Determining the relationship between end-of-life decisions expressed in advance directives and resuscitation efforts during cardiopulmonary resuscitation.

In recent years, there has been an increased focus on end-of-life decisions and the use of medical technology. It is not well documented in the literature whether or not and to what extent patients' advance directives are used for directing resuscitative efforts. The purpose of this study was to determine how useful patients' advance directives were to members of the health care team in determining treatment and end-of-life decisions among patients who received cardiopulmonary resuscitation (CPR) efforts. Medical records of 135 adult patients who had undergone CPR efforts within the previous year were reviewed to determine if and to what extent advance directives were useful in directing end-of-life care and treatment decisions. Only 35 of these patients had advance directives. Three categories for advance directives emerged: those that were "independently directive," those that were "vague and required further clarification," and those that were "nondirective." Information from this study may be used to clarify treatment options for end-of-life care and to determine if and what further interventions are required to ensure that advance directives can be executed as meaningful documents.

Animal assisted therapy and the individual with spinal cord injury.

Spinal cord injury (SCI) is a devastating event that results in significant adjustments during the acute and rehabilitation phase. During this period, it is imperative to maintain the patient's self-esteem, reduce stress levels, encourage the expression of feelings, and provide sensory stimulation. Animal Assisted Therapy (AAT) involves the use of animals as a complement to more traditional forms of therapy. The program is based on the knowledge that animals have a positive influence on people who are ill in the healthcare setting. The Animals Heal Hearts Program (TM) has two components, pet visitation and pet therapy. Pet visitation consists of allowing a patient to have his/her own personal dog for a visit, provided there are no medical contraindications. Pet therapy is a structured program using a dog that has completed behavioral and health screening. Dogs are used in the hospital to reduce patients' stress, increase their self-esteem, and help them express feelings. The dogs provide sensory stimulation as patients view and handle the animals and learn about animals and pets. A carefully planned and evaluated program ensures that it is safe and effective.

Evolution of a role to enhance care coordination.

The recent trend toward shorter hospital stays has prompted health care personnel in acute care settings to reevaluate models of coordinating patient care. In whatever model is adopted, there must be someone whose role is to focus on achieving quality patient outcomes in a shorter time frame. Our institution has piloted several different models with various job classes to fulfill the role. However, the primary focus of the models-to enhance care coordination-remained unchanged. The initial care coordination model was the development of patient care coordinator role by converting the charge nurse position on the unit. The second model our institution developed occurred during a management restructuring. This model created a new position, a nursing practice coordinator, who had previously been a management support person with supervisory responsibilities. We now envision the role to be assumed by a nurse practitioner. The nurse practitioner's broader scope of practice potentially can further enhance coordination of care. In this article, the authors describe the development process, issues and interventions, and lessons learned during each step of redesigning a case management model.

Definition of the human T-cell epitopes of Fel d 1, the major allergen of the domestic cat.

BACKGROUND: A heterodimeric acidic glycoprotein (Fel d 1) has been defined as the major allergen of the domestic cat. Because T-cell help is required for the initiation and maintenance of allergic responses, it is of importance to determine the T-cell-reactive regions of the Fel d 1 molecule. METHODS: Overlapping peptides corresponding to the two chains of Fel d 1 were tested in proliferation assays on polyclonal T-cell lines and for the ability to bind Fel d 1-specific IgE in ELISA and histamine release assays. RESULTS: Assay of T-cell lines derived from 53 subjects allergic to cats demonstrated that the majority of T-cell reactivity is found in chain 1 of Fel d 1. Two peptides (Fel-1 and Fel-2) containing major epitopes, alone or as a mixture, efficiently activated T cells and exhibited minimal detectable reactivity with IgE by ELISA or histamine release assay. CONCLUSIONS: Two Fel d 1 peptides containing major T-cell epitopes have been identified, have been shown to bind minimal Fel d 1-specific IgE, and are now being tested for the ability to decrease T-cell responses in patients with cat allergy as a new form of immunotherapy.

Pallidotomy: a surgical intervention for control of Parkinson's disease.

Parkinson's disease, a chronic incurable disorder, has a significant impact on quality of life. Parkinson's disease results from chronic degeneration of cells in the basal ganglia that produce dopamine. It typically affects elderly individuals producing muscle rigidity and akinesia. Traditionally, Parkinson's disease has been controlled by medications. However, for some patients, medications may no longer be effective, or may produce drug-related complications. For this group of patients, pallidotomy is gaining support as an intervention to control the debilitating symptoms of Parkinson's disease, thus enabling a person to perform everyday tasks. Although the procedure was developed in the 1950s, contemporary technology has allowed a resurgence of the intervention. With the focus on relief of two of the major symptoms of Parkinson's disease, the pallidotomy procedure is gaining support as a surgical intervention for this disease. Therefore, it is important for the health care team to have an understanding of the disease process, surgical intervention and postoperative care to enhance quality outcomes for this patient population.

Management of the patient with a pituitary tumor resection.

The resection of a pituitary tumor represents a challenging diagnosis for the critical care nurse. There are important nursing assessments that can assist in identifying post-surgical complications. Detailed teaching instructions by the critical care nurses will also assist in minimizing the patient's postoperative complications.

Coordinated care for the SCI patient.

The delivery of quality patient care in a timely, cost-effective manner is of utmost importance in health care settings. In an attempt to promote continuity and coordination of care, appropriate utilization of resources, and increased patient and health care provider satisfaction, a coordinated care system of patient care delivery was implemented for the spinal cord injured patient. Coordinated care is a multi-disciplinary approach that focuses on achieving patient outcomes within effective time frames which have been established by all members of the health care team involved in the treatment of the SCI patient. Integral to the concept of coordinated care is the utilization of a critical path and variance tracking and analysis. A critical path is a multidisciplinary plan which identifies the time frame in which key events and patient outcomes should occur during an episode of care in order to achieve an optimal use of resources and length of stay. Variance tracking is the comparison of the actual care delivered with the expected plan and the identification of reasons why the care differed.

Enhanced immunoreactivity and preferential heterodimer formation of reassociated Fel d I recombinant chains.

In this study we have addressed the question of whether reassociating the two recombinant protein chains that comprise the major cat dander allergen, Fel d I, would change the overall IgE and allergic patient T cell immunoreactivity compared to the native molecule. To accomplish this, the chains were combined under reducing and denaturing conditions, then allowed to reassociate by dilution and extensive dialysis against a physiological buffer. An initial examination of the reaction products using quantitative capture ELISA demonstrated comparable reactivity to Fel d I. Further analysis, using a pool of cat allergic patient plasma, showed that the products of the reassociation reaction (rFel d I) also possessed an enhanced IgE binding capacity. Depletion ELISA results gave only a 5% difference in reactivity between rFel d I and the native protein versus a 20% difference with the mixture of the two chains. Comparative secondary T cell stimulation assays were subsequently performed using cat allergic patient peripheral blood lymphocytes. Here the results demonstrated no loss of reactivity with the reassociated chains as compared to Fel d I or the two mixed recombinant chains. To biochemically characterize the products of the reassociation reaction we have performed reverse phase HPLC and then analysed the isolated fractions by mass spectrometry. It was clear from these results that like the native Fel d I, the products of the reassociation reaction favored heterodimer formation, with no homodimer being detected. This implies that the reassociated protein chains had preferentially adopted a native-like conformation.

Spinal cord stimulation for chronic intractable pain: nursing implications.

Spinal cord stimulation (SCS) became available in the 1970s as a treatment option for patients with constant or recurring pain. This invasive procedure is performed after all other efforts have failed to prove effective in controlling pain. Advanced technology enables the patient to perform adjustments to maximize comfort with the use of a magnet or portable programmer. Nursing care is guided by a specific plan of care for the SCS patient population. A patient population-specific standard may be useful.

Potential therapeutic recombinant proteins comprised of peptides containing recombined T cell epitopes.

The complete primary structure of Fel d I2 has been determined and shown to be comprised of two separate polypeptide chains (designated chain 1 and 2). Overlapping peptides covering the entire sequence of both chains of Fel d I have been used to map the major areas of human T cell reactivity. The present study describes three non-contiguous T cell reactive regions of < 30 aa in length that were assembled in all six possible configurations using PCR and recombinant DNA methods. These six recombinant proteins comprised of defined non-contiguous T cell epitope regions artificially combined into single polypeptide chains have been expressed in E. coli, highly purified, and examined for their ability to bind to human cat-allergic IgE and for human T cell reactivity. Several of these recombined T cell epitope-containing polypeptides exhibit markedly reduced IgE binding as compared to the native Fel d I. Importantly, the human T cell reactivity to individual T cell epitope-containing regions is maintained even though each was placed in an unnatural position as compared to the native molecule. In addition, T cell responses to potential junctional epitopes were not detected. It was also demonstrated in mice that s.c. injection of T cell epitope-containing polypeptides inhibits the T cell response to the individual peptides upon subsequent challenge in vitro. Thus, these recombined T cell epitope-containing polypeptides, which harbor multiple T cell reactive regions but have significantly reduced reactivity with allergic human IgE, constitute a novel potential approach for desensitization to important allergens.

Coordinated care for the neuroscience patient: future directions.

A coordinated care model was developed on a neuroscience unit to achieve positive outcomes in a cost-effective environment. This included the development of a patient care coordinator (PCC) role, critical paths and a system for variance tracking. The PCC was responsible for coordinating care of patients and ensuring that patients progressed toward expected outcomes. Multidisciplinary critical paths were developed for four medical diagnoses. To evaluate the effectiveness of the program, an analysis of length of stay data, cost comparison, patient and staff satisfaction, and variance reports of one critical path, the microvascular decompression for trigeminal neuralgia were completed. Results from the pilot project were positive and provided valuable information for the use of coordinated care as a hospital-wide patient care delivery model.

A pilot program to promote professional growth for neuroscience nurses.

A pilot program was developed as a strategy to increase professional growth on a neuroscience unit. The primary objective of the program was to allow staff nurses to participate in activities that interface with the neuroscience patient population. Nurses could choose an area of interest that related to their unit responsibilities. This experience provided the participants with the unique opportunity to participate in patient care from the perspective of another discipline. The staff were enthusiastic about the experience and shared it eagerly with their peers. Participants' evaluation of the program was overwhelmingly favorable. The data suggest that this program was an effective means of increasing professional growth and staff development.

Complete sequence of the allergen Amb alpha II. Recombinant expression and reactivity with T cells from ragweed allergic patients.

This study defines the complete primary structure of Amb alpha II, an important allergen produced by short ragweed (Ambrosia artemisiifolia). The deduced amino acid sequence derived from the cDNA indicates that Amb alpha II shares approximately 65% sequence identity with the Amb alpha I multigene family of allergens. Full-length cDNA encoding Amb alpha I.1 and Amb alpha II have been expressed in E. coli and purified. An in-frame linker encoding polyhistidine has been added to the 5' end of the cDNA to facilitate purification using Ni2+ ion affinity chromatography, yielding greater than 90% pure recombinant protein in a single step. T cells from patients allergic to ragweed proliferate in response to pollen extract as well as purified recombinant Amb alpha I.1 and Amb alpha II. T cell lines established using either Amb alpha I.1 or II as the stimulating Ag exhibit a high level of cross-reactivity to both proteins. This result is entirely consistent with the extensive primary sequence identity shared by these two proteins. These data suggest that allergic humans recognize shared T cell epitopes on these two related molecules.