Refeeding Syndrome in the Critically Ill: a Literature Review and Clinician's Guide.

PURPOSE OF REVIEW: To provide an overview of current methods of diagnosis and management of refeeding syndrome in the critically ill patient population. RECENT FINDINGS: Despite recent publications indicating refeeding syndrome (RFS) is an ongoing problem in critically ill patients, there is no standard for the diagnosis and management of this life-threatening condition. There is not a "gold standard" nutrition assessment tool for the critically ill. Currently, the National Institute for Health and Clinical Excellence criteria represent the best clinical assessment tool for RFS. Diagnosis and management with the help of a multidisciplinary metabolic team can decrease morbidity and mortality. Although a universal definition of RFS has yet to be defined, the diagnosis is made in patients with moderate to severe malnutrition who develop electrolyte imbalance after beginning nutritional support. The imbalances potentially can lead to cardiac, pulmonary, and gastrointestinal complications and failure. Standardizing a multidisciplinary nutrition care plan and formulating a protocol for critically ill patients who develop RFS can potentially decrease complication rates and overall mortality.

Stimulation of the rat subthalamic nucleus is neuroprotective following significant nigral dopamine neuron loss.

Deep brain stimulation of the subthalamic nucleus (STN-DBS) is efficacious in treating the motor symptoms of Parkinson's disease (PD). However, the impact of STN-DBS on the progression of PD is unknown. Previous preclinical studies have demonstrated that STN-DBS can attenuate the degeneration of a relatively intact nigrostriatal system from dopamine (DA)-depleting neurotoxins. The present study examined whether STN-DBS can provide neuroprotection in the face of prior significant nigral DA neuron loss similar to PD patients at the time of diagnosis. STN-DBS between 2 and 4 weeks after intrastriatal 6-hydroxydopamine (6-OHDA) provided significant sparing of DA neurons in the SN of rats. This effect was not due to inadvertent lesioning of the STN and was dependent upon proper electrode placement. Since STN-DBS appears to have significant neuroprotective properties, initiation of STN-DBS earlier in the course of PD may provide added neuroprotective benefits in addition to its ability to provide symptomatic relief.

A qualitative evaluation of medical student learning with concept maps.

PURPOSE AND AIMS: The purpose of this study was to investigate the ways in which the use of concept maps influenced the learning processes of third year internal medicine students in the context of medical education. Reported here are the qualitative results of this study. METHODS: One-hundred thirty four medical students were taught to use concept mapping as a learning strategy at the beginning of their internal medicine rotations. Upon completion of the internal medicine rotation students were asked to evaluate how concept maps fostered the process of linking theoretical information to clinical practice. Additionally, students described how concept maps impacted their learning. RESULTS: In this study, concept maps fostered a positive connection between theory and practice. Additionally, students described three major themes impacting their learning: concept mapping as a facilitator of knowledge integration and critical thinking, as a teaching methodology and finally, as a learning method. CONCLUSIONS: This study suggests concept maps may be an instructional method to foster the learning and thinking process of medical students.

Wear debris from hip or knee replacements causes chromosomal damage in human cells in tissue culture.

Wear debris was extracted from 21 worn hip and knee replacements. Its mutagenic effects were tested on human cells in tissue culture using the micronucleus assay and fluorescent in situ hybridisation. The extracted wear debris increased the level of micronuclei in a linear dose-dependent manner but with a tenfold difference between samples. The concentration of titanium +/- vanadium and aluminium within the wear debris was linearly related both to the level of centromere-positive micronuclei in tissue culture, indicating an aneuploid event, and to the level of aneuploidy in vivo in peripheral blood lymphocytes. The concentration of cobalt and chromium +/- nickel and molybdenum in the wear debris correlated with the total index of micronuclei in tissue culture, both centromere-positive and centromere-negative i.e. both chromosomal breakage and aneuploidy events. The results show that wear debris can damage chromosomes in a dose-dependent manner which is specific to the type of metal. The results from studies in vitro correlate with those in vivo and suggest that the wear debris from a worn implant is at least partly responsible for the chromosomal damage which is seen in vivo.

Eicosapentaenoic acid and gamma-linolenic acid induce apoptosis in HL-60 cells.

Enteral nutrition with eicosapentaenoic acid (EPA; 20:5 n-3) and gamma-linolenic acid (GLA; 18:3 n-6) decreased pulmonary inflammation by reducing neutrophil counts and chemotactic factors in bronchoalveolar lavage fluid during acute respiratory distress syndrome (ARDS). We hypothesize that the anti-inflammatory effects of EPA and GLA may be due, in part, to induction of neutrophil apoptosis. The purpose of this study was to determine whether EPA and GLA, alone or in combination, trigger apoptotic cell death in the human promyelocytic leukemia HL-60 cell line. HL-60 cells were incubated with 10, 20, 50, and 100 micromol/L EPA, GLA, or various combinations of EPA and GLA for 2, 4, 8, 12, and 24 hs. Oleic acid (18:1 n-9) was used as a fatty acid control. Flow cytometry using dual staining with propidium iodide and annexin V-FITC assessed apoptosis, necrosis, and viability. Apoptosis was verified by DNA fragmentation as assessed by agarose gel electrophoresis. EPA, GLA, and various combinations of EPA and GLA significantly induced apoptosis and reduced cell viability in HL-60 cells. Viability was significantly reduced to the same extent with the combination of 50 micromol/L EPA\20 micromol/L GLA compared with 100 micromol/L EPA. These data indicate that EPA and GLA, alone or in combination, reduce cell survival by induction of apoptosis. Thus, induction of apoptosis by select dietary n-3 (EPA) and n-6 (GLA) polyunsaturated fatty acids may be the mechanism of the resolution of pulmonary inflammation in ARDS.

Influence of preoperative computed tomography on patients undergoing appendectomy.

The frequency of computed tomography (CT) ordered by emergency department physicians at our facility was noted to sharply increase in early 1998 after a New England Journal of Medicine (NEJM) article recommending routine CT in patients with suspected appendicitis. Numerous studies have proven the accuracy of CT for detecting acute appendicitis; however, the most appropriate use of CT continues to evolve. We sought to evaluate the effect of increased CT use on negative appendectomy rate and perforation rate at our institution and to better delineate in whom CT is most beneficial. CT use was retrospectively evaluated and found to sharply increase in April 1998. The authors then reviewed the medical records of 291 consecutive patients undergoing appendectomy 18 months before and after the NEJM article. Patients with interval appendectomies and those 12 years of age or younger were excluded. The remaining 226 patients constitute the study cohort. The study cohort was then divided into the two groups. The "Discriminate Group" consists of patients from the 18 months before the NEJM article impact and a period of selective CT use. The "Indiscriminate Group" comprises patients from the subsequent 18 months in which CT use was substantially higher and routinely obtained before surgical evaluation. After chart review an objective clinical score (Alvarado score) was assigned to each patient. Comparison was then made between the two groups on perforation rate, negative appendectomy rate, time delay to operating room, and Alvarado score. Additionally patients undergoing preoperative CT were compared with those without CT. These groups were also evaluated on the basis of negative appendectomy rate, perforation rate, and delay to the operating room. CT in patients with abdominal symptoms associated with appendicitis increased from 188 in the Discriminate Group to 1035 in the Indiscriminate Group. In the Discriminate Group the negative appendectomy rate was 15.1 per cent. After the indiscriminate use of CT the negative appendectomy rate decreased to 13.3 per cent, but this was not significant. Males experienced a decrease in the negative appendectomy rate from 10.1 to 6.9 per cent, whereas the rate for females increased slightly from 21.3 to 22.9 per cent. Again we found no statistical significance in these changes. The overall perforation rate of 17.9 per cent in the first 18 months decreased to 13.3 per cent in the following 18 months but again was not statistically significant. The Alvarado scores between the Discriminate and Indiscriminate groups were 6.7 and 7.3, respectively (P = 0.02). Patients with preoperative CT averaged 11.9 hours to the operating room compared with 6.5 hours for those without CT (P = 0.03). Use of CT did not decrease perforation rate but did globally reduce negative exploration (P = 0.05). This reduction in negative exploration however was not discriminated by sex. CT use in suspected acute appendicitis has greatly increased over the past several years. The dramatic increase in CT use at our institution has not resulted in dramatic decreases in negative appendectomy rate or statistically significant changes in perforation rate. The optimal use of CT in evaluating patients with suspected appendicitis has yet to be determined. Surgical consultation should be obtained early to avoid indiscriminate tests.

Does alcohol intoxication alter the assessment and outcome of "observation-status" trauma patients?

We assessed the effect of blood alcohol concentration (BAC) on the evaluation, outcome, and hospital charges of our observation-status trauma patient population. We conducted a retrospective study over 18 months; any patient initially admitted with <24-hour observation status, Glasgow Coma Score of 15, and negative drug screen was eligible. Patients were divided on the basis of BAC (BAC+ = >80 mg/dL; BAC- = <80 mg/dL). Two hundred twenty-six patients were observed during the study (2765 admissions). For the 66 BAC+ patients (range 90-392 mg/dL) there was a strong male predominance. There was no difference in diagnostic evaluation schema, delayed diagnosis, complications, cost, or conversions to full admission between the groups. We conclude that evaluation, outcome, and charges of observation trauma patients are the same regardless of BAC. Intoxication did not mask injury; therefore BAC+ patients do not require observation on the sole basis of intoxication if their evaluation is otherwise negative.

Role of duodenography in the diagnosis of blunt duodenal injuries.

BACKGROUND: The differentiation of duodenal perforation from duodenal hematoma is not always possible with computed tomography (CT). Our diagnostic guideline has included duodenography to investigate CT findings of periduodenal fluid or wall thickening. However, the utility of duodenography as a diagnostic study in blunt abdominal trauma is not defined. We evaluated duodenography as a diagnostic test in patients with suspected blunt duodenal injuries (BDIs). METHODS: During a 10-year period, 96 patients out of 25,608 trauma admissions had CT findings of possible BDI and underwent duodenography. Demographic and clinical data, diagnostic methods, and management were derived from prospectively collected data. CT and duodenography studies were reviewed and correlated with surgical findings and outcome. All CT scans were obtained with intravenous contrast; oral contrast was used in 32 patients. Duodenography was analyzed using the 2 x 2 method and Bayes theorem. RESULTS: Indications for duodenography included periduodenal fluid without extravasation (76%), abnormal duodenal wall thickening (16%), and retroperitoneal extraluminal gas (5%). Eighty-six duodenography studies were reported as normal, six were consistent with hematoma, one was indeterminate, and only three revealed extravasation. Two of these three patients with duodenal perforation had retroperitoneal extraluminal air. Only one patient underwent exploration on the basis of duodenography. No blunt duodenal perforation was diagnosed by CT. Overall, duodenography had sensitivity of 54% and specificity of 98%. For BDIs requiring repair, duodenography sensitivity was only 25%; the false-negative rate was also 25%. Retroperitoneal extraluminal air was a useful sign of duodenal perforation, occurring in two of three patients with BDI and only in one without BDI (p < 0.001). CONCLUSION: Duodenography has a low sensitivity in patients with suspected BDI by CT findings and is of minimal utility in diagnostic evaluation. Retroperitoneal extraluminal air seen on CT is an important sign of BDI requiring surgical repair.

Outcome of the current management of splenic injuries.

BACKGROUND: For patients > 55 years, nonoperative management (NOM) of blunt splenic injury remains controversial. Conflicting reports of excessively high or acceptably low failure rates have discouraged widespread application of NOM in these older patients. However, the small number of patients in these studies limits the impact of their conclusions. METHODS: We manage splenic injury nonoperatively in all appropriate patients without regard to age. We present the largest series of patients > 55 years who have been managed nonsurgically, in a retrospective review of all patients with blunt splenic injury admitted to our trauma center between 1996 and 1999. RESULTS: In 4 years, 542 patients were admitted with blunt splenic injury. Eighty-three patients were > 55 years, and 61 of these patients underwent NOM. Seven older patients failed NOM and required delayed splenectomy, yielding a failure rate of 11.4%. This failure rate was statistically equivalent to the 7% failure rate of patients < 55 years. This study has a power of 80% to detect a failure rate change from 7% to 20%. By multivariate analysis, the only factor that significantly increased the risk of NOM failure was splenic injury grade. Patients > 55 years had a higher mortality than younger patients regardless of NOM/operative treatment. Splenic injury did not directly cause any of the deaths in patients > 55 years who had NOM or failure of NOM. High-grade splenic injuries fail NOM in those > 55 years. CONCLUSION: Nonoperative management of lower grade splenic injuries in patients > 55 years can be accomplished with an acceptably low failure rate. Only grade of splenic injury, not patient age, increases the risk of NOM failure.

Learning in clinical nursing practice.

In this study, a qualitative interpretivist perspective was used to analyze the following research question: How does clinical nursing practice facilitate learning? Forty nurses working in acute care, long-term care, and home care were interviewed about their clinical practice experiences and the learning that resulted. Data were analyzed using a constant comparative method. Study results indicate that clinical nursing practice facilitates both personal and professional development of nurses by fostering an examination of the concepts of self-respect, hope, control, vulnerability, acceptance, loss, and persistence. Implications for continuing educators and staff development instructors are drawn.

Oligodendrocyte-type 2 astrocyte-derived trophic factors increase survival of developing dopamine neurons through the inhibition of apoptotic cell death.

Survival of embryonic dopamine (DA) neurons is extremely low (5-20%) following transplantation. Strategies to increase this survival are critical to the future of transplantation for Parkinson's disease. We demonstrate here that a factor(s) released from striatal oligodendrocyte-type 2 astrocytes (SO2A) greatly improves the survival and phenotype expression of mesencephalic DA neurons in culture while simultaneously decreasing the presence of apoptotic nuclear profiles, as detected by the TUNEL method and bisbenzamide/tyrosine hydroxylase double labeling. This SO2A-derived trophic factor(s) has minimal effects on glia and no effect on nondopaminergic mesencephalic neurons. The developmental period during which this SO2A trophic effect occurs (E14-18) coincides with the period when mesencephalic grafts are undergoing the highest rates of apoptosis, i.e., immediately following implantation. Therefore, SO2A-derived trophic factor(s) offers great potential for the augmentation of grafted DA neuron survival.

Is routine roentgenography needed after closed tube thoracostomy removal?

BACKGROUND: Efficacy of chest radiograph protocol after tube thoracostomy tube (CT) removal. METHODS: Retrospective review (July of 1995 to July of 1996) of 141 patients with CT followed throughout their hospitalization. Excluded patients died (23 patients) or had thoracotomy (13 patients) before CT removal. RESULTS: A total of 105 patients had 113 CT removed (mean age, 36.9 years; Injury Severity Score = 23.4; CT duration, 5.0 days). Protocol chest radiographs were performed on average at 7.9 and 22.1 hours. Recurrent pneumothorax (RHPTX = new interpleural air) occurring in 12 patients (11%) and persistent pneumothorax (PHPTX = same volume of interpleural air) occurring in 13 patients (12%) caused no clinical problems and were treated without tube replacement. Three patients had symptoms after removal; none had RHPTX. Two patients had clinical signs; one reaccumulated a hemothorax requiring CT replacement, the other improved without replacement. CONCLUSIONS: Clinically significant RHPTX/PHPTX after CT removal is infrequent. Signs not symptoms detect CT removal complications. At our institution, chest radiographs are obtained in a delayed manner from protocol and offer no benefit over clinical assessment.

Diminished viability, growth, and behavioral efficacy of fetal dopamine neuron grafts in aging rats with long-term dopamine depletion: an argument for neurotrophic supplementation.

We examined the behavioral and morphological correlates of the response to a single intrastriatal dispersed cell graft of fetal rat ventral mesencephalic tissue in male Fischer-344 rats of varying age (4, 17, and 24-26 months old) and history of mesostriatal dopamine (DA) depletion (1 or 14 months). Our goal was to determine the impact of advancing age and duration of DA depletion in the host on DA graft viability and function. The findings can be summarized as follows. (1) Fetal DA neuron grafts that were effective in completely ameliorating amphetamine-induced rotational behavior in young rats with short-term lesions were virtually without effect in aged rats with long-term lesions. Middle-aged rats with long-term lesions responded to these grafts with partial behavioral recovery. (2) Age of the host at the time of transplantation, and not duration of DA depletion, was the primary determinant of response to DA grafts. (3) Diminished efficacy of grafts in lesioned aging rats was related to decreased survival and neurite extension of transplanted DA neurons. (4) Co-grafts of DA neurons with Schwann cells as a source of neurotrophic support improved the behavioral outcome of grafts in aged lesioned rats. These findings support the view that the DA-depleted striatum of aged rats is an impoverished environment for survival, growth, and function of DA grafts. Consistent with this view, local supplementation of the neurotrophic environment of grafted DA neurons with products of co-grafted Schwann cells, a demonstrated source of neurotrophic activity for embryonic DA neurons, improved graft outcome.

Concept maps: a strategy to teach and evaluate critical thinking.

The purpose of this article is to describe a study that implemented concept maps as a methodology to teach and evaluate critical thinking. Students in six senior clinical groups were taught to use concept maps. Students created three concept maps over the course of the semester. Data analysis demonstrated a group mean score of 40.38 on the first concept map and 135.55 on the final concept map, for a difference of 98.16. The paired t value comparing the first concept map to the final concept map was -5.69. The data indicated a statistically significant difference between the first and final maps. This difference is indicative of the students' increase in conceptual and critical thinking.

Developing collaborative partnerships in continuing nursing education: walking the talk.

The purpose of this article is to describe and analyze a reciprocal partnership developed among four university-based continuing education providers in Wisconsin. Members of this partnership collaborated in developing a statewide program to address the educational needs of nurses moving from acute or long-term care into community nursing. Components of the reciprocal partnership model were applied in developing this program. The partners identified that, despite the initial time investment, the collaborative approach was an advantage. The collaborative approach enhanced the quality of the program developed and reached a wider audience. Continuing nursing educators may want to consider partnership arrangements for program development and implementation.

Family perspectives on dying in long-term care settings.

Dying is a central experience in the life of a family. Yet there are few studies of dying in long-term care and the role of a family. The dynamic relationships among families, staff, and residents in long-term care facilities related to the process of dying is an area where research is needed. As part of a larger study of death and dying in long-term care settings, 11 family members who recently had experienced the loss of a relative in the long-term care setting were interviewed. The purpose of this study was to describe family perspectives on death and dying in long-term care facilities and to discuss ways staff may be helpful to families in coping with the loss of a family member. Analyzing death and dying from the family perspective offers health care providers an opportunity to expand the understanding of the phenomenon of death in long-term care facilities and to incorporate care activities that families view as helpful. Major themes emerged from this study, including the caring behaviors of staff, participating in the dying process, and providing spiritual support. The themes and practice implications are discussed in this article.

Attachment/detachment: forces influencing care of the dying in long-term care.

Death occurs among older adults in institutions more often than at home with family and friends. The older people are, the more likely they are to die in a nursing home. The purpose of this study was to describe staff and administrator's perspectives on death and dying in long-term care and to explore problems in providing humane care to dying residents that fosters gentle closure to life. Using focus group interviews as the primary data collection method, 22 focus group sessions were conducted in 11 nursing homes. Separate group sessions were held for staff and administrators in the nursing homes. The core variable identified in this study was the attachment of staff to residents in long term care. Attachment enhanced the quality of terminal care and fostered a gentle closure to life. Mediating forces influencing the process of attachment were identified as individual forces, as well as forces internal and external to the nursing home.

Therapeutic touch, nursing practice and contemporary cutaneous wound healing research.

The nursing profession is and always has been at the cutting edge of research and development into innovative and effective methods to treat, manage and enhance wound regeneration. One such method which was developed specifically for nursing science is a non-invasive, easily administered technique known as therapeutic touch (TT). Although there have been numerous anecdotal reports over the last two decades attesting to the efficacy of TT for cutaneous wounds, there have been only five experimental studies to date which have examined the phenomena in a scientifically rigorous manner. These five studies utilized randomized, double-blind, placebo controlled protocols to analyse the effect of an experimental derivative of TT-non-contact therapeutic touch (NCTT)-on the healing rate of surgically administered full thickness human dermal wounds. The experiments introduced many original concepts and approaches to healing research and nursing practice. The data from the five studies indicated a statistically significant accelerated rate of wound healing for the treatment group in the initial two experiments, and non-significant and reverse significant effects for the remaining three studies. Although, experimentally, these results are far from impressive, clinically, the significant results of the first two experiments should be enough to encourage the nurse clinician to explore and utilize a similar non-invasive TT treatment method for patients with dermal lacerations. While the results of the studies were inconsistent overall, the series of experiments nonetheless significantly expanded the theoretical boundaries and understanding of the TT process and, due to the rigorous, double-blind methodological protocols used, have established the critical groundwork and guidelines for future nursing science research in the area.

Creating mosaics: the interrelationships of knowledge and context.

This qualitative interpretivist study analyzed the interrelationships between the knowledge gained through continuing nursing education programs and the context of nurses' clinical practice. The content of nursing continuing education programs offered 9-12 months previously was reviewed. Forty semi-structured, tape-recorded interviews were conducted with nurses from hospitals, nursing homes and home care agencies to determine their use of this new knowledge. Findings indicate that nurses used information from continuing education programs to construct a knowledge base and that this process was affected by the structural, human resources, political and symbolic frames of the context in which nurses practice.