Are Health-Care Providers Well Prepared in Providing Optimal End-of-Life Care to Critically Ill Patients? A Cross-Sectional Study at a Tertiary Care Hospital in the United States.

It is important for health-care providers to be comfortable in providing end-of-life (EOL) care to critically ill patients and realizing when continuing aggressive measures would be futile. Therefore, there is a need to understand health-care providers' self-perceived skills and barriers to providing optimum EOL care. A total of 660 health-care providers from medicine and surgery departments were asked via e-mail to complete an anonymous survey assessing their self-reported EOL care competencies, of which 238 responses were received. Our study identified several deficiencies in the self-reported EOL care competencies among health-care providers. Around 34% of the participants either disagreed (strongly disagree or disagree) or were neutral when asked whether they feel well prepared for delivering EOL care. Around 30% of the participants did not agree (agree and strongly agree) that they were well prepared to determine when to refer patients to hospice. 51% of the participants, did not agree (agree and strongly agree) that clear and accurate information is delivered by team members to patients/family. The most common barrier to providing EOL care in the intensive care unit was family not accepting the patient's poor prognosis. Nursing staff (registered nurse) had higher knowledge and attitudes mean competency scores than the medical staff. Attending physicians reported stronger knowledge competencies when compared to residents and fellows. More than half of the participants denied having received any previous training in EOL care. 82% of the participants agreed that training should be mandatory in this field. Most of the participants reported that the palliative care team is involved in EOL care when the patient is believed to be terminally ill. Apart from a need for a stronger training in the field of EOL care for health-care providers, the overall policies surrounding EOL and palliative care delivery require further evaluation and improvement to promote better outcomes in caring patients at the EOL.

Isolated dysphagia unmasking bulbar neurosarcoidosis and pulmonary sarcoidosis.

Dysphagia is a rare manifestation of sarcoidosis. It is more commonly the result of esophageal compression by enlarged mediastinal lymph nodes rather than direct esophageal involvement and rarely secondary to neurosarcoidosis and oropharyngeal dysphagia. We report a 54 year old female presenting with a six month history of worsening dysphagia. She denied respiratory symptoms. Physical exam was normal. ESR was 61 mm/hr. Serum ACE level was 65 mcg/L. Chest X-ray was normal. Esophagram revealed a large amount of contrast pooling in pharyngeal recesses with intermittent laryngeal aspiration. Swallow videofluorography showed a decreased retraction of the base of the tongue, limited laryngeal elevation, and a large amount of contrast pooling in pharyngeal recesses with intermittent laryngeal aspiration. EGD showed a normal opening of the upper esophageal sphincter and the cricopharyngeus appeared normal. Proximal esophageal biopsies were normal. Brain MRI with gadolinium was normal. Lumbar puncture was performed. CSF showed a moderate pleocytosis, a WBC count of 19 with 97% lymphocytes, an elevated total protein level of 85 mg/dl (15-60). Neck CT scan showed no oropharyngeal tissue thickening or infiltration, no masses or enlarged lymph nodes. Chest CT scan showed enlarged intrathoracic lymph nodes and no esophageal compression. Bronchoscopy showed the vocal cords to be intact, and the CD4/CD8 ratio in BAL was 5.3. Subcarinal lymph node EBUS biopsy revealed non caseating granulomas. The patient was started on IV methylprednisolone. Three days later, the swallow videofluorography showed a near complete response to steroids. The patient tolerated regular consistency diet with thin liquids, and she was discharged on a slow taper of prednisone over a period of three months. A unique case of isolated dysphagia unmasking bulbar neurosarcoidosis and pulmonary sarcoidosis is herein reported.

A renal angiomyolipoma with extension to the renal vein and asymptomatic fat pulmonary embolus.

Renal angiomyolipoma (AML) is a rare benign tumor that can extend into the renal vein, inferior vena cava and the right atrium. AML is a mesenchymal tumor composed of smooth muscle, fat and vascular elements. In rare instances, the tumor may release a fatty tissue to the pulmonary vasculature, which can lead to cardiopulmonary collapse and death. Only four cases of fat pulmonary embolism secondary to AML have been reported in the literature but our case was the first to present as asymptomatic. Our patient had left renal AML extending to the renal vein that was associated with fat pulmonary embolus. The patient underwent uncomplicated radical nephrectomy and was discharged home on no anticoagulation. Follow-up chest computed tomography showed no extension of the pulmonary embolism. Whether embolectomy or anticoagulation is necessary in asymptomatic pulmonary embolism secondary to renal AML is unclear. Although controversial, some surgeons prefer to place an inferior vena cava filter prior to radical nephrectomy to prevent dislodgement of new intraoperative emboli, which can lead to catastrophic outcome.

Gastroduodenal artery aneurysm, diagnosis, clinical presentation and management: a concise review.

Gastroduodenal artery (GDA) aneurysms are rare but a potentially fatal condition if rupture occurs. They represent about 1.5% of all visceral artery (VAA) aneurysms and are divided into true and pseudoaneurysms depending on the etiologic factors underlying their development. Atherosclerosis and pancreatitis are the two most common risk factors. Making the diagnosis can be complex and often requires the use of Computed Tomography and angiography. The later adds the advantage of being a therapeutic option to prevent or stop bleeding. If this fails, surgery is still regarded as the standard for accomplishing a definite treatment.

Phrenic nerve injury and diaphragmatic paralysis following pacemaker pulse generator replacement.

Diaphragmatic paralysis (DP) is a common condition. It can be unilateral or bilateral and the diagnosis is usually based on a clinical and radiological findings. Bilateral diaphragmatic paralysis is usually symptomatic with dyspnea and acute respiratory failure while unilateral diaphragmatic paralysis is typically asymptomatic and when present, symptoms usually depend on the presence of underlying pulmonary or neurologic disease. DP can be the result of various chest conditions that affect the phrenic nerve such as tumors, vascular abnormalities or traumatic incidents during surgery as well as blunt or penetrating chest or neck injuries. We report a unique case of phrenic nerve injury and unilateral diaphragmatic paralysis secondary to pacemaker pulse generator replacement that was successfully treated with diaphragmatic plication.

Small cell lung cancer doubling time and its effect on clinical presentation: a concise review.

Small cell lung cancer (SCLC) is one of many types rapidly growing malignant diseases, such as Burkitt's lymphoma and testicular germ cell cancers. At present, there is no reliable way to screen for SCLC, and imaging modalities tend to be delayed in detecting this type of cancer. The clinical presentation of acutely and rapidly growing SCLC can mimic those of pulmonary inflammatory or infectious disorders, and in some instances, this delays appropriate management and negatively affects patient outcome.

Cement pulmonary embolism after percutaneous vertebroplasty and kyphoplasty: an overview.

BACKGROUND: Because of the aging of the American population, osteoporotic vertebral fractures are becoming a common problem in the elderly. Minimally invasive percutaneous vertebral augmentation techniques have gained a great deal of importance in relieving the pain associated with these fractures, and are becoming the standard of care. METHODS: These procedures involve the injection of polymethylmethacrylate (PMMA) into the vertebral body. However, these techniques have their complications, and among these, pulmonary embolism is one of the most feared. It is attributable to the passage of cement into the pulmonary vasculature. After encountering a case of PMMA embolism in our practice, we decided to highlight this topic and discuss the incidence, clinical presentation, diagnosis, and treatment of cement pulmonary embolisms.

Fasting hyperglycemia upon hospital admission is associated with higher pneumonia complication rates among the elderly.

BACKGROUND: Hyperglycemia is an independent predictor of adverse outcomes during hospitalization. In patients who have pneumonia, significant hyperglycemia is associated with poor outcomes. This study evaluates the interaction of the degree of hyperglycemia and complication rates stratified by age in non-critically ill patients admitted to the hospital for care of community-acquired pneumonia. METHODS: Retrospective review of patient records coded for pneumonia. Analysis included 501 non-critically ill patients admitted to a tertiary care hospital in New York City. Data were stratified by diabetes status, age (less than 65 and 65 and over), and fasting blood glucose (FBG) within the first 24 hours of hospitalization. Among patients with no history of diabetes, FBG was stratified as "normal" [FBG /=126 mg/dl (7 mmol/l)]. The diabetic group included known diabetics regardless of FBG. The Pneumonia Severity Index (PSI) was calculated for all patients. Complications rates, hospital length of stay and mortality were compared among the groups. RESULTS: In patients age 65 and older, complication rates were 16.7% in normoglycemics, 27.5% in the "mild-hyperglycemia" group, 28.6% in the "severe hyperglycemia" group, and 25.5% in those with known diabetes. The mild and severe-hyperglycemics had similar complication rates (p = 0.94). Compared to the normal group, mild and severe groups had higher rates of complications, p = 0.05 and p = 0.03, respectively. PSI tended to be higher in those over the age of 65. PSI was not significantly different when the normal, mild, severe, and known diabetes groups were compared. PSI did not predict complications for new hyperglycemia (normals' mean score 87, mild 84.7, severe 93.9, diabetics 100). Hospital mortality did not differ among groups. Length of stay was longer (p = 0.05) among mild-hyperglycemics (days = 8.4 s.e. 14.3) vs. normals (days = 6.2 s.e.6.5). CONCLUSION: This study shows that FBS between 101-125 mg/dl (5.7-6.9 mmol/l) on hospital admission increases pneumonia complication rates among the elderly with no previous diagnosis of diabetes.

Evaluation of magnolia bark extract in chromosomal aberration assays.

Magnolia bark extract (MBE) has been used historically in traditional Chinese and Japanese medicines, and more recently as a component of dietary supplements and cosmetic products. The genotoxic potential of MBE was studied in two in vitro chromosomal aberration assays. In Chinese hamster ovary (CHO) cells, exposure for 3 h to MBE at concentrations of 0-30 microg/ml in the absence of a metabolic activation system (S9) and 0-7 microg/ml with S9 did not induce chromosomal aberrations, whereas higher concentrations were cytotoxic and did not allow for analysis of aberrations. Extended exposure for 18 h without metabolic activation at concentrations up to 15 microg/ml also resulted in a negative response. In V79 cells derived from Chinese hamster lung tissue, treatment for 6h with concentrations up to 52 and 59 microg/ml in the absence and presence of S9, respectively, did not increase the incidence of chromosomal aberrations compared to negative controls. Furthermore, MBE exposure for 24 h without metabolic activation did not induce aberrations. The results of these studies demonstrate that MBE is not genotoxic under the conditions of the in vitro chromosomal aberration assays in CHO and V79 cells, and support the safety of MBE.

Use of capnometry to verify feeding tube placement.

OBJECTIVE: To investigate the effectiveness of capnometry (carbon dioxide monitoring) in verifying gastric placement of a stylet-guided nasogastric tube in intubated, mechanically ventilated patients. DESIGN: A prospective descriptive study. SETTING: Fourteen-bed medical-surgical intensive care unit, 11-bed coronary care unit, and 18-bed chronic ventilator unit in a 700-bed teaching hospital. PATIENTS: A total of 53 adult patients on mechanical ventilation and enteral feedings. INTERVENTIONS: After the feeding tube was inserted to 30-cm length and before the first chest roentgenogram was taken, the end-tidal carbon dioxide detector was attached to the proximal end of the feeding tube. It was left in place for 1 min and was observed for a change in color (originally purple, it will turn tan or even yellow on contact with carbon dioxide). If the end-tidal carbon dioxide detector remained purple, it was interpreted as gastrointestinal placement; if it turned tan or yellow, it was interpreted as airway placement. The first chest roentgenogram was taken to confirm observations made with the end-tidal carbon dioxide detector. The feeding tube was advanced and a final chest roentgenogram verified its position below the diaphragm. MEASUREMENTS AND MAIN RESULTS: In 52 of the 53 placements, no carbon dioxide was detected. The position in the gastrointestinal tract was confirmed by the two-step procedure. There were no false positives; the technique was 100% specific. One placement out of the 53 was found to be in the trachea. The end-tidal carbon dioxide detector appropriately detected carbon dioxide. This indicated no false negatives. To verify the sensitivity, 20 placements were made directly into the trachea through an endotracheal tube. In all 20 cases, carbon dioxide was detected. No false negatives occurred, indicating 100% sensitivity. Testing in spontaneously breathing patients was not conducted. CONCLUSIONS: Capnometry is a safe method for verifying proper feeding tube placement. The first chest roentgeno-gram can be safely eliminated. With this method, less time and money will be expended in feeding tube placement, making capnometry an efficacious new method.