Do rural primary health care nurses feel equipped for palliative care?

Community primary health care nurses in rural and remote settings are required to provide palliative care as part of their generalist role. They have limited access to specialist medical and nursing support and sometimes there are no resident GPs. A study consisting of a mailed survey and follow-up interviews was conducted to explore the experiences of these nurses and to determine how personally and professionally equipped they felt for palliative care service provision. Most participants were registered nurses experienced in nursing and in rural and remote settings, who juggled multiple generalist work roles. They had only occasional palliative care patients, and more than half had provided palliative care for a friend or family member. Some nurses found palliative care rewarding, others preferred not to have to do it. However, even those who did not enjoy working with palliative care patients often went beyond the 'call of duty' to support a home death if that was what the patient wanted. Three-quarters had attended palliative care education in the last 2 years but 88% wanted more education. Barriers to education included competing work roles, work load, geographical isolation and lack of backfill. Support from managers and peers was considered important, as was accessing timely and relevant clinical support.

Removal of C-spine protection by A&E triage nurses: a prospective trial of a clinical decision making instrument.

OBJECTIVE: To investigate if triage nurses could safely apply a set of clinical criteria, removing hard collars and spinal boards at initial triage assessment. METHODS: The Nexus clinical decision rules were applied by trained triage nurses to patients who attended the department with cervical collars and/or on spinal boards. Patients were excluded if they were felt to be in need of immediate medical assessment. Data were collected on the time to nursing assessment, time to medical assessment and time spent restrained. Patients were followed up until discharge and their radiological diagnosis confirmed. Hospital records were checked to ensure that no patients re-presented with injuries that had been missed at initial assessment. RESULTS: In total, 112 patients were included in the study. Clinical criteria were met in 59 patients and their collar removed at triage assessment. For low risk patients, this reflects a mean reduction in time spent restrained of 23.3 minutes (p<0.005; 95% confidence interval 20.18 to 26.54). No patient who had a collar removed was found to have a significant injury. CONCLUSIONS: Simple criteria can be applied by accident and emergency triage nurses to allow safe removal of cervical collars and spinal boards. The reduced time patients spent immobilised represents an important improvement in patient care.

Antiangiogenic potential of camptothecin and topotecan.

PURPOSE: To determine the inhibitory nature of sublethal doses of camptothecin (CPT) and topotecan (TPT) treatments on normal human endothelial cells in vitro, as well as the in vivo antiangiogenic activity as compared to another antiangiogenic compound, TNP-470 and to a nonspecific cytotoxic agent, cisplatin. METHODS: Growth inhibition was determined by the crystal violet assay to measure relative cell numbers. (3)H-thymidine uptake was used to determine the inhibitory effect of CPT and TPT on DNA synthesis in vitro. Cell viability was determined using trypan blue exclusion assays. Cell cycle response to CPT was determined by flow cytometric analysis of propidium iodide-stained nuclei. In vivo inhibition of angiogenesis was determined by the disc angiogenesis system (DAS), where surgical sponge discs were placed subcutaneously in the rat dorsum and the ability of systemic treatment with liposomal CPT (LCPT), TPT, TNP-470 or cisplatin to inhibit vascular growth into the discs was evaluated. Quantitation of vascular growth was determined using toluidine blue staining of sectioned discs followed by digital image analysis. RESULTS: Treatment with 50 nM CPT or TPT inhibited human umbilical venular endothelial cell (HUVEC) growth as shown by crystal violet staining, but was not cytotoxic to the cells. This was evidenced by the fact that cell numbers did not increase or decrease with treatment, but remained static while cells were viable for over 96 h posttreatment. (3)H-thymidine uptake in HUVEC was inhibited as early as 5 min, reached a maximum inhibition at 24 h and lasted over 96 h posttreatment. Cell cycle analysis of CPT-treated HUVEC showed arrest in S-phase at 12 h with a concurrent decrease in population of cells in G(1). Accumulation of cells at the G(2)/M-phase was discernible at 24 h along with the S-phase inhibition. Treatment of rats with 1 mg/kg LCPT or TPT every other day for 14 days resulted in approximately 30% inhibition of vascular growth into the discs. This inhibition was similar to the inhibition seen with TNP-470, an established and potent angiogenic inhibitor. In contrast, cisplatin was not as effective in inhibiting vascular growth into the discs. CONCLUSIONS: In this work we showed that CPT and TPT inhibit human endothelial cell growth in vitro in a non-cytotoxic manner and that this inhibition lasts more than 96 h after drug removal. We also showed that LCPT and TPT, unlike a nonspecific cytotoxic agent, cisplatin, are as effective as TNP-470 in inhibiting angiogenic growth in the in vivo disc angiogenesis model. From this observation we propose that in addition to their proven tumoricidal activities, camptothecins may have an indirect in vivo antitumor effect mediated through the inhibition of angiogenesis.

Relationship between thickness, chapping and Staphylococcus aureus colonization of bovine teat tissue.

Post-milking measurements of teat skin chapping score, teat thickness and colonization by Staphylococcus aureus were determined for 11.5 d. Three teats on each of twelve Holstein cows, free from Staph. aureus intramammary infections, were immersed in 1 M-NaOH solution to induce teat chapping; the fourth teat served as a control. To achieve different degrees of chapping, one teat per cow received one immersion after each milking for three consecutive milking periods, a second teat received two immersions, and the third teat received one immersion which coincided with the last immersion of the other two teats. All teats were challenged twice with a skim milk broth culture of Staph. aureus (5 x 10(6) cfu) after the first and second milking following NaOH treatment. Measures were initiated with the milking following the last Staph. aureus challenges. Tissue thickness of the lateral side of the teat (barrel) and colonization by Staph. aureus declined with time. Thickness of the teat end varied more erratically. Teat skin chapping score was positively correlated (P < 0.001) with tissue thickness of the barrel and Staph. aureus colonization. Thickness of the barrel was not significantly correlated with Staph. aureus colonization. Barrel thickness as a covariate had a significant effect (P < 0.05) on teat skin colonization of Staph. aureus, whereas teat skin score and teat end thickness had no significant effect. Thus, thickness of the lateral side of the teat explained the greatest variation in Staph. aureus teat skin colonization in the model tested.

The vision of a nurse-coroner. A "protector of the living through the investigation of death".

1. The coroner must possess medical knowledge to make judgments based on symptomatology, history, post-mortem appearance, toxicology, and other diagnostic studies combined with evidence revealed by other aspects of the investigation. 2. One role of the nurse-coroner is providing the families of the deceased what they need to survive the death in terms of factual information, accuracy in the determination of cause and manner of death, and psychological and, sometimes, physical support. 3. Nurse-coroners are the facilitators of information that is learned from the dead, so that living members of society will have healthier, happier, longer lives.

Carotid artery stenosis: a prospective comparison of CT angiography and conventional angiography.

OBJECTIVE: The purpose of this study was to prospectively compare CT angiography with conventional angiography for detecting stenosis at the carotid bifurcation. SUBJECTS AND METHODS: Thirty-five patients referred for evaluation of carotid artery disease were studied with conventional angiography followed by CT angiography 4-24 hr later. Seventy carotid arteries were studied. CT angiograms were acquired by using 40-sec spiral scans with a 2-mm/sec table speed, 2-mm beam collimation, and IV iodinated contrast material injected at 2.5 ml/sec. Studies were interpreted on the CT workstation by using three-dimensional shaded surface objects and multiplanar reformations requiring 10-15 min per artery. The conventional and CT angiograms were interpreted by separate observers who did not know the results of the other imaging study. The degree of stenosis was determined by using the guidelines of the North American Symptomatic Carotid Endarterectomy Trial collaborators. Each artery was categorized as normal, mildly stenosed (1-29%), moderately stenosed (30-69%), severely stenosed (70-99%), or occluded. RESULTS: The degree of carotid artery stenosis on the CT angiograms correlated well with that seen on the conventional angiograms (r = .928, p < .001). With CT angiography, all occluded internal carotid arteries were correctly identified, and no arteries were wrongly classified as occluded. The degree of stenosis was overestimated on CT angiograms by greater than 10% in 16 arteries, especially when calcified atherosclerotic plaque was present. In some of these cases, the severity of the stenosis was underestimated on the conventional angiograms. All arteries, except one, with severe disease seen on conventional angiograms were correctly classified on the basis of the results of CT angiography. CONCLUSION: Results of CT angiography had a high degree of correlation with results of conventional angiography in the evaluation of carotid artery stenosis. CT angiography is multiplanar and allows differentiation of calcified plaque from contrast material, which provides information about plaque calcification, ulceration, and size that cannot be obtained with conventional angiography.

Islet cell tumors: comparison of dynamic contrast-enhanced CT and MR imaging with dynamic gadolinium enhancement and fat suppression.

Ten patients with 11 islet cell tumors underwent dynamic contrast material-enhanced computed tomography (CT) and magnetic resonance (MR) imaging within a 1-month period. MR imaging depicted all 11 tumors, and CT depicted seven of the 11 tumors. CT did not depict four of seven tumors that measured 2.5 cm in diameter or less. Islet cell tumors had low signal intensity on T1-weighted fat-suppressed MR images, and gastrinomas were best shown with this technique. Two of three insulinomas less than 1.5 cm in diameter were best shown on dynamic contrast-enhanced fast low-angle shot (FLASH) images as uniform areas of high signal intensity. Hepatic metastases were seen in five patients and showed peripheral ringlike enhancement best demonstrated on dynamic gadolinium-enhanced FLASH images. Hepatic lesions were most conspicuous on T2-weighted fat-suppressed spin-echo images. MR imaging with dynamic gadolinium enhancement and fat suppression is a promising tool in the investigation of islet cell tumors.

Difficulties in developing a respite program.

St. Paul's Hospital Palliative Care Unit is a 15-bed integrated AIDS and non-AIDS unit that has been open since 1989. A respite program has also been operating since 1989. Overall admissions to the unit have comprised approximately one-third AIDS patients and two-thirds non-AIDS patients. However, the respite patients have consisted of about two-thirds AIDS patients and one-third non-AIDS patients. The 53 patients in the first three years of the respite program have generated 96 respite admissions and 37 non-respite admissions. In the course of developing this program a number of questions and issues have arisen relating to goals and objectives of the respite program, perceptions of the patient and caregivers, and the effectiveness of the program. A review of the utilization patterns of this program and a discussion of selected case histories will be instructional for those who are considering developing their own respite programs.

A filing system for medical literature.

The author reviews the types of systems available for personal literature files and makes specific recommendations for filing systems for family physicians. A personal filing system can be an integral part of family practice, and need not require time out of proportion to the worth of the system. Because it is a personal system, different types will suit different users; some systems, however, are more reliable than others for use in family practice. (Can Fam Physician 1988; 34:425-433.).

Obstetrical anaesthesia at Winnipeg Women's Hospital 1975-83: anaesthetic techniques and complications.

The obstetrical anaesthesia experience of the Winnipeg Women's Hospital from 1975 to 1983 was reviewed (n = 22,925 infants). Use of narcotics in labour for analgesia decreased from 38.7 to 18.3 per cent of the deliveries. For analgesia during spontaneous vaginal deliveries, epidural anaesthesia increased from 6.0 to 24.0 per cent, inhalational analgesia decreased from 53.7 to 3.2 per cent while "no anaesthetic intervention" rose from 40.3 to 72.8 per cent. Use of epidural anaesthesia for Caesarean section increased from 58.7 to 82.6 per cent. The most common acute complications of anaesthesia were hypotension and inadvertent dural puncture during epidural catheterization. The incidence of hypotension decreased from 28.3 to 17.4 per cent during the nine-year period. Dural puncture decreased from 4.7 to 1.1 per cent of all epidural administrations. Postpartum complaints (that were thought to be related to anaesthesia) were mainly headache, back pain and sore throat. The incidence of these complaints also decreased over the study period.

The effect of ketamine anaesthesia on the acidotic fetal lamb.

The following study in pregnant ewes was done to examine the effects of ketamine-oxygen anaesthesia on the fetal lamb made acidotic by partial occlusion of the umbilical cord. Fifteen pregnant ewes were instrumented under general anaesthesia to allow continuous measurement of maternal and fetal mean arterial pressure and pulse rate and for withdrawal of arterial blood samples for blood gas analysis. An occlusion loop was loosely secured around the umbilical cord. Following a recovery period of 48 hours, a tracheostomy was performed on each ewe. After a control period, the umbilical occlusion loop was slowly inflated until fetal pH had decreased to 7.12-7.15. Following inflation the animals were divided into groups A and B. Group A received no anaesthesia. In Group B, the ewes received ketamine 3 mg X kg-1 intravenously and controlled ventilation with FIO2 of 1.0. After ten minutes ketamine 1 mg X kg-1 was given. In both groups radioactive microspheres were injected into the fetus at 0, 5, and 15 minutes. Ketamine anaesthesia in the pregnant ewe abolished the fetal hypertension and bradycardia produced by partial cord occlusion. All fetuses survived the 15 minutes of ketamine anaesthesia and there were no significant changes in arterial blood gases or pH. Blood flows determined by the microsphere method to the brain, heart, and kidneys were not significantly altered by ketamine. We conclude that ketamine-oxygen anaesthesia does not cause further deterioration in the acidotic fetal lamb.

Paresthesias and motor dysfunction after labor and delivery.

The incidence of paresthesias and motor dysfunction associated with 23,827 deliveries at Winnipeg Women's Hospital during a 9-yr period (1975-1983) was 18.9/10,000 deliveries. All the symptoms resolved within 72 hr after supportive therapy only. The frequency of paresthesias and motor dysfunction was greater in primiparas, women who had forceps- or vacuum-assisted deliveries, and women who had epidural or general anesthesia. Significant neurologic deficits after labor and delivery with or without epidural anesthesia were rare. Epidural anesthesia is a safe technique in this regard.

Clonidine prolongs canine tetracaine spinal anaesthesia.

Using a randomized blind cross-over design, the comparative efficacy of clonidine in prolonging tetracaine spinal anaesthesia was studied in six mongrel dogs. Lumbar subarachnoid injections (1 ml) of: tetracaine 4 mg with clonidine 150 micrograms, tetracaine 4 mg with epinephrine 200 micrograms, tetracaine 4 mg, clonidine 150 micrograms, epinephrine 200 micrograms, and five per cent dextrose in H2O (vehicle) were administered randomly to each animal at 5-7 day intervals. Subarachnoid tetracaine produced a motor blockade of 186 +/- 58 (mean +/- SEM) min. Both clonidine and epinephrine produced a similar prolongation of tetracaine motor blockade, 135 per cent (p less than 0.01) and 116 per cent (p less than 0.05) respectively, compared with tetracaine alone. No motor blockade was observed in dogs receiving clonidine, epinephrine or five per cent dextrose in H2O. The addition of clonidine to tetracaine spinal anaesthesia produced a significant increase in duration of sensory blockade, 56 per cent (p less than 0.01) and 107 per cent (p less than 0.01) respectively, when compared to tetracaine with and without epinephrine. Subarachnoid clonidine alone produced a sensory blockade of 76 +/- 17 minutes, while only one animal receiving subarachnoid epinephrine had a sensory blockade (40 minutes). No neurologic deficits were observed in any of the animals. The study concludes that during spinal anaesthesia with tetracaine in dogs, clonidine is as effective as epinephrine in prolonging motor blockade, but is more effective in prolonging sensory blockade.

Isoflurane potency and cardiovascular effects during short exposures in the foetal lamb.

Isoflurane is a relatively new volatile anaesthetic in clinical practice and increasing use for obstetrical patients might be expected. A previous study demonstrated that a 60-90 minute exposure of the foetus to isoflurane resulted in a significant fall in foetal cardiac output with development of foetal acidosis. To determine the cardiovascular effects of a shorter exposure of the foetal lamb to isoflurane and the potency (MAC) of isoflurane in the foetus, the following study was done. Eleven pregnant ewes were surgically prepared by placing indwelling arterial and venous catheters into the mother and foetus. After a 48-hour recovery period, isoflurane, two per cent in oxygen, was administered to six ewes via a tracheostomy for 30 minutes. Foetal cardiac outputs and regional blood flows were measured by the microsphere method. In five ewes the concentration of isoflurane was varied and MAC determinations were done on both ewe and foetus. Arterial blood levels of isoflurane were used to determine foetal MAC. Exposure to isoflurane resulted in a significant decrease in maternal and foetal mean arterial blood pressures and in foetal heart rate. Exposures up to 30 minutes did not result in foetal acidosis or a significant fall in cardiac output. Maternal and foetal MAC for isoflurane were determined to be 0.86 and 0.34 per cent respectively.