The quality of intensive care unit nurse handover related to end of life: a descriptive comparative international study.

BACKGROUND: Quality ICU end-of-life-care has been found to be related to good communication. Handover is one form of communication that can be problematic due to lost or omitted information. A first step in improving care is to measure and describe it. OBJECTIVE: The objective of this study was to describe the quality of ICU nurse handover related to end-of-life care and to compare the practices of different ICUs in three different countries. DESIGN: This was a descriptive comparative study. SETTINGS: The study was conducted in seven ICUs in three countries: Australia (1 unit), Israel (3 units) and the UK (3 units). PARTICIPANTS: A convenience sample of 157 handovers was studied. METHODS: Handover quality was rated based on the ICU End-of-Life Handover tool, developed by the authors. RESULTS: The highest levels of handover quality were in the areas of goals of care and pain management while lowest levels were for legal issues (proxy and advanced directives) related to end of life. Significant differences were found between countries and units in the total handover score (country: F(2,154)=25.97, p=<.001; unit: F(6,150)=58.24, p=<.001), for the end of life subscale (country: F(2, 154)=28.23, p<.001; unit: F(6,150)=25.25, p=<.001), the family communication subscale (country: F(2,154)=15.04, p=<.001; unit: F(6,150)=27.38, p=<.001), the family needs subscale (F(2,154)=22.33, p=<.001; unit: F(6,150)=42.45, p=<.001) but only for units on the process subscale (F(6,150)=8.98, p=<.001. The total handover score was higher if the oncoming RN did not know the patient (F(1,155)=6.51, p=<.05), if the patient was expected to die during the shift (F(1,155)=89.67, p=<.01) and if the family were present (F(1,155)=25.81, p=<.01). CONCLUSIONS: Practices of end-of-life-handover communication vary greatly between units. However, room for improvement exists in all areas in all of the units studied. The total score was higher when quality of care might be deemed at greater risk (if the nurses did not know the patient or the patient was expected to die), indicating that nurses were exercising some form of discretionary decision making around handover communication; thus validating the measurement tool.

Isolated cardiac involvement in primary amyloidosis: presenting as sick sinus syndrome and heart failure.

Cardiac amyloidosis is an infiltrative cardiomyopathy with a grave prognosis. Its clinical manifestations include restrictive cardiomyopathy, diastolic heart failure, conduction defects, and arrhythmias. Isolated cardiac involvement and significant conduction disturbances are reported very infrequently. We report a rare case of isolated cardiac involvement in primary amyloidosis, in a 76-year-old man who initially presented with sick sinus syndrome that necessitated permanent pacemaker insertion. Subsequent symptoms of heart failure led to additional evaluation, including an endomyocardial biopsy that revealed primary cardiac amyloidosis. Medical therapy improved the patient's symptoms, and he was discharged from the hospital in stable condition. In addition to discussing the patient's case, we review the relevant medical literature.

A systematic review of variability and reliability of manual and automated blood pressure readings.

AIMS AND OBJECTIVES: To compare the accuracy and appropriateness of auscultatory (manual) and oscillometric (automated) devices for measuring blood pressure in clinical settings. BACKGROUND: Accurate measurement of blood pressure is integral to early recognition of deterioration in the condition of a patient. Despite recommendations regarding the use of auscultatory devices in situations where treatment decisions are made dependent on blood readings, the use of automated machines is becoming common practice. DESIGN: Systematic review. METHODS: A search of the Medline, CINAHLPlus and The Cochrane Library databases was undertaken for papers published in English between January 1997-May 2009. Sixteen studies were identified that fulfilled the inclusion criteria. After quality assessment, all were included in the review. Results are presented in tabular and narrative form. RESULTS: In 10 of the studies reviewed, the authors came to the conclusion that oscillometric devices were less accurate than auscultatory devices. However, in most cases the oscillometric device appears sufficiently accurate for clinical use, the exceptions being use with hypertensive patients, patients with arrhythmia and after trauma. Only two studies assessed the comparative accuracy of aneroid devices, and these indicated that they were more accurate than oscillometric devices, but the differences were not clinically important. CONCLUSIONS: There are situations where the substitution of oscillometric for auscultatory devices could have particularly serious repercussions for the patient, such as when the patient is either hypertensive or hypotensive. However, further research is required on the use of aneroid sphygmomanometers as a replacement for mercury devices. RELEVANCE TO CLINICAL PRACTICE: Practitioners should be made aware of the need to use auscultatory devices in specific circumstances, such as in management of hypertension, after the patient has experienced trauma or where there is significant potential for deterioration in the patient's condition.

Clear cell meningioma: a clinicopathologic study of 18 tumors and examination of the use of CD10, CA9, and RCC antibodies to distinguish between clear cell meningioma and metastatic clear cell renal cell carcinoma.

Clear cell meningiomas (CCM) can be difficult to distinguish from metastatic clear cell renal cell carcinomas by standard light microscopy. Distinction is important in deciding patient management and establishing prognosis. The purpose of this study is to evaluate the use of immunomarkers CA9, CD10, and RCC in differentiating between CCM and clear cell renal cell carcinoma. The study retrospectively reviewed the clinicopathologic features of 18 patients with CCM (9 females, 9 males; age range at the time of surgery 16 to 86 y) including immunostaining results with antibodies to CA9, CD10, and RCC. Immunostaining results were compared with those found in 26 cases of clear cell renal cell carcinoma. The most common sites of origin for the CCM included the meninges overlying the frontal lobe (n=7), cavernous sinus (n=3), and cerebellopontine angle/posterior fossa (n=2). All tumors had at least a 10% clear cell component (mean 41%). All tumors showed a sheet-like growth pattern. Other commonly observed morphologic features included increased cellularity (n=12), nucleolation (n=8), small cell change (n=6), microcalcifications (n=5), and necrosis (n=5). A mean of 1.9 mitotic figures per 10 high-power fields and a mean Ki-67 labeling index of 12.1% were observed. Seven tumors (38.9%) showed CA9 immunoreactivity, 5 tumors (27.8%) CD10 staining, and 0 cases showed RCC staining. Immunostaining results observed in the clear cell renal cell carcinoma group included 93.8% CA9 staining (15/16 cases evaluated), 100% CD10 staining (15/15 cases), and 36.4% RCC staining (4/11 cases). Follow-up was available in 16 CCM patients (mean follow-up of 58.9 mo); 10 patients (62.5%) developed at least 1 recurrence requiring surgical intervention. In conclusion, meningiomas with at least a 10% clear cell component tend to behave in a more aggressive fashion with increased risk of recurrence. Immunohistochemical staining with antibodies to CA9, CD10, and RCC are potentially useful in differentiating CCM from metastatic renal cell carcinoma. In the majority of cases in which immunostaining was observed in meningiomas, staining was focal (involving <5% of neoplastic cells) in comparison with CA9 and CA10 immunostaining in renal cell carcinomas in which more than 50% of tumor cells stained the majority of cases.

Non-therapeutic omission of medications in acutely ill patients.

AIMS AND OBJECTIVES: To examine documentation of medication administration in medical and surgical patients. STUDY OBJECTIVES: (1) Determine the point prevalence of non-therapeutic medication omissions; (2) identify documented reasons for non-therapeutic medication omissions; (3) examine the relationship between length of stay and medication omissions; and (4) explore the impact of outlier status (e.g. medical patients managed on surgical wards) on medication administration. BACKGROUND: Acutely ill patients are particularly sensitive to health care errors. We previously identified a 26% rate of non-therapeutic medication omissions in patients admitted unexpectedly to intensive care unit (ICU) from medical and surgical wards. DESIGN: A point prevalence survey of 162 medical and surgical patients across four sites in the South West of England. METHOD: Data collected included: all instances of, and reasons for, non-therapeutic medication omission. We also recorded whether the patient was an 'outlier' and examined nursing documentation where no reason for medication omission was given on the drug chart. RESULTS: The number of patients who missed at least one medication was high across all sites (n = 129/162; 79.6%, range 60-88%), with a total of 1077 doses omitted. Patients who were outliers (e.g. surgical patients on a medical ward) were more likely to miss medications (100% versus 74%, p < 0.001). The most common missed medications were analgesia and anti-inflammatory drugs (28%, 299/1077); 203 of these were due to patient refusal. CONCLUSIONS: The extent of medications omitted for non-therapeutic reasons in medical and surgical patients is of concern. None were recorded as an adverse drug event; however, the extent of omitted or refused medications suggests the need for a review of prescribing and drug administration processes. These findings have important implications for the role of ICU outreach and liaison services, for example, including medication management in the monitoring of patients pre/post-ICU admission and support/education provided for ward staff. RELEVANCE TO CLINICAL PRACTICE: Detailed analysis of medication records suggests a number of areas of medication administration that would benefit from review.

Interobserver and intraobserver reproducibility in focal cortical dysplasia (malformations of cortical development).

PURPOSE: Malformations of cortical development (MCD) (cortical dysplasias) are well-recognized causes of intractable epilepsy. Although a histologic classification system for MCD has been proposed by Palmini et al. (Neurology; 2004; 62:S2), studies to date have not assessed reproducibility. The purpose of this study was to analyze inter- and intraobserver agreement among eight experienced neuropathologists (NPs) with respect to this classification system. METHODS: Sections from 26 epilepsy resections were selected to represent the range of pathologies described by Palmini et al. Recuts of single sections from each case were sent to the NPs to classify. The slides were resent at a later date for reclassification. Kappa analysis for both inter- and intraobserver concordance was performed. RESULTS: Interobserver agreement was moderate (kappa = 0.4968). There was > or =62.5% (5 of 8 NPs) agreement for 19 of 26 cases. The greatest concordance was present when making focal cortical dysplasia (FCD) types IIA/B classifications (12 of the 14 cases with > or =75% consensus). Mild MCD (types I/II) and FCD types IA/B classifications were the least reproducible, and used most frequently in cases without consensus. Intraobserver concordance was moderate to very good (range kappa = 0.4654-0.8504). The category with the fewest classification changes made on reevaluation was FCD type IIB (4.2%), whereas that with the most changes was mild MCD (types I/II) (52.9%). DISCUSSION: Interobserver concordance using this approach was moderate. The classification categories with the greatest concordance were FCD type IIA/B, and the least, mild MCD and FCD types IA/B. In addition, difficulty in differentiating Mild MCD/FCD type I lesions from normal and/or gliotic tissue was noted.

Focal cortical dysplasia type II (malformations of cortical development) aberrantly expresses apoptotic proteins.

bcl-XL, bax, bcl-2, and p53 are apoptotic proteins essential to normal neural development. Aberrant expression of these proteins has been observed in several central nervous system neoplasms. Immunoexpression of these markers is studied in 21 patients with focal cortical dysplasia type II (Taylor-type cortical dysplasia; malformations of cortical development) who had undergone lesionectomy for treatment of pharmacoresistant epilepsy. Paraffin immunohistochemistry using standard methodology was performed on representative sections using antibodies to bcl-XL, bax, bcl-2, and p53. Aberrant expression of bcl-XL, bax, bcl-2, and p53 was observed in the majority of cases, with dysmorphic neurons staining positively for bcl-XL, bax, and bcl-2 in 71%, 76%, and 24% of cases, respectively, and balloon cells staining positively for bcl-XL, bax, and bcl-2 in 89%, 78%, and 17% of cases, respectively. Most cases (86%) showed some expression of p53, with the majority showing expression of p53 most prominently in balloon cells. Previous work has shown gangliogliomas and dysembryoplastic neuroepithelial tumors, both dysplasia-associated neoplasms, to demonstrate aberrant expression of apoptotic markers, suggesting a possible common mechanism of development for these 2 processes in patients in whom they coexist.

An open-label trial of olanzapine for corticosteroid-induced mood symptoms.

BACKGROUND: Prescription corticosteroids are given for a variety of common medical conditions. Psychiatric symptoms including depression, psychosis, and especially mania are common side effects of corticosteroid therapy. However, minimal data are available on the treatment of corticosteroid-induced psychiatric symptoms. METHOD: In this study, 12 outpatients with manic or mixed symptoms secondary to corticosteroids were enrolled in a 5-week prospective, open-label trial of olanzapine. Psychiatric symptom measures included the Hamilton Rating Scale for Depression (HRSD), Young Mania Rating Scale (YMRS), and Brief Psychiatric Rating Scale (BPRS). Side effects were monitored with the Simpson Angus Scale (SAS), Abnormal Involuntary Movement Scale (AIMS), and Barnes Akathisia Scale (BAS). Weight and blood glucose were obtained at baseline and exit. Olanzapine dosing was flexible beginning at 2.5 mg/day and titrated upward as necessary to a maximum dose of 20 mg/day. Data were analyzed with Wilcoxon signed rank tests using baseline and exit data on all 12 participants. RESULTS: Participants showed significant reductions in YMRS (primary outcome measure), HRSD, and BPRS scores with no significant change in the SAS, AIMS, BAS, weight, or blood glucose levels. One participant discontinued early due to lack of efficacy. CONCLUSION: These data suggest that olanzapine is well tolerated and appears to be useful for mood disturbances associated with corticosteroid therapy. Controlled trials seem warranted to confirm these observations.