Identifying Critically Ill Veterans Who Require Nutrition Intervention: A Quality Improvement Study Comparing Nutrition Risk Tools.

BACKGROUND: Identification of intensive care unit (ICU) patients who require nutrition intervention is crucial to initiating nutrition therapy. This prospective quality improvement study evaluated the Nutritional Risk Screening (NRS) 2002, Malnutrition Universal Screening Tool (MUST), and Nutrition Risk in Critically Ill (NUTRIC) score in comparison with the Veterans Administration Nutrition Status Classification (VANSC) tool to determine which best identified the need for nutrition intervention. METHODS: A convenience sample of 150 ICU patients was evaluated using the VANSC, NRS 2002, MUST, and the NUTRIC score. The resultant score, need for nutrition intervention, and presence of malnutrition were recorded for patients. Interventions were defined as need for enteral or parenteral nutrition, nutritional supplements, or diet change. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), Matthews Correlation Coefficient (MCC), F1 score, and accuracy to predict need for nutrition intervention were calculated for each screening tool. RESULTS: Of the 150 patients, 49 (33%) required 1 or more nutrition interventions. The NRS 2002 (0.878) and VANSC (0.816) had the highest sensitivity. The NUTRIC (0.921) and VANSC (0.911) had the highest specificity. The VANSC (0.816) and MUST (0.687) had the highest PPV. The VANSC (0.911) and NRS 2002 (0.872) had the highest NPV. The VANSC (0.727) and MUST (0.528) had the highest MCC. The VANSC (0.816) and MUST (0.680) had the highest F1 score. CONCLUSIONS: Trialing several tools to identify their efficacy and reliability individual setting may help determine the most appropriate tool to utilize for your patient population and specific goals.

GluA4 subunit of AMPA receptors mediates the early synaptic response to altered network activity in the developing hippocampus.

Development of the neuronal circuitry involves both Hebbian and homeostatic plasticity mechanisms that orchestrate activity-dependent refinement of the synaptic connectivity. AMPA receptor subunit GluA4 is expressed in hippocampal pyramidal neurons during early postnatal period and is critical for neonatal long-term potentiation; however, its role in homeostatic plasticity is unknown. Here we show that GluA4-dependent plasticity mechanisms allow immature synapses to promptly respond to alterations in network activity. In the neonatal CA3, the threshold for homeostatic plasticity is low, and a 15-h activity blockage with tetrodotoxin triggers homeostatic upregulation of glutamatergic transmission. On the other hand, attenuation of the correlated high-frequency bursting in the CA3-CA1 circuitry leads to weakening of AMPA transmission in CA1, thus reflecting a critical role for Hebbian synapse induction in the developing CA3-CA1. Both of these developmentally restricted forms of plasticity were absent in GluA4(-/-) mice. These data suggest that GluA4 enables efficient homeostatic upscaling and responsiveness to temporal activity patterns during the critical period of activity-dependent refinement of the circuitry.

Second-line and third-line chemotherapy for lung cancer: use and cost.

OBJECTIVES: To identify commonly prescribed first-, second-, and third-line chemotherapy regimens for persons with lung cancer and to evaluate the utilization patterns and costs of care associated with receiving these regimens. STUDY DESIGN: Retrospective data analysis. METHODS: Using health insurance claims from January 1, 2002, through December 31, 2006, patients with lung cancer were identified by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis codes. An algorithm was developed to identify first-, second-, and third-line chemotherapy. Patients were stratified by the number of discrete regimens received or by their specific chemotherapy agent or combination of agents. Data were analyzed for up to 2 years from the date of the initial first-line regimen and for 1 year from the second and third lines. Patient costs were based on total reimbursements for each group during the observation period. RESULTS: Of patients receiving first-line chemotherapy, 25% and 10% received second-line and third-line chemotherapy, respectively. Docetaxel, gefitinib, and erlotinib hydrochloride were the most commonly prescribed second-line regimens; gefitinib and docetaxel were the most commonly prescribed third-line regimens. The most commonly prescribed second- and third-line agents changed substantially over time. Total costs and costs per patient per month increased as the number of lines of chemotherapy prescribed increased. CONCLUSIONS: Second- and third-line chemotherapy is prescribed infrequently, and patterns of prescribing are changing over time. Direct medical care costs increase substantially with additional lines of therapy.

Susceptibility for homeostatic plasticity is down-regulated in parallel with maturation of the rat hippocampal synaptic circuitry.

Homeostatic regulation, i.e. the ability of neurons and neuronal networks to adjust their output in response to chronic alterations in electrical activity is a prerequisite for the pronounced functional plasticity in the developing brain. Cellular mechanisms of homeostatic plasticity have mainly been studied in cultured preparations. To understand the developmental time frame and properties of homeostatic plasticity under more physiological conditions, we have here compared the effects of activity deprivation on synaptic transmission in acutely isolated and cultured hippocampal slices at different stages of development. We find that transmission at both glutamatergic and GABAergic synapses is strongly and rapidly (15 h) regulated in the opposite directions in response to inactivity during narrow, separated time windows early in development. Following this critical period of synaptic development, induction of the homeostatic response requires longer periods (40 h) of inactivity. At glutamatergic synapses, activity blockade led to an increase in the amplitude and frequency of mEPSCs, and the threshold for induction of this response was increased during development. In contrast, homeostatic regulation at GABAergic synapses was expressed in a qualitatively distinct manner at different developmental stages. Immature neurons responded rapidly to inactivity by regulating mIPSC frequency, while longer activity blockade led to a decrease in the mIPSC amplitude independent of the neuronal maturation. The susceptibility of immature networks to homeostatic regulation may serve as a safety mechanism against rapid runaway destability during the time of intense remodelling of the synaptic circuitry.

Clinical judgement and information seeking by nurses and physicians working with cancer patients.

This study examined and compared the processes of information collection and clinical judgement by nurses (n=107) and physicians (n=27) working with cancer patients. The data was collected in two university hospitals by means of a computer-simulated case description and the thinking-aloud method. Data interpretation was based on SPSS statistical software and the method of content analysis. Statistical differences between the two groups were tested with non-parametric Kruskal-Wallis Anova or the Mann-Whitney U-test. The Wilcoxon test was applied in pairwise comparisons. Independent questions were analysed by cross-tabulation and Pearson's chi(2). According to the results nurses and physicians apply different approaches to clinical judgement and problem-solving. On the basis of the status statement they received in the program both groups pointed to similar problems and sought a great deal of additional information. However the type of information required was different in the two groups. There were also significant differences in the knowledge base applied for purposes of clinical judgement: nurses tended to rely on personal knowledge, physicians on theory. Physicians were able to identify their patient's major clinical problems, but nurses had more difficulty doing this. On the other hand, nurses took a broader view on the general well-being of patients than physicians did.

Synaptic activation of a presynaptic kainate receptor facilitates AMPA receptor-mediated synaptic transmission at hippocampal mossy fibre synapses.

The development of GluR5-selective kainate receptor ligands is helping to elucidate the functions of kainate receptors in the CNS. Here we have further characterised the actions of a GluR5 selective agonist, ATPA, and a GluR5 selective antagonist, LY382884, in the CA3 region of rat hippocampal slices. In addition, we have used LY382884 to study a novel synaptic mechanism. This antagonist substantially reduces frequency facilitation of mossy fibre synaptic transmission, monitored as either AMPA or NMDA receptor-mediated EPSCs. This suggests that GluR5-containing kainate receptors on mossy fibres function as autoreceptors to facilitate the synaptic release of L-glutamate, in a frequency-dependent manner.

A critical role of a facilitatory presynaptic kainate receptor in mossy fiber LTP.

The mechanisms involved in mossy fiber LTP in the hippocampus are not well established. In the present study, we show that the kainate receptor antagonist LY382884 (10 microM) is selective for presynaptic kainate receptors in the CA3 region of the hippocampus. At a concentration at which it blocks mossy fiber LTP, LY382884 selectively blocks the synaptic activation of a presynaptic kainate receptor that facilitates AMPA receptor-mediated synaptic transmission. Following the induction of mossy fiber LTP, there is a complete loss of the presynaptic kainate receptor-mediated facilitation of synaptic transmission. These results identify a central role for the presynaptic kainate receptor in the induction of mossy fiber LTP. In addition, these results suggest that the pathway by which kainate receptors facilitate glutamate release is utilized for the expression of mossy fiber LTP.

Attitudes of patients with breast and prostate cancer toward complementary therapies in Finland.

This study aimed to describe the attitudes of patients with breast cancer and those with prostate cancer toward complementary therapies. The data were collected with a postal questionnaire administered to 216 patients with breast cancer (response rate, 55.4%) and 1 90 patients with prostate cancer (response rate, 54.9%) in southern and southwestern Finland. The questionnaire was composed of 44 Likert-type statements, which were analyzed using descriptive statistics, chi2 tests, t tests, and two-way analyses of variance. More than half (54%) of the patients with breast cancer and 45% of the patients with prostate cancer believed that people with cancer may benefit from complementary therapies, although they did not think these therapies actually could cure cancer. More than half of the respondents were dubious about using complementary therapies as long as there was no solid scientific evidence. Most believed that complementary therapies were used because they gave people hope (women, 88%; men, 72%) or "something to cling to" (women, 83%; men, 76%). The respondents believed most in dietary therapies and least in healing. There was much confusion and uncertainty about the professional competencies and expertise of the people who provided complementary therapies. Approximately one fourth of the respondents had spoken to their physician about complementary therapies. Only a few had talked about the matter with nursing staff. About half of the respondents thought that physicians and nurses took a negative attitude toward complementary therapies. In both groups, patients who had talked with their physician about complementary therapies tended to show a more positive attitude.

Post-insult activity is a major cause of delayed neuronal death in organotypic hippocampal slices exposed to glutamate.

We investigated the pathophysiological mechanisms of glutamate-induced delayed neuronal damage in rat hippocampal slice cultures [Stoppini et al. (1991) J. Neurosci. Methods 37, 173-182], with propidium iodide as a marker of cell death. Exposure of the cultures to growth medium containing 10 mM glutamate for 30 min resulted in a slowly developing degeneration of hippocampal principal cells, starting from the medial end of the CA1 region and reaching the dentate gyrus by 48 h. By 24 h, most pyramidal cells in CA1 were damaged. An acute phase of degeneration preceded the delayed damage at 2-6 h, affecting cells in a spatially diffuse manner. When tetrodotoxin (0.5 microM) was present during the glutamate insult, a marked protection (mean 57%, P<0.001) of the CA1 damage was observed. Rather strikingly, when tetrodotoxin was applied immediately following or even with a delay of 30 min after the insult, a similar amount of protection was achieved. In field recordings carried out after the insult, the glutamate-treated slices exhibited spontaneously occurring negative shifts with a duration of 1-10 s and an amplitude of up to 400 microV in the CA3 region, whereas the control slices were always quiescent. Taken together, the results suggest that post-insult neuronal network activity, rather than the direct action of exogenous glutamate, is a major cause of delayed CA1 pyramidal cell death in the organotypic slices. These observations may have implications in the design of neuroprotective strategies for the treatment of brain traumas which are accompanied by delayed and/or distal neuronal damage.

Patient participation in decision making about care.

The purpose of this study was to find out how cancer patients perceive patient participation in decision-making and to see which factors in their view facilitate and restrict participation. Data were collected in focus group interviews with 25 patients, most of whom had breast cancer. Data interpretation was based on the method of qualitative content analysis. The results showed that patients, nurses and physicians all play a part in terms of how patients participate in decision-making. Patients defined participation in decision-making in terms of asking questions, obtaining/providing information and choosing from/presenting different alternatives. Among the factors that were thought to promote participation in decision-making were the patient's activity, the presence of a primary nurse/physician, the encouragement of nurses and physicians to participate, the treatment of patients as equals, and nurses and physicians having enough time for patients. As for factors hindering participation in decision-making, reference was made to patient ignorance, physical and mental imbalance and shyness on the part of the patient. Obstacles to participating in decision-making that originated in the nurses and physicians were the tendency for them to treat patients as objects, to fall in a routine, problems with information dissemination and lack of time.

Enhanced hippocampal long-term potentiation in mice lacking heparin-binding growth-associated molecule.

Heparin-binding growth-associated molecule (HB-GAM) (pleiotrophin) is a highly conserved extracellular matrix-associated protein implicated in a diverse range of developmental processes, including the formation and plasticity of neuronal connections. Using gene targeting, we have in the present study created HB-GAM-deficient mice that are viable and fertile and show no gross anatomical abnormalities. The hippocampal structure as well as basal excitatory synaptic transmission in the area CA1 appear normal in the mice lacking HB-GAM. However, hippocampal slices from HB-GAM-deficient mice display a lowered threshold for induction of long-term potentiation (LTP), which reverts back to the wild-type level by application of HB-GAM. HB-GAM expression in hippocampus is activity-dependent and upregulated in several neuropathological conditions. Thus, we suggest that HB-GAM acts as an inducible signal to inhibit LTP in hippocampus.

An exploratory study of clinical decision-making in five countries.

PURPOSE: To identify the cognitive processes nurses use in their decision-making in long- and short-term care settings in five countries, and the demographic variables associated with their decision-making. METHOD AND SAMPLES: The instrument used was a 56-item questionnaire that has been shown to be reliable in earlier studies. The sample consisted of five convenience samples of registered nurses working in either geriatric wards (n = 236) or acute medical-surgical wards (n = 223) in hospitals or nursing homes in Canada, Finland, Sweden, Switzerland, and the United States. FINDINGS: Five models of decision-making were identified on the basis of factor analysis. They represent both analytical and intuitive cognitive processes. Analytical cognitive processes were emphasized in information collection, problem definition, and planning of care, and intuitive cognitive processes were emphasized in planning, implementing, and evaluating care. Professional education, practical experience, field of practice, and type of knowledge were significantly associated with decision-making models as well as with country of residence of the participants. The highest proportion of analytically oriented decision-makers was found among nurses in long-term care, the decision-making of nurses in short-term care was more intuitively oriented. CONCLUSIONS: The results indicate that decision-making of participants varied from country to country and in different nursing situations. Future research should be focused on reasons for these differences, the relationship between the task and the nurses' type of knowledge, and how nurses use their knowledge to make decisions in different nursing situations.

Giving birth. Perceptions of Finnish childbearing women.

PURPOSE: To describe the lived experience of childbirth with women giving birth in Finland. DESIGN: Phenomenology. METHODS: Twenty Finnish women who had recently given birth were interviewed within 2 weeks following childbirth, sharing their perceptions of meaning of their childbirth experiences. Culturally appropriate strategies for qualitative data collection were employed. Trustworthiness of the data was ensured. RESULTS: The richness and diversity of the childbirth experience emerged from the data. One theme identified was a sense of awe at the creation of a new life within the context of birth as a bittersweet paradox. A strong sense of maternal confidence or self-efficacy was identified, which influenced the women's perception of and management of childbirth pain. Feelings of self-actualization were articulated as Finnish women successfully negotiated a challenging life event. CLINICAL IMPLICATIONS: Perinatal nurses should increase their sensitivity to the socio-cultural context of giving birth by acknowledging women's experiences as legitimate sources of knowledge.

Cancer patients' views and experiences of participation in care and decision making.

The purpose of this study was to explore the views and experiences of adult cancer patients about patient participation in care and decision making and the preconditions for this participation. The data were collected by means of focused interviews; in addition the patients completed depression and problem-solving instruments. The sample comprised 34 cancer patients from the haematological and oncological wards of one university hospital in Finland. The results revealed considerable variation in the patients' views on their participation in care and decision making. Some of the patients understood participation either in terms of contributing to the decision making or in terms of expressing their views on treatment options. Some considered that their participation in care was impossible. Patient participation in care and decision making was promoted by good health, access to information, assertiveness, good interactive relationships with nurses and physicians, and encouragement by nurses and physicians to participate. Factors restricting such patient participation were poor health, ignorance, anxiety, age, time pressures of staff, lack of time, high staff turnover and poor interactive relationships. With regard to participation in medical decision making, the patients were divided into three groups: (1) active participants (n = 7), (2) patients giving active consent (n = 9), and (3) patients giving passive consent to medical decisions (n = 18).

How relatives adjust after the death of a patient with cancer in hospice.

This study aims to discover (1) how relatives adjust to their new life situations following the death of a patient with cancer in hospice and (2) how those relatives have been supported by healthcare professionals both before and after the patient's death. The data were collected with a structured questionnaire administered to relatives of patients with cancer who died in a Finnish hospice in 1998 and 1999. The questionnaires were administered by the hospice staff to all family members who met the criteria specified (n = 589). The final sample comprised 258 family members, most of whom were the deceased patients' spouses. The Mann-Whitney U-test and the Kruskal-Wallis test were used to analyze the data. Instrument reliability was ascertained by the Cronbach alpha coefficient. The relatives had little difficulty accepting their new life situation and adjusting to their new role. The main factors affecting adjustment were being the patient's spouse and the age of both patient and relative. Relatives believed that they received a moderate amount of support from healthcare professionals, both before and after the patient's death. Most of the information they received concerned the patient's illness and treatment and daily condition. Communication was honest and based upon the relatives' needs. Emotional support before the patient's death consisted mainly of accepting the relative and listening to what relatives had to say.

Security associated with pregnancy and childbirth--experiences of pregnant women.

The aim of this study was to describe security associated with pregnancy and childbirth. Security was described as a human need and as human value. Data were collected in semi-structured interviews in two maternity health care clinics. Data interpretation was based on the method of content analysis. A convenience sample of 20 volunteer Finnish women was interviewed during pregnancy. The elements creating security associated with pregnancy and childbirth were maternity health care, social support, sense of control, and attitudes. The feeling of security was manifested in different resources, feelings and behavior. If the feeling of security associated with pregnancy and childbirth was impaired, the participants would resort to their network of social support, contact health care or social welfare services, or try to achieve a sense of security by their own resources. Feeling secure during pregnancy influences the pregnant woman's resources, feelings and behavior. It is important that professionals in maternity health care talk with the client about issues that influence her individually-experienced security associated with pregnancy and childbirth. These include examination of the client's network of social support and informing the client about the health care and social welfare services available.

Informational and emotional support for cancer patients' relatives.

The purpose of this study was to find out what cancer patients' relatives think about the actions of health care professionals in terms of providing informational and emotional support. The sample consisted of 168 relatives of patients from oncological wards all over Finland. The data were collected with a questionnaire specifically developed for this study. Non-parametric tests were used for statistical analysis. The results clearly highlighted the importance of informing relatives about the patient's illness. However, less than one-third of the relatives said they received much information. Relatives' need for emotional support was clearly at a lower level than their need for information. Even so, only very little support was provided in relation to relatives' needs.

High-frequency synaptic stimulation induces association of fyn and c-src to distinct phosphorylated components.

Signaling via tyrosine kinases appears necessary for regulation of synaptic efficacy. Interactions of the src-family kinases with phosphorylated proteins were studied in area CAI of rat hippocampal slices 10 min after induction of long-term potentiation (LTP) by 100 Hz/l s stimulation (HFS). HFS enhanced association of the src-family kinases fyn and c-src with an approximately 120 kDa tyrosine phosphorylated component containing the focal adhesion kinase (FAK) and its homologue PYK2. Association of fyn with FAK and of c-src with PYK2 was increased following the HFS. Further, increase in tyrosine phosphorylation of PYK2 was detected following the HFS. These results suggest that fyn and c-src are involved in distinct signaling pathways and provide evidence for activation of FAK and PYK2 following synaptic stimulation inducing LTP in vitro.

A description of birth in Finland.

The health care of women and children living in Finland is described. In the Finnish health care delivery system, perinatal health care is family centered, maximizing professional support through use of nurses in the delivery of primary care across the childbearing year and technological interventions are judiciously used based on evidence of efficacy.