Introduction of the Liverpool Care Pathway for end of life care to emergency medicine.

AIM: To improve the care of patients presenting to the emergency department who are acutely dying or those in whom further disease-modifying treatment is not appropriate. DESIGN: A quality improvement report on the implementation of a modified Liverpool Care Pathway for the Dying Patient (LCP) in an emergency medicine department. SETTING: The emergency medicine department of Ninewells Hospital, Dundee. Ninewells Hospital is the tertiary referral and teaching hospital for the east coast of Scotland and North East Fife. KEY MEASURES FOR IMPROVEMENT: The pathway was introduced after a 2001 study and a 2003 audit showed that the department had an increasing role in the care of the acutely dying, but some inconsistency in approach. Key measures for improvement were to improve communication between staff, improve the consistency of care and improve the perceived quality of care given. Senior decision making remains a crucial element of the pathway. STRATEGIES FOR CHANGE: A modified LCP was developed and launched in November 2005. Change was managed via a series of meetings and a pilot process. Serial review and audit allowed ongoing quality review of the pathway and improvements. RESULTS: The care of the dying patient has become a more consistent and positive endeavour. Nursing staff are very satisfied with its use, and it is hoped that the LCP pathway can be developed further within the organisation. CONCLUSIONS: It has been a rewarding undertaking to improve the care of dying patients, but one which has taken time and has required consistent management of change to promote the positive outcomes.

Systemic lupus erythematosus in a filly.

Systemic lupus erythematosus (SLE) was diagnosed in a 2-year-old Standardbred filly. Clinical signs of SLE included weight loss, bilateral symmetric alopecia, seborrhea, oral ulceration, and lymphadenopathy. Abnormal laboratory findings included a Coombs test-positive hemolytic anemia and positive antinuclear antibody test result. Histologic evaluation of multiple skin biopsy specimens revealed interface dermatitis with linear deposition of IgG at the basement membrane zones of the epidermis and hair follicles. The filly did not respond to glucocorticoid treatment and was euthanatized. Necropsy findings included membranous glomerulonephritis and fibrous synovitis. On the basis of these findings, SLE should be considered in the differential diagnosis of immune-mediated skin disease in horses. Definitive diagnosis of SLE relies on recognition of multisystemic disease and confirmatory histopathologic and immunopathologic findings.

Medical charts and malpractice: how to avoid costly errors and omissions.

A thorough and well-organized medical chart can prevent malpractice from occurring, discourages the filing of groundless lawsuits, and is a useful tool in defending a physician in a medical malpractice action. This paper suggests methods by which a physician may improve record keeping and minimizing medico-legal exposure.

Differences in antagonist affinities at muscarinic receptors in chick and guinea-pig.

1. The antimuscarinic effects of a number of muscarinic antagonists in left atrium and ileum of the chick and guinea-pig were evaluated. 2. In agreement with findings in the guinea-pig, pirenzepine did not differentiate between muscarinic receptors in the left atrium and ileum of the chick. However, its affinity in this species was 5- to 10-fold higher than that observed in similar mammalian tissues. 3. Gallamine, methoctramine and himbacine are cardioselective antagonists in the guinea-pig with a selectivity index of 20, 25 and 10 respectively. However, in the chick, while himbacine maintained its cardioselective effect, gallamine was non-selective and methoctramine was only 4-fold more selective. 4. Secoverine, a non-selective antagonist in guinea-pig exhibited a small degree of cardioselectivity in the chick. 5. The ileoselective effect of 4-DAMP in the chick was much greater than that observed in the guinea-pig. 6. It is concluded that muscarinic receptors in cardiac and smooth muscles of the chick differ from those in the guinea-pig.