Directives Limiting Care in the Perianesthesia Setting: A Foucauldian Case Study Report.

PURPOSE: The purpose of this inquiry is to explore how adult patients with limiting directives, their families, and clinicians make decisions about resuscitative status during anesthesia. Although current practice guidelines recommend mandatory reconsideration of do not resuscitate and other limiting directives before anesthesia, the automatic suspension of directives limiting care continues in the adult perianesthesia setting. How patients and clinicians talk about these limiting directives is underexplored in the literature. DESIGN: This qualitative inquiry used the Foucauldian Poststructural Case Study Design. METHODS: Data were collected through interviews and observation of patients with existing advance directives who underwent surgery, family members, and perianesthesia clinicians who participated in their care. Contextualizing analysis, a qualitative methodology that fits well with Foucauldian Poststructural Case Study Design, was used to rigorously examine the data. FINDINGS: Twenty-seven participants completed the observation and interview components of the study. Observation data were collected from an additional 18 participants. Four authoritative discourses that constructed choices available to patients and clinicians were identified. The "We'll just suspend" discourse permeates perianesthesia culture and produces a will to suspend the limiting directive among clinicians. Discourses about lack of time, a desire not to talk about advance directives unless it is essential to care, and confusion about who is responsible for addressing the limiting directive were also identified in the case. In addition, patients had difficulty translating advance directive choices into the perianesthesia context, and this difficulty may be misunderstood by clinicians as agreement with the plan of care. Finally, power networks may sequester knowledge about patients' choices, leading to tension among clinicians and creating barriers to honoring patients' advance directive choices. CONCLUSIONS: Results suggest that even where policies of mandatory advance directive reconsideration exist, patients may experience environments that constrain their choices and decision-making agency.

Effects of Lidocaine on Mitomycin C Cytotoxicity.

PURPOSE: Intra-Tenon or subconjunctival injection of a solution of mitomycin C (MMC) and 1% preservative-free lidocaine (as an anesthetic) has gained popularity for its use in trabeculectomy, a filtering surgery for glaucoma. To our knowledge, no studies have analyzed the impact of lidocaine on the cytotoxic effects of MMC in this setting. This study was conducted to evaluate in vitro fibroblast cytotoxicity to a solution of MMC (0.2 mg/ml) and 1% preservative-free lidocaine. DESIGN: Experimental study. PARTICIPANTS: Nonhuman subject research. METHODS: Cultured human conjunctival fibroblasts were incubated in phosphate-buffered saline (PBS) (control), MMC (0.2 mg/ml), a mixture of 0.2 mg/ml MMC + 1% preservative-free lidocaine, or 1% preservative-free lidocaine. Samples were taken at 2, 5, 10, 30, and 60 minutes, and a 3-[4,5-dimethylthiazol-2-yl]-2,5 diphenyl tetrazolium bromide (MTT) assay with photoabsorbance testing was used to assess conjunctival cell viability. MAIN OUTCOME MEASURE: Mean photoabsorbance. RESULTS: Mean photoabsorbance across all time intervals was 0.680 for solutions incubated in PBS, 0.642 for MMC, 0.612 for MMC + 1% preservative-free lidocaine, and 0.605 for 1% preservative-free lidocaine. A 2-way analysis of variance analyzing solution, time, and solution-time interaction on photoabsorbance showed that PBS was least cytotoxic and an optimal control for this study. Tukey post hoc comparisons showed that MMC was more cytotoxic than PBS (P < 0.001). However, both MMC + 1% preservative-free lidocaine and 1% preservative-free lidocaine were more cytotoxic than MMC and PBS (P < 0.01 for all). No significant differences in cytotoxicity comparing lidocaine-containing solutions were observed. CONCLUSIONS: In this in vitro study, we found an increase in cytotoxicity when MMC (0.2 mg/ml) was combined with 1% preservative-free lidocaine. We note that lidocaine did not inhibit MMC cytotoxicity and exhibited a significant cytotoxic effect on its own.

Development of a Sensitive High-Resolution Mass Spectrometry Approach for Urea Nitrogen Quantitation in Small Volumes of Bronchoalveolar Lavage Fluid (BALF).

A sensitive, selective, and quantitative method incorporating high-resolution mass spectrometry was developed for the determination of blood urea nitrogen (BUN) in bronchoalveolar lavage fluid. The method requires no sample cleanup or derivatization prior to analysis. High-performance liquid chromatography (HPLC) on a Hypersil Gold PFP column (100 × 3 mm, 3 µm particle size) connected to a C18 guard column was employed for a 10 min chromatographic separation. The detection of urea was achieved using a Thermo Scientific Q-Exactive Plus instrument incorporating selected ion monitoring (SIM) modes for the protonated adduct of urea. The urea analytical measuring range for the method is 0.047-17.134 mg/dL, resulting in a BUN analytical measurement range of 0.022-8.007 mg/dL, which allows for quantitation over 3 orders of magnitude (R2 = 0.999). In addition, the method is suitable for small sample volumes (15 µL) with a high level of accuracy, precision, and specificity.

Giving nurses a voice during ethical conflict in the ICU.

BACKGROUND: Ethical conflict and subsequent nurse moral distress and burnout are common in the intensive care unit. There is a gap in our understanding of nurses' perceptions of how organizational resources support them in addressing ethical conflict in the intensive care unit. RESEARCH QUESTION/OBJECTIVES/METHODS: The aim of this qualitative, descriptive study was to explore how nurses experience ethical conflict and use organizational resources to support them as they address ethical conflict in their practice. PARTICIPANTS AND RESEARCH CONTEXT: Responses to two open-ended questions were collected from critical care nurses working in five intensive care units at a large, academic medical center in the Midwestern region of the United States. ETHICAL CONSIDERATIONS: This study was approved by the Institutional Review Board at the organization where the study took place. FINDINGS: Three main interwoven themes emerged: nurses perceive (1) intensive care unit culture, practices, and organizational priorities contribute to patient suffering; (2) nurses are marginalized during ethical conflict in the intensive care unit; and (3) organizational resources have the potential to reduce nurse moral distress. Nurses identified ethics education, interprofessional dialogue, and greater involvement of nurses as important strategies to improve the management of ethical conflict. DISCUSSION: Ethical conflict related to healthcare system challenges is intrinsic in the daily practice of critical care nurses. Nurses want to be engaged in discussions about their perspectives on ethical conflict and play an active role in addressing ethical conflict in their practice. Organizational resources that support nurses are vital to the resolution of ethical conflict. CONCLUSION: These findings can inform the development of interventions that aim to proactively and comprehensively address ethical conflict in the intensive care unit to reduce nurse moral distress and improve the delivery of patient and family care.

Association of Dry Eye Disease With Dyslipidemia and Statin Use.

PURPOSE: To determine whether an association exists between dry eye disease (DED) and statin use and/or dyslipidemia. DESIGN: Retrospective, case-control study. METHODS: Setting: University of North Carolina (UNC)-affiliated healthcare facilities. STUDY POPULATION: 72,931 patients seen at UNC ophthalmology clinics over a 10-year period. MAIN OUTCOME MEASURES: Odds ratios (ORs) calculated between DED and a history of low, moderate, or high-intensity statin use; and ORs calculated between DED and abnormal lipid panel values. RESULTS: Total of 39,336 individuals (53.9% female) were analyzed after exclusion of individuals with confounding risk factors for DED. Of these, 3,399 patients (8.6%) carried a diagnosis of DED. Low-, moderate-, and high-intensity statin regimens were used by 751 subjects (1.9%), 2,655 subjects (6.8%), and 1,036 subjects (2.6%). Lipid abnormalities were identified as total cholesterol >200 mg/dL, 4,558 subjects (11.6%); high-density lipoprotein (HDL) <40 mg/dL, 2,078 subjects (5.3%); low-density lipoprotein (LDL) >130 mg/dL, 2,756 subjects (7.0%); and triglycerides (TGs) >150 mg/dL, 2,881 subjects (7.3%). The odds ratios (OR) of carrying a diagnosis of DED given the presence of low-, moderate-, and high-intensity statin use were 1.39 (95% confidence interval [CI]: 1.13-1.72); OR 1.47 (95% CI: 1.30-1.65), and OR 1.46 (95% CI: 1.21-1.75), respectively. The OR of carrying a diagnosis of DED given the presence of total cholesterol >200 mg/dL, HDL <40 mg/dL, LDL >130 mg/dL, and TGs >150 mg/dL were 1.66 (95% CI: 1.52-1.82), 1.45 (95% CI: 1.26-1.67), 1.55 (95% CI: 1.39-1.74), and 1.43 (95% CI: 1.27-1.61), respectively. CONCLUSIONS: A history of statin use or dyslipidemia is associated with an increased odds of having a DED diagnosis. Further studies are needed to determine whether statin use and/or dyslipidemia increases the risk of DED.

Office-based Air-Fluid Exchange for Diabetic Post-Operative Vitreous Cavity Hemorrhage.

Post-operative vitreous cavity hemorrhage (POVCH) is observed in 6-75% of eyes undergoing pars plana vitrectomy (PPV) for proliferative diabetic retinopathy (PDR). We describe our technique for office-based Air fluid exchange (AFX) in the treatment of POVCH. Sixteen eyes (15 patients) with PDR and POVCH undergoing office-based AFX between January 2006 and November 2016 were retrospectively identified. The pre- and post- procedure visual acuity (VA) and complications were compared between eyes with and without traction retinal detachment (TRD). Medicare charges for office-based AFX versus PPV were also analyzed. Mean (± standard deviation [SD]) age at the time of AFX was 55.31 (± 8.02) years. Nine eyes (56.25%) had TRD prior to PPV and 11 eyes (68.75%) were pseudophakic. The improvements in mean (±SD) logMAR VA at the last postoperative visit (3 - 8 months) were 1.38 (± 0.99), 0.82 (± 0.91) and 2.09 (± 0.53) in all eyes, TRD eyes and non-TRD eyes, respectively. Complications included cataract progression, hypotony, and recurrence of TRD and ghost cell glaucoma. The total cost of outpatient AFX was $1,409.59 less than that of PPV. Office-based AFX is a cost-effective alternative treatment for non-clearing diabetic POVCH with an acceptable risk profile.

Adult Perianesthesia Do Not Resuscitate Orders: A Systematic Review.

PURPOSE: The purpose of this systematic review is to assess if Do Not Resuscitate (DNR) orders should be routinely rescinded during anesthesia, determine if consensus on retaining DNR orders exists in the literature, and explore the current state of clinical practice. DESIGN: This systematic review followed preferred reporting items for systematic reviews and meta-analyses guidelines. METHODS: In June 2018, the Cumulative Index to Nursing and Allied Health Literature and PubMed databases were systematically searched using defined inclusion/exclusion criteria. FINDINGS: Ninety-one articles from the databases were pooled with 16 works identified as formative to the research questions. Forty-nine articles were analyzed and included in this study. CONCLUSIONS: It is unethical to automatically rescind DNR orders during anesthesia. Patients have the right to retain their DNR orders unaltered or modify them for the perianesthesia period. Sufficient evidence exists to create meaningful policy at every level. A consensus exists among professional organizations that the standard of care is a required reconsideration of DNR orders before anesthesia.

Achieving High Affinity and Selectivity for Asymmetric Dimethylarginine by Putting a Lid on a Box.

The methylation states of Lys and Arg represent a particularly challenging set of targets to distinguish selectively in water using synthetic receptors. To date, trimethyllysine (Kme3) is the only post translational modification (PTM) of the eight possible methylation states of Lys and Arg that can be recognized selectively. Here, we report the first synthetic receptor capable of selectively recognizing asymmetric dimethylarginine (Rme2a). This was achieved by using a biased dynamic combinatorial chemistry (DCC) library to generate a receptor mimicking the 5-sided box-like shape of Rme2 reader proteins, a feature that has been hypothesized to impart selectivity. Additionally, we synthesized a thioether-linked analogue of the resulting receptor to provide a novel scaffold with maintained selectivity but greater stability. This work introduces strategies that can be applied towards achieving selectivity based on subtle differences in hydrophilic guests in aqueous solutions.

Correction: Arterial tortuosity syndrome: 40 new families and literature review.

In the published version of this paper the author Neus Baena's name was incorrectly given as Neus Baena Diez. This has now been corrected in both the HTML and PDF versions of the paper.

Everyday Ethical Comportment: An Evolutionary Concept Analysis.

BACKGROUND: The formation of everyday ethical comportment is an essential part of nursing education in the 21st century, but the concept is more abstract and confusing than the dominant bioethical models frequently used in nursing education. METHOD: The purpose of this analysis is to explore the concept of everyday ethical comportment and determine whether the concept remains viable for nursing as a discipline. Rodgers' method of evolutionary concept analysis guided a systematic literature review. Following PRISMA guidelines, 32 articles containing the keywords everyday ethical comportment were identified, and 20 are included in this study. RESULTS: The analysis identified four critical attributes of everyday ethical comportment (embodiment, skilled relational know-how, caring, and salience). The concept's surrogate and related terms, antecedents, and consequences were also identified. CONCLUSION: Everyday ethical comportment is underrepresented in the literature. Although it remains viable for nursing as a discipline, the concept's future sustainability is questionable. [J Nurs Educ. 2018;57(8):460-468.].

Corneal hysteresis in post-radial keratotomy primary open-angle glaucoma.

PURPOSE: Corneal hysteresis (CH) is a corneal biomechanical property measured by the ocular response analyzer (ORA). It is associated with primary open-angle glaucoma development, progression, and severity as well as intraocular pressure (IOP) measurement. Decreases in CH and changes in IOP measurements have been described for laser-assisted refractive surgery; however, patients with prior radial keratotomy (RK) have not been examined. We have performed a cohort study examining CH and intraocular pressure measurements (Goldmann applanation and ORA values including Goldmann-correlated and cornea-compensated IOP [adjusted for corneal hysteresis]) in RK patients and myopic controls with POAG. METHODS: Eighty POAG patients (28 RK and 52 myopic controls) were recruited. Central corneal thickness (CCT), prostaglandin analogue (PGA) use, perimetric stage, and history of cataract and glaucoma filtration surgery were assessed through chart review. Participants underwent testing with the ORA (yielding measures of CH, cornea-compensated [IOPcc], Goldmann-correlated IOP [IOPgc], and corneal resistance factor [CRF]), Goldmann applanation, A-scan for axial length (AL), and corneal topography. Slit lamp exam was performed to assess for number of incisions in RK patients. RESULTS: Adjusting for AL and CCT, CH was significantly lower in the RK group with an estimated difference of 0.8585 mmHg (p = 0.0112). Cornea-compensated intraocular pressure was significantly higher in the RK group after controlling for Goldmann applanation, AL, and CCT (2.35 mmHg difference, p < 0.001). Corneal resistance factor and IOPgc were not significantly different. A correlational analysis did not reveal a significant correlation between numbers of RK incisions and CH. CONCLUSIONS: We report significant differences, with lower CH and higher IOPcc, when comparing eyes with glaucoma and either a history of RK or myopia. These findings may aid in establishing normative decreases in CH with RK and POAG and indicate a possible under-estimation of pressure in RK patients.

A Database Study of Visual Outcomes and Intraoperative Complications of Postvitrectomy Cataract Surgery.

PURPOSE: To analyze the visual outcomes and rate of intraoperative complications of phacoemulsification surgery after prior pars plana vitrectomy (PPV). DESIGN: Retrospective, multicenter database study. PARTICIPANTS: Eyes that underwent phacoemulsification between June 2005 and March 2015 at 8 sites in the United Kingdom. METHODS: Study eyes were classified as vitrectomized (prior PPV group) or nonvitrectomized (reference group) depending on the vitreous state at the time of cataract surgery. Eyes with multiple intraocular surgeries or history of ocular diseases known to cause cataract progression or increased risk of intraoperative complications during phacoemulsification were excluded. MAIN OUTCOME MEASURES: Logarithm of the minimum angle of resolution (logMAR) visual acuity (VA), rate of intraoperative complications, and time interval to cataract surgery. RESULTS: Eyes in the prior PPV group (n = 2221) had worse preoperative logMAR VA (0.96±0.60 vs. 0.62±0.52, P < 0.0001), were from younger patients, and had longer axial lengths than the nonvitrectomized group (n = 136 533). At all postoperative time points measured up to 24 weeks, mean vision was poorer in the prior PPV group (0.41±0.47 vs. 0.17±0.29 at 4-12 weeks, P < 0.0001) and a smaller proportion of eyes achieved postoperative VA ≤0.30 logMAR (Snellen, ≥20/40) (60.8% vs. 86.5% at 4-12 weeks, P < 0.0001). The rate of posterior capsular rupture was not different between the prior PPV (1.5%) and the nonvitrectomized (1.7%) groups, but the incidences of zonular dialysis (1.3% vs. 0.6%) and dropped nuclear fragments (0.6% vs. 0.2%) were higher in the prior PPV group (P < 0.0001). The mean time interval between PPV and cataract surgery was 399 days. CONCLUSIONS: We found a significant improvement in VA with postvitrectomy cataract surgery. However, compared with eyes without prior PPV, there was a worse mean postoperative vision of 0.2 logMAR units, a higher rate of zonular dialysis and dropped nuclear fragments, and a similar rate of posterior capsule rupture.

Repeat Intravitreal Dexamethasone Implant for Refractory Cystoid Macular Edema in Syphilitic Uveitis.

PURPOSE: To report the successful utilization of adjunctive repeat intravitreal corticosteroid therapy for the treatment of cystoid macular edema in syphilis-related uveitis. METHODS/PATIENTS: An HIV-positive patient with treated ocular syphilis who developed refractory cystoid macular edema (CME) was treated with repeat intravitreal corticosteroid therapy including dexamethasone intravitreal implants. RESULTS: Treatment led to the resolution of CME and improvement in visual acuity. CONCLUSIONS: Intravitreal corticosteroid therapy may be a viable adjunctive treatment for refractory CME in patients with treated syphilitic uveitis. Corticosteroid-induced exacerbation of infection is unlikely in patients with an adequate serologic treatment response.

Arterial tortuosity syndrome: 40 new families and literature review.

PURPOSE: We delineate the clinical spectrum and describe the histology in arterial tortuosity syndrome (ATS), a rare connective tissue disorder characterized by tortuosity of the large and medium-sized arteries, caused by mutations in SLC2A10. METHODS: We retrospectively characterized 40 novel ATS families (50 patients) and reviewed the 52 previously reported patients. We performed histology and electron microscopy (EM) on skin and vascular biopsies and evaluated TGF-ß signaling with immunohistochemistry for pSMAD2 and CTGF. RESULTS: Stenoses, tortuosity, and aneurysm formation are widespread occurrences. Severe but rare vascular complications include early and aggressive aortic root aneurysms, neonatal intracranial bleeding, ischemic stroke, and gastric perforation. Thus far, no reports unequivocally document vascular dissections or ruptures. Of note, diaphragmatic hernia and infant respiratory distress syndrome (IRDS) are frequently observed. Skin and vascular biopsies show fragmented elastic fibers (EF) and increased collagen deposition. EM of skin EF shows a fragmented elastin core and a peripheral mantle of microfibrils of random directionality. Skin and end-stage diseased vascular tissue do not indicate increased TGF-ß signaling. CONCLUSION: Our findings warrant attention for IRDS and diaphragmatic hernia, close monitoring of the aortic root early in life, and extensive vascular imaging afterwards. EM on skin biopsies shows disease-specific abnormalities.

Cataract Surgery Outcomes in Eyes With Primary Epiretinal Membrane.

Importance: Primary epiretinal membrane (ERM) is a common retinal disorder with a prevalence of 4% to 18.5%. Although ERM and cataracts commonly occur together, to our knowledge, no studies have investigated the outcome of cataract surgery alone in this setting. Objective: To analyze the visual outcome and cystoid macular edema risk with cataract surgery in eyes with primary ERM. Design, Setting, and Participants: In this retrospective clinical database study, data were collected from July 2003 to March 2015 from 8 locations in the United Kingdom. Cataract surgery data of 217 557 eyes were extracted from the electronic medical record of the UK National Health Service. After exclusion of 57 561 eyes with combined surgery, prior vitrectomy, copathology, and complications, 812 eyes with primary ERM and 159 184 reference eyes were analyzed. Main Outcomes and Measures: We report on visual acuity (VA), the incidence of cystoid macular edema, and the need for ERM surgery. Results: The mean (SD) age of patients in the ERM group was 73.7 (9.23) years, and 395 of 812 were men (46.8%). The mean (SD) age of patients in the reference group was 74.4 (12.19) years, and 65 265 of 159 184 were men (41%). Epiretinal membrane eyes assessed at 4 to 12 weeks postoperatively gained 0.27 (0.32) logMAR (approximately 3 Snellen lines), with 200 of 448 (44.6%) improving by 0.30 logMAR or more (≥3 Snellen lines) and 32 of 448 (7.1%) worsening by 0.30 logMAR or more. Reference eyes gained a mean (SD) of 0.44 (0.26) logMAR (approximately 4 Snellen lines), with 48 583 of 77 408 (62.8%) improving by 0.30 logMAR or more and 2125 of 77 408 (2.7%) worsening by 0.30 logMAR or more. Although all eyes with preoperative VA of 20/40 or less improved, only reference eyes with preoperative VA of more than 20/40 showed improvement. Cystoid macular edema developed in 57 of 663 ERM eyes (8.6%) (95% CI, 6.69-10.98) and 1731 of 125 435 reference eyes (1.38%) (95% CI, 1.32-1.45) (P < .001). Epiretinal membrane surgery was performed in 43 of 663 (6.5%) ERM eyes. Conclusions and Relevance: On average, VA improved 0.27 logMAR (approximately 3 Snellen lines) in eyes with ERM. Eyes with ERM and VA of 20/40 or less showed more benefit after cataract surgery than those with better preoperative vision. However, compared with eyes without ERM, higher rates of cystoid macular edema and a lower postoperative VA gain were noted.

Ophthalmic findings in patients with arterial tortuosity syndrome and carriers: A case series.

INTRODUCTION: Arterial tortuosity syndrome (ATS) is a rare autosomal recessive disease hallmarked by tortuosity, stenosis, and aneurysm development of large- and medium-sized arteries. Mutations in SLC2A10, a gene that encodes the facilitative glucose transporter GLUT10, cause ATS. Several case reports have noted associated ophthalmic findings such as keratoconus, keratoglobus, and myopia without detailed descriptions or standardized examinations. We report the ophthalmic findings in a cohort of compound heterozygous ATS patients and heterozygous carriers of SLC2A10 mutations. METHODS: Five ATS patients and three carriers were identified through an ATS specialty clinic at the Arkansas Children's Hospital in Little Rock, Arkansas. Patients underwent complete eye examinations, including corneal pachymetry, topography, and optical coherence tomography when indicated. RESULTS: All five patients with ATS had myopia and thin corneas with an average central corneal thickness of 426 µm, and three had corneal ectasia, two with early keratoconus and one with keratoglobus and deep stromal corneal opacities. One patient had bilateral high irregular astigmatism, and one had unilateral high regular astigmatism. All carriers had myopia, one had corneal thinning, and one developed keratectasia in one eye many years after laser-assisted in situ keratomileusis (LASIK) surgery. CONCLUSION: We document a spectrum of ophthalmic manifestations of ATS with universal findings of myopia, corneal thinning, and a propensity for corneal ectasia leading to keratoconus or keratoglobus. Heterozygous carriers may develop keratectasia after corneal refractive surgery. Our data support regular eye examinations for all patients carrying SLC2A10 mutations with follow-up tailored to clinical findings.

Idiopathic Intracranial Hypertension Progressing to Venous Sinus Thrombosis, Subarachnoid Hemorrhage, and Stroke.

Idiopathic intracranial hypertension (IIH) is a syndrome characterized by increased intracranial pressure (ICP), the absence of structural lesions on neuroimaging, and normal cerebrospinal fluid composition. Cerebral venous sinus thrombosis (CVST) is a common cause of increased ICP and can be differentiated from IIH with magnetic resonance venography. We describe a young woman with typical IIH who underwent lumbar puncture and was treated with a short course of high-dose corticosteroids followed by acetazolamide. She subsequently developed CVST, subarachnoid hemorrhage, and stroke. Risk factors that may have resulted in CVST are discussed.