacunar infarction. Leukoaraiosis only was defined when patient had leukoaraiosis without lacunar infarction leukoaraiosis without lacunar infarction. RESULTS: In total, 75 patients (37 with leukoaraiosis and 38 controls) were enrolled in this study. The demographic and clinical characteristics were similar in the two groups. FMD was lower in patients with leukoaraiosis than in controls (p0.05). CONCLUSIONS: The bioavailability of NO in the vascular endothelium is decreased in patients with leukoaraiosis only and in those who also have ischemic leukoaraiosis compared to controls. These results are suggestive of a causative role of endothelial dysfunction in the pathomechanism of leukoaraiosis.

Expression of Immediate-Early Gene Proteins by Transient Occlusion of Anterior Inferior Cerebellar Artery in Vestibular Nuclei of Sprague-Dawley Rats

BACKGROUND: Anterior cerebellar artery (AICA) occlusion results in vestibular dysfunctions because the AICA supplies the vestibular nuclei (VN) in the brain stem as well as the peripheral vestibular organs in the inner ear. The purpose of this study was to evaluate the expression of immediate-early gene products, a metabolic marker of neural excitation in neurons, by AICA occlusion in the VN of Sprague-Dawley rats. METHODS: After chloral hydrate anesthesia all animals were subjected to unilateral AICA occlusion by using a microsurgical clamp for 30 min to induce a transient ischemia. Unilateral labyrinthectomy was chemically undertaken to eliminate vestibular afferent activity. Immunohistochemical staining and image analysis for cFos, FosB, Krox-24, and JunB proteins were performed 2 hours after AICA occlusion. RESULTS: There was a high expression of cFos protein in the bilateral medial and inferior VN 2 hours after AICA occlusion. AICA occlusion induced minimal changes in cFos protein expression in the lateral and superior VN. Mild to moderate expressions of FosB and JunB protein in VN was observed 2 hours after ischemic injury of the brain stem and inner ear. On the contrary, the number of cFos and FosB immunoreactive neurons significantly decreased in the medial vestibular nucleus ipsilateral to the injured labyrinth 2 hours after AICA occlusion in the UL group. CONCLUSIONS: These results suggest that ischemic afferent activity from the peripheral vestibular apparatus is essential for the expression of immediate-early gene products in the medial and inferior VN of rats following AICA occlusion.

A Case of Oropharyngeal Carotid Space Mass Presenting with Isolated Hypoglossal Nerve Palsy

The isolated hypoglossal nerve palsy is less frequently seen, but occasionally it appears as the initial or solitary sign of an intracranial or extracranial space-occupying lesion or a vascular abnormality of the internal carotid artery. We present a 55-year-old woman with isolated hypoglossal nerve palsy due to an oropharyngeal carotid space mass.