Acting with dedication and expertise: Relatives' experience of nurses' provision of care in a palliative unit.

OBJECTIVES: Admission of a cancer patient to a palliative unit when near the final stage of their disease trajectory undoubtedly impacts their relatives. The aim of our study was to illuminate and interpret relatives' lived experiences of health personnel's provision of care in a palliative ward. METHODS: A phenomenological/hermeneutic approach was employed that was inspired by the philosophical tradition of Heidegger and Ricoeur and further developed by Lindseth and Nordberg. The perspectives of the narrator and the text were interpreted by highlighting relatives' views on a situation in which they have to face existential challenges. The analysis was undertaken in three steps: naïve reading, structural analysis, and comprehensive understanding, including the authors' professional experiences and theoretical background. RESULTS: Six subthemes appeared: the dying person, the bubble, the sight, the cover, the provision for children's needs, and the availability of immediate help. These components were further constructed into three themes: the meaning of relating, the meaning of action, and the meaning of resources. Our comprehensive understanding of the results suggests that the most important theme is "acting with dedication and expertise." SIGNIFICANCE OF RESULTS: The following aspects are crucial for relatives of cancer patients hospitalized in a palliative ward: time and existence, family dynamics, and care adjusted to the situation. Our study results led to reflections on the impact of how nurses behave when providing care to patients during the palliative phase, and how they interact with relatives in this situation. We found that cancer patients in a palliative unit most appreciate nurses who act with dedication and expertise.

Trapping and observing single atoms in a blue-detuned intracavity dipole trap.

A single atom strongly coupled to a cavity mode is stored by three-dimensional confinement in blue-detuned cavity modes of different longitudinal and transverse order. The vanishing light intensity at the trap center reduces the light shift of all atomic energy levels. This is exploited to detect a single atom by means of a dispersive measurement with 95% confidence in 10 micros, limited by the photon-detection efficiency. As the atom switches resonant cavity transmission into cavity reflection, the atom can be detected while scattering about one photon.

[Acute ischemia of the extremities. As critical as a myocardial infarct]. / Akute Extremitätenischämie. Bedrohlich wie ein Myokardinfarkt.

Acute limb ischemia is a vascular-surgical emergency requiring immediate referral to a hospital provided with all the necessary therapeutic facilities. Essential initial measures are protection of the limb against continued cooling, management of pain, and bolus administration of heparin. For the physician providing further care, not only an accurate history, but, ideally, also the results of earlier investigations such as ECG, abdominal US or Doppler studies, provide useful information. In patients who have not undergone prior surgery vascular-surgical management, that is, embolectomy with a balloon catheter, is the treatment of choice. Furthermore, the patient requires continuing care after discharge; here, wound management and the supervision of anticoagulation measures that might be needed are important tasks for the general practitioner.

[Peripheral arterial occlusive disease. Symptoms, basic diagnosis and staged therapy]. / Periphere arterielle Verschlusskrankheit (pAVK). Symptomatik, Basisdiagnostik und Stufentherapie.

Intermittent claudication or rest pain are typical symptoms of peripheral arterial occlusive disease (PAOD) affecting the lower limbs. The pain is localized one level below that of the occlusion. Initial investigations should determine skin temperature and color, pulse status, stenotic sounds and Doppler occlusive pressures. If intermittent claudication is present, angiography of the pelvis and legs then follows. Treatment is stage-dependent: while in stages I and IIa conservative treatment such as cessation of smoking, administration of acetylsalicylic acid and walking training suffices, stages IIb and higher require invasive measures extending from PTA to amputation of gangrenous parts of the limb.

[Aortic stent versus open prosthesis implantation. How can the aneurysm be excluded?]. / Aortenstent versus offene Prothesenimplantation. Wie wird das Aneurysma ausgeschaltet?

The diagnosis of an infrarenal aortic aneurysm mandates not only regular ultrasonographic monitoring, but also careful instruction of the patient about an emergency, that is, symptoms associated with rupture, and how to react. If ultrasound reveals a clear increase in the size of the aneurysm, or if a diameter of 5 cm is reached, the indication for surgery is established. Two options are then available: implantation of an aortic stent, which has the advantage of being a minimally invasive procedure, or open prosthesis implantation. However, the benefits and risks of both options must be carefully weighed up, since the patients are often elderly and have cardiopulmonary problems. Postoperative surveillance of the patient comprises three- to six-monthly follow-up with ultrasound or CT scan.

[Cerebrovascular insufficiency--2. When is surgery indicated?]. / Zerebrovaskuläre Insuffizienz--Teil 2. Wann lohnt die Operation?

For the vascular-surgical treatment of cerebrovascular insufficiency, prior staging is essential. In stage I only the 80-89% asymptomatic stenosis should be operated on. Using this approach, the stroke risk decreases significantly in comparison with conservative treatment. Stage II disease is the domain of vascular surgery. In stage II a and b, an operation makes sense only exceptionally in the noncomatose patient and within the first 6 hours following the event. Prior to disobliteration of stage IV stenoses, CT and MRI findings need to be considered. In the presence of a contralateral high-grade stenosis of the internal carotid, surgery is recommended here too. The classical method is carotid disobliteration with patchplasty. Possible alternativeas are eversion endarterectomy and carotid bifurcation-plasty.

[Use of the sitting position in neurosurgery. Results of a 1998 survey in Germany]. / Anwendung der sitzenden Position in der Neurochirurgie. Ergebnisse einer Umfrage aus 1998 in Deutschland.

OBJECTIVES: This 1998 survey was carried out on the use of the sitting position for neurosurgical procedures in the posterior fossa and operations of the craniospinal and cervical spine region by the dorsal approach. In addition, anesthetic management of the sitting position and the compliance with recommendations of the Neuroanesthesia Study Group of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) published in 1995 were investigated and compared to results of a 1995 survey. METHODS: A questionnaire was sent to 152 departments of anesthesiology in Germany providing anesthesia for neurosurgical procedures. 85 institutions (56%) responded to the survey, data from 78 hospitals were enrolled into the study. The sitting position was preferred for posterior fossa surgery by 45% of the neurosurgeons, for craniospinal operations by 35% and for cervical spine surgery by the dorsal approach by 39%. To 97% of the institutions the recommendations of the Neuroanesthesia Study Group of the DGAI were well known, 19% modified their anesthetic approach due to these recommendations. Recommendations of the Study Group on neuro-monitoring, in particular on the use of ultrasound (precordially or transoesophageally) for the detection of venous air embolism were followed by all institutions. 45% of the participants of the study preoperatively undertook diagnostic measures to preclude a probe-patent foramen ovale which predisposes the patient to paradoxical air embolism. CONCLUSIONS: The survey demonstrates that the use of the sitting position in German neurosurgery is still high when compared to other Western countries, but a tendency for decline over last 3 years can be observed from our data. In addition, our data appears to indicate a positive effect of the Study Group's recommendations on anesthetic management of the sitting position in neurosurgery.

[Heart-skin syndrome and cardiac myxoma: presentation of a case and clinical experience of 17 years]. / Syndrome cardio-cutané et myxomes cardiaques: présentation d'un cas et expérience chirurgicale de 17 ans.

Between 1971 and 1988, cardiac myxoma was identified in 13 (0.003%) of 4000 patients who underwent open-heart surgery at the hôpital du Sacré-Coeur in Montreal. One patient with multiple right atrial tumours also had abnormal cutaneous pigmentation compatible with the recently identified syndrome of "Carney's complex." This syndrome has also been associated with endocrine abnormalities such as primary nodular adrenal hyperplasia, with or without Cushing's syndrome. The authors review the literature and compare the findings with their experience in the surgical treatment of cardiac myxomas.

Lipoprotein composition changes induced by fenofibrate in dysbetalipoproteinemia type III.

Fenofibrate (300 mg daily) was given to 9 subjects (7 men, 2 women) with dysbetalipoproteinemia type III. The treatment brought about important plasma level reductions in cholesterol (-35%), triglycerides (-56%), VLDL-cholesterol (-63%) and VLDL-triglycerides (-59%). The VLDL-C/TG ratio, which was 0.40 before treatment, was 0.30 after 4 weeks of fenofibrate, still suggestive of type III. LDL-C, when measured by conventional methods, was unchanged but isolation of the IDL (1.006-1.019 g/ml) fraction from the 1.006 g/ml infranatant revealed that true LDL-C levels actually increased in 6 individuals while IDL-C decreased considerably. The total HDL-C increase was mostly due to a 33% HDL3-C change. Apolipoprotein levels were considerably modified, notably apo B, C-III and E which were decreased, as well as the lipoprotein particles containing combinations of these apolipoproteins, namely LpE:B and LpC-III:B. Apo A-I was slightly modified as LpA-I: A-II particle levels increased and LpA-I decreased. There were marked compositional modifications of apo B-containing lipoproteins which corresponded to changes of the whole lipoprotein profile. Some abnormal classes of lipoproteins (e.g., beta-VLDL, dense LDL), characteristic of this disease, tended to disappear and were in some cases replaced by material of different size and density.

Sequence of cellular responses in rabbit aortas following one and two injuries with a balloon catheter.

In order to further elucidate the pathogenesis of intimal proliferation and increased thrombogenesis following repeated arterial injuries we studied the sequence of the cellular changes following two injuries of rabbit aortas with a balloon catheter. Following the first injury, the de-endothelialized surface was covered by a platelet monolayer. Polymorphonuclear leucocytes adhered to the inner surface of this monolayer and did not appear to penetrate the vessel wall. By 4 to 7 days, areas of neointima had formed. Within seconds after the reinjury at 7 days after the de-endothelialization small platelet aggregates formed on injured neointimal smooth muscle cells. Within I min platelet thrombi and fibrin strands formed. At 30 min most of the platelet thrombi had become fibrin-rich. Polymorphonuclear leucocytes had accumulated and many had begun to penetrate into the neointimal tissue. The number and extent of penetration of leucocytes into the inner parts of the arterial wall increased with time. Four days after the injury the neointimal cushions were restored and thickened. Both following the first and second injury the formation of neointimal cushions was accompanied by a change in the polarity of the inner layers of medial smooth muscle cells, some of which appeared to have migrated into the neointima.

Distribution of cellular responses in rabbit aortae following one and two injuries with a balloon catheter.

To investigate the mechanisms involved in the cellular reactions to arterial injuries, we studied the distribution of the deposits on the injured intima and the pattern of neointimal thickening following single and double injuries of rabbit aortae with a balloon catheter. Thirty minutes after the first injury most, but not all, of the inner surface of the aortae was covered by adherent, spread platelets. Seven days following the first injury areas of neointima, mainly proliferating smooth muscle cells, had formed around and opposite the orifices of branch vessels. The rest of the inner aortic surface consisted of acellular subendothelial matrix. Thirty minutes after the second injury, 7 days after the first, single platelets adhered once more to parts of the reinjured subendothelium, mostly between the orifices. Numerous fibrin-rich, platelet thrombi were present mainly on the surface of the injured neointima. Thirty minutes after both the first and second injury polymorphonuclear leucocytes adhered to the inner surface downstream from the orifices of branch vessels and in longitudinally oriented zones opposite the orifices. Four days following the second injury, the neointima was restored with the same distribution as before the second injury, and few thrombi, adherent platelets, or leucocytes remained.

Effect of fenofibrate treatment on type III hyperlipoproteinemia.

The effect of treatment with fenofibrate was investigated in nine patients (seven men) presenting with type III hyperlipoproteinemia. This therapy produced a statistically significant decrease in serum triglyceride, cholesterol, apolipoproteins B, CII, CIII, and E levels. Particular attention was focused on lipoproteins containing apolipoprotein B. The concentration of particles recognized by monoclonal antibodies (BL3, BL5, and BL7), associated with atherosclerotic disease, was lowered by the treatment. The most dramatic decrease was observed for lipoproteins LpE:B and LpCIII:B, which are particularly enhanced in type III hyperlipoproteinemia.

Injury to cultured endothelial cells by thrombin-stimulated platelets.

In vivo, stimulated platelets may injure the endothelium. We have used cultured endothelial cells to assess endothelial cell damage caused by platelet stimulation with thrombin. Endothelial cells were cultured from umbilical veins and semiconfluent cultures were labeled with Na2 51CrO4. Twenty four hours later washed human platelets (final concentration 200,000 platelets/microliters) and thrombin (final concentration 4 units/ml) were added to the medium and the culture dish was shaken for 15 minutes. The percentage of cells detached from the culture dish and the percentage of 51Cr lost from the endothelial cells into the ambient fluid during the shaking were determined and used as indicators of cell injury. Increased percentages of loosened cells and 51Cr in the ambient fluid were observed with platelet suspension and thrombin compared to controls with neither platelet suspension nor thrombin and controls with either platelet suspension or thrombin. The platelet-free supernatant obtained after reaction of the platelets with thrombin also increased the percentage of loosened cells, but it did not increase the percentage of 51Cr in the ambient fluid to a significant degree. Thrombin alone caused a moderate loss of 51Cr, but no increased loosening of cells. Treatment of the platelets with acetylsalicylic acid prior to the experiment depressed the detachment effect of thrombin-stimulated platelets, but did not alter the effect on the release of 51Cr into the ambient fluid. Scanning and transmission electron microscopy of cultured endothelial cells exposed to thrombin-stimulated platelets confirmed the presence of loosening and injury to the endothelial cells. Thus, platelet stimulation with thrombin had at least two effects on the cultured endothelial cells: a loosening effect caused by material released from the platelets; an injury effect which, in order to reach its maximum, required the presence of stimulated platelets.

A simple device for staining electron microscopy grids.

A simple holder for electron microscopy grids is described. It consists of a rod covered with dental wax (Ladd, Cat. No. 32165). Multiple slits for holding grids are made in the wax. The rod is attached to a rubber cork that fits into the test tubes filled with staining or rinsing solutions. The device has simplified and standardized the staining procedure, and stain precipitates due to air exposure are avoided.

The adaptation of the fetal red cells of newborn lambs to extrauterine life: the role of 2,3-diphosphoglycerate and and adult hemoglobin.

The purpose of this study was to determine the interrelationship of the rise and fall of 2,3-diphosphoglycerate (DPG) with the increase in adult hemoglobin and the decrease in red cell oxygen hemoglobin affinity after birth in normal lambs. It was found that the mean maximum DPG level was 26.71 +/- 4.98 mol/g Hb at 7.5 +/- 1.1 days. At the same time the mean P50 and adult hemoglobin level was 27.0 +/- 1.4 mm Hg and 31.1 +/- 11.i%, respectively. In the individual lambs, the level of their maximum DPG correlated inversely with the amount of adult hemoglobin (r-0.77, P less than 0.05). Once the DPG began to decrease, there was an inverse correlation between the DPG and the adult hemoglobin present in the red cell (r = 0.68, P less than 0.001). It appeared that the rise in DPG postanatally is only a compensatory mechanism until an adequate amount of adult hemoglobin is present. This fact was borne out by the second part of the study in which exchange transfusions with adult red cells were performed on five newborn lambs during the first 24 hr after birth and aborted the rise in DPG.