An ethnography of managing emotions when talking about life-threatening illness.

AIM: This ethnographic study was concerned with how dying patients, palliative care staff and family caregivers communicate about life-threatening illness in a palliative care setting in Ethiopia. BACKGROUND: Ethiopia, as a developing country, had few resources for caring for those requiring end-of-life care. However, palliative care was supported by local champions in Ethiopia and by the Federal Ministry of Health. INTRODUCTION: The disclosure of bad news was discouraged because it was believed that such disclosure may lead to unnecessary distress and to loss of hope. METHODS: Non-participant observation amounting to 276 h of observation and ethnographic interviews with four patients, six family caregivers and five palliative care staff during two periods of data collection (November 2011-January 2012 and May 2012-August 2012) in Addis Ababa, Ethiopia. FINDINGS: Although palliative care staff create openness in communication with patients and family caregivers about terminal illness and dying, ultimately palliative care staff deferred to family wishes about significant news disclosures, in order to avoid upset. Family caregivers were found to avoid disclosing news of a terminal illness to their family member and wished to keep the patient in closed awareness. In contrast, an open awareness context existed between palliative care staff and family caregivers. DISCUSSION: In managing truth telling in different cultural settings, medical and nursing staff as well as health policy makers need to take into account the various awareness contexts highlighted in this study. Palliative care staff should consider how actions such as protecting patients from upset may inadvertently deny the patient the right to exercise control. CONCLUSION AND IMPLICATIONS FOR POLICY: Health policy makers should ensure that the design and implementation of palliative care services should not be a wholesale adoption of Western style services but ensure that such services are adapted to reflect the religious, cultural and social needs of the community. Foreign workers and volunteers who deliver palliative care services and education in Ethiopia should reflect local religious and cultural sensitivities.

Successful use of blunt microdissection catheter in a chronic total occlusion of a celiomesenteric artery.

Chronic mesenteric ischemia is often a disabling condition associated with intestinal angina, weight loss, and sitophobia (a morbid aversion of food). Significant stenosis of two of the three main arteries of the gut is usually required to produce symptoms. Surgical therapy has included reimplantation and bypass grafting, usually with synthetic conduits and occasionally endarterectomy. Newer techniques have made endovascular treatment an emerging modality in managing some of the difficult lesions in the mesenteric circulation that cause chronic mesenteric ischemia. We describe the first reported case of blunt microdissection using a Frontrunner XP(R) CTO Catheter (Lumend, Redwood City, CA) to successfully cross, subsequently wire and stent a four-year-old chronic total occlusions in a celiac trunk, which also gave origin to the superior mesenteric artery.

Elimination of rabies from red foxes in eastern Ontario.

The province of Ontario (Canada) reported more laboratory confirmed rabid animals than any other state or province in Canada or the USA from 1958-91, with the exception of 1960-62. More than 95% of those cases occurred in the southern 10% of Ontario (approximately 100,000 km2), the region with the highest human population density and greatest agricultural activity. Rabies posed an expensive threat to human health and significant costs to the agricultural economy. The rabies variant originated in arctic foxes: the main vector in southern Ontario was the red fox (Vulpes vulpes), with lesser involvement of the striped skunk (Mephitis mephitis). The Ontario Ministry of Natural Resources began a 5 yr experiment in 1989 to eliminate terrestrial rabies from a approximately 30,000 km2 study area in the eastern end of southern Ontario. Baits containing oral rabies vaccine were dropped annually in the study area at a density of 20 baits/km2 from 1989-95. That continued 2 yr beyond the original 5 yr plan. The experiment was successful in eliminating the arctic fox variant of rabies from the whole area. In the 1980's, an average of 235 rabid foxes per year were reported in the study area. None have been reported since 1993. Cases of fox rabies in other species also disappeared. In 1995, the last bovine and companion animal cases were reported and in 1996 the last rabid skunk occurred. Only bat variants of rabies were present until 1999, when the raccoon variant entered from New York (USA). The success of this experiment led to an expansion of the program to all of southern Ontario in 1994. Persistence of terrestrial rabies, and ease of elimination, appeared to vary geographically, and probably over time. Ecological factors which enhance or reduce the long term survival of rabies in wild foxes are poorly understood.

The transcription factor Bright associates with Bruton's tyrosine kinase, the defective protein in immunodeficiency disease.

Binding of the transcription factor Bright to Ig heavy chain loci after B cell activation is associated with increased heavy chain transcription. We now report that Bright coprecipitates with Bruton's tyrosine kinase (Btk), the defective enzyme in X-linked immunodeficiency disease (xid). Furthermore, we observed Btk in the nucleus of activated murine B cells, and mobility shift assays suggest that it is a component of the Bright DNA-binding complex. While BRIGHT protein was synthesized in activated spleen cells from xid mice, it did not bind DNA or associate stably with Btk. These data suggest that deficiencies in BRIGHT DNA-binding activity may contribute to the defects in Ig production seen in xid mice.

Self-association of the alpha subunit of phosphorylase kinase as determined by two-hybrid screening.

The structural organization of the (alphabetagammadelta)(4) phosphorylase kinase complex has been studied using the yeast two-hybrid screen for the purpose of elucidating regions of alpha subunit interactions. By screening a rabbit skeletal muscle cDNA library with residues 1-1059 of the alpha subunit of phosphorylase kinase, we have isolated 16 interacting, independent, yet overlapping transcripts of the alpha subunit containing its C-terminal region. Domain mapping of binary interactions between alpha constructs revealed two regions involved in the self-association of the alpha subunit: residues 833-854, a previously unrecognized leucine zipper, and an unspecified region within residues 1015-1237. The cognate binding partner for the latter domain has been inferred to lie within the stretch from residues 864-1059. Indirect evidence from the literature suggests that the interacting domains contained within the latter two, overlapping regions may be further narrowed to the stretches from 1057 to 1237 and from 864 to 971. Cross-linking of the nonactivated holoenzyme with N-(gamma-maleimidobutyroxy)sulfosuccin-imide ester produced intramolecularly cross-linked alpha-alpha dimers, consistent with portions of two alpha subunits in the holoenyzme being in sufficient proximity to associate. This is the first report to identify potential areas of contact between the alpha subunits of phosphorylase kinase. Additionally, issues regarding the general utility of two-hybrid screening as a method for studying homodimeric interactions are discussed.

Effector-sensitive cross-linking of phosphorylase b kinase by the novel cross-linker 4-phenyl-1,2,4-triazoline-3,5-dione.

The dienophile 4-phenyl-1,2,4-triazoline-3,5-dione (PTD) was identified as a novel protein cross-linker, and utilized as a conformational probe of phosphorylase b kinase (PhK), a hexadecameric enzyme with the subunit composition (alphabetagammadelta)4. In its reaction with this enzyme, PTD produced five major cross-linked conjugates as resolved by denaturing gel electrophoresis: alphabeta, betagammagamma, alphagamma and a doublet of differently migrating homodimers, betabeta1 and betabeta2. Cross-linking in the presence of six different activators of the kinase targeted to its various subunits caused substantial changes in the amounts of three of the conjugates. The formation of alphagamma was increased by all of the activators but the largest enhancement was caused by exogenous Ca2+/calmodulin. All except one of the activators decreased the amount of betagammagamma formed, with Mg2+ having the greatest effect, and all except two increased the amount of betabeta1, with Mg2+ again having the largest influence. From the overall similarity of the changes in cross-linking by PTD induced by the various activators, we conclude that, even though they are targeted to different sites and subunits, they induce activated conformations of PhK that have certain structural features in common. Regarding the mechanism of cross-linking by PTD, its reaction with a model nucleophile suggests that its initial reaction with a side chain nucleophile of PhK involves a 1,4-conjugate addition to form a urazole adduct, with the secondary cross-linking reaction occurring through an as yet unknown pathway.

The inhibitory effects of N omega-nitro-L-arginine methyl ester on nitric oxide synthase activity vary among brain regions in vivo but not in vitro.

We studied the effects of intracerebroventricular and intraperitoneal injection and the in vitro effects of N omega-nitro-L-arginine methyl ester (L-NAME), an inhibitor of nitric oxide synthase, on the nitric oxide synthase activities of the cerebellum, brainstem, hypothalamus, hippocampus, and the remainder of the brain after dissections. Male rats were chronically implanted with lateral icv guide cannula. L-NAME was injected in doses of 0.2, 1, and 5 mg intracerebroventricularly, and 50 mg/kg intraperitoneally. L-NAME induced dose-dependent suppression of NOS activities in each brain region. The threshold dose was 0.2 mg; 1 mg L-NAME completely abolished brain nitric oxide synthase activity 90 min after the injection. Brain NOS activities returned to baseline level 48 h after the injection of 5 mg L-NAME. There were significant differences between the sensitivity of various regions to L-NAME after in vivo but not in vitro administration of the enzyme inhibitor. These findings indicate that intracerebroventricular injection of L-NAME is a useful tool for inhibiting brain nitric oxide synthase activities in vivo. The differences between the sensitivity of different brain regions to L-NAME as well as the relative fast recovery of nitric oxide synthase activities must be taken into account when L-NAME is administered intracerebroventricularly to rats.

Circadian variation of nitric oxide synthase activity and cytosolic protein levels in rat brain.

The circadian variation of nitric oxide synthase (NOS) activity and cytosolic protein content in the cerebellum, brainstem, hypothalamus, hippocampus, and the remainder of the brain were studied in rats. Both NOS activity and cytosolic protein concentrations were the highest during the dark period and lowest in the light period. Hypothalamic NOS activity exhibited the most pronounced change in activity with time increasing by approximately 120% from mid-light to mid-dark.

Hospital selection of home infusion therapy companies as preferred providers.

The process by which a hospital selected home infusion therapy providers is described. Administrators at a 379-bed teaching hospital decided to attempt to reduce the high mean length of stay by expanding the use of home infusion therapy. Direct diversification into this field by the hospital was not feasible, so it was decided to establish contractual agreements with providers. A task force was appointed to evaluate and choose vendors in the area and to increase the number of patient referrals. The task force examined reports on past experience with providers, price lists, the range and level of services offered, and the amount of free care given and visited the companies' facilities. The group designated three providers as preferred and two as unacceptable. The number of patients referred increased from 21 during the 12 months before the task force was convened to 46 in the first 9 months afterward, for a saving of 2198 patients days. After one year the task force met again to consider company requests for evaluation or reevaluation, establish a plan for publicizing the benefits of home infusion therapy, and replace the site visits with a requirement for accreditation by the Joint Commission. After two years, the task force developed provider-evaluation criteria to streamline the process and reflect the experience gained. The responsibility for reviewing providers was transferred to the P&T committee. When a direct venture into home infusion therapy is not fiscally desirable, contracting for services can still offer the advantages of reduced length of stay and decreased drug expenses.