Strategies for the nurse executive to keep the rural hospitals open

Rural hospitals are confronted with multiple challenges to survive in the competitive health care environment of today's world. Declining population, corporate mergers and downsizing, transportation, cost of technology, and health manpower shortages are only a few of the issues rural hospitals must be prepared to address in order to survive. Federal- and state-administered programs are available that can contribute to the survival of the rural hospital. The nurse executive has a key role in contributing to the planning, development, and implementation of survival strategies.     

Emergency open lung biopsy

Twenty-eight patients underwent open lung biopsy on an emergency basis. The clinical course in each case was deteriorating rapidly, and all were in respiratory failure. The correct diagnosis was established in 96% of the biopsies (27 of the 28 patients). The clinical diagnosis prior to biopsy was in error or incomplete in 15 (55%) of the patients. Specific therapy was lifesaving in 12 of the 28 patients. The value of the procedure outweighed the complications. Thrombocytopenia and positive end-expiratory pressure ventilation were not contraindications to biopsy.     

Peripheral airways as a determinant of ventilatory function in the human lung

We have investigated the morphological differences responsible for the variability in two tests of pulmonary function, maximal expiratory flow rates (MEF) and the frequency dependence of dynamic compliance (CDYN ratio). Functional measurements were obtained from 53 normal and minimally diseased postmortem human lungs. Morphological measurements performed on these same lungs included airway diameter at three levels in the bronchial tree, the amount of bronchial gland mass, and the alveolar surface to volume ratio. Multiple regression analysis suggests that the diameter of the peripheral conduction airways (membranous bronchioles) is the major morphological determinant for both MEF and the CDYN ratio in lungs at any particular age. Age-dependent changes in both functional tests were associated primarily with differences in the alveolar surface to volume ratio. Minimal emphysema and a lesion associated with cigarette smoking, respiratory bronchiolitis, have no demonstrable effect on either MEF or the CDYN ratio. These studies provide further evidence that the peripheral conducting airways are a major determinant of ventilatory function in the normal human lung.     

Current approaches to the use of radiotherapy in patients with non-small-cell lung cancer

Interactions of specific amino acid residues of the carboxyl-terminal domain of MetRS with the CAU anticodon of tRNAMet assure accurate and efficient aminoacylation. The substitution of one such residue, Trp461 by Phe, impairs the binding of cognate tRNA, but enhances the binding of noncognate tRNAs, particularly those containing G at the wobble position. However, the enhanced binding of noncognate tRNAs is not accompanied by the increased aminoacylation of these tRNAs. A genetic screening procedure was designed to isolate methionyl-tRNA synthetase mutants which were able to aminoacylate a GGU (threonine) anticodon derivative of tRNAfMet. One such mutant, obtained from W461F MetRS, had an Ile29 to Thr substitution in helix A located in the amino-terminal dinucleotide-fold domain that forms the site for amino acid activation. Analysis of the catalytic properties of the I29T/W461F enzyme indicates that the mutation in helix A of the dinucleotide-fold domain affects kcat for aminoacylation of tRNAs having a GGU threonine anticodon. Interactions with cognate tRNAfMet (CAU), as well as with methionine and ATP were not affected by the Ile29 to Thr substitution. We conclude that the I29T substitution leads to a slight adjustment of the alignment of the CCA stem of noncognate tRNAs (GGU) in the catalytic domain of the enzyme, reflected in the increase in kcat, which also allows mischarging in vivo. A function of Ile29 is therefore to minimize the mischarging of tRNAThr (GGU) by methionyl-tRNA synthetase. The methods described here provide useful tools for examining the mechanisms of tRNA selection by aminoacyl-tRNA synthetases.     

Thoracoscopic lung biopsy or open lung biopsy for interstitial lung disease

Both traditional open lung biopsy through a limited thoracotomy and VATS lung biopsy are effective methods for obtaining parenchymal samples in patients who have respiratory insufficiency and radiographic pulmonary infiltrates. For patients with slowly progressive disease processes, who require an elective biopsy, VATS biopsy is the procedure of choice because of the ability to visualize and sample multiple areas of the lung, and because of the decreased postoperative pain. On the other hand, when patients are critically ill and already on high-level ventilatory support, the VATS method offers no advantages over the standard minimal thoracotomy.     

Different approaches to the measurement of therapist empathy and their relationship to therapy outcomes.

Correlated measures of therapist empathy (N. Kagan's, et al, Affective Sensitivity Scale, the Interpersonal Checklist, A. Langield's Role Construct Repertory Test, R. Carkhuff's Empathetic Understanding in Interpersonal Process Scale, and the G. Barrett-Lennard Relationship Inventory) with each other, with R. Carkhuff and B. Berenson's Self-Exploration in Interpersonal Process Scale, and with the Tennessee Self-Concept Scale and MMPI measures of outcome. With the possible exception of client-perceived and tape-judged empathy, the empathy measures were unrelated to each other, indicating that previous research has been measuring several different variables employing a common label. Only tape-judged empathy was related to depth of self-exploration. Client-perceived empathy was strongly related to therapy outcome, tape-judged empathy less so, and the remaining empathy measures were unrelated to outcome. Implications for research methodology and for therapeutic theory are discussed. (28 ref.) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Psychosocial and ethical issues in surgical approaches to end-stage lung disease

This study aimed to determine whether alterations in cardiovascular dynamics before syncope are related to changes in spontaneous respiration. Fifty-two healthy subjects underwent continuous heart rate (HR), arterial blood pressure (BP), and respiratory measurements during 10-min periods of spontaneous and paced breathing (0.25 Hz) in the supine and 60 degrees head-up tilt positions. Data were evaluated by power spectrum and transfer function analyses. During tilt, 27 subjects developed syncope or presyncope and 25 remained asymptomatic. Subjects with tilt-induced syncope had significantly greater increases in low-frequency (0.04-0. 15 Hz) systolic BP, diastolic BP, and HR power during tilt than the asymptomatic subjects (P 相似文献   

Colorectal cancer: comparison of laparoscopic with open approaches

PURPOSE: We compared laparoscopic with open colectomy for treatment of colorectal cancer. METHODS: We performed a retrospective review of patients undergoing colectomy for colorectal cancer between January 1991 and March 1996 at a large private metropolitan teaching hospital. Operative techniques included open (n=90) and laparoscopic (n=80) colectomy. Laparoscopic colectomy was further subdivided into the following groups: facilitated (n=62), with extracorporeal anastomosis; near-complete (n=9), with small incision for specimen delivery only; complete (n=3), with specimen removal through the rectum; and converted to an open procedure (n=6). Main outcome measures included operative time, blood loss, time to oral intake, length of postoperative hospitalization, morbidity, lymph node yield, recurrence, survival, and costs. RESULTS: Operative time was equivalent in the laparoscopic and open groups (laparoscopic, 161 minutes; open, 163 minutes; P=0.94). Blood loss was less for the laparoscopic group (laparoscopic, 104 ml; open, 184 ml; P=0.001), and resumption of oral intake was earlier (laparoscopic, 3.9 days; open, 4.9 days; P=0.001), but length of hospitalization was similar. Mean lymph node yield in the laparoscopic group was 12 compared with 16 in the open group (P=0.16). Rates of morbidity, recurrence, and survival were similar in both groups. No port-site recurrences occurred. CONCLUSIONS: Laparoscopic and open colectomy were therapeutically similar for treatment of colorectal cancer in terms of operative time, length of hospitalization, recurrence, and survival rates. The laparoscopic approach was superior in blood loss and resumption of oral intake.     

Analysis of small lung nodules diagnosed by open lung or thoracoscopic biopsy

We examined clinicopathologic findings in 86 cases with peripheral lung nodules less than 30 mm in size diagnosed by open lung or video-assisted thoracoscopic surgery (VATS) biopsy. Biopsies were conducted because of the new appearance or enlargement of nodules as evidenced in a comparison with retrospective chest films in 47 patients, X-ray findings of malignancy suspicion without retrospective films in 13, enlargement of nodules after the administration of antituberculosis agents in 9, and a past history of malignancy in 17. Mean tumor size was 18.1 mm in primary lung cancer (n = 29), 16.2 mm in metastatic lung cancer (n = 13), 16.3 mm in tuberculosis (n = 18), 15.3 mm in nonspecific inflammation (n = 12), 16.7 mm in benign lung tumors (n = 7), 7.5 mm in intrapulmonary lymph node (n = 2), and 19.4 mm in others (n = 5). Among primary lung cancers with a clear N-factor, the percentage of T1N0M0 cancers was up to 72%. No significant difference was observed in either of the reasons for these biopsies and the size of nodules among diseases. To detect early lung cancer and increase the rate of cure, small pulmonary nodules that could be hardly diagnosed using bronchoscopic or needle aspiration biopsy should be diagnosed positively using VATS biopsy.     

Antireflux surgery: a current comparison of open and laparoscopic approaches

The technologic advances of laparoscopic surgery have recently resulted in a renaissance of antireflux surgery as a minimal invasive alternative to life long medical treatment in patients with gastroesophageal reflux disease. The now vast experience has shown that, in experienced hands, laparoscopic antireflux surgery is feasible, shortens the hospital stay and recovery period, and provides a cosmetically more satisfying result than the open procedures. The rate of intra- and postoperative complications of laparoscopic antireflux procedures is, however, not significantly lower than that reported after open procedures. The laparoscopic approach is even associated with some additional sources for complications, i.e., trocar injuries, perforations of the esophagogastric junction, and herniation of the repair into the chest with a significant rate of early reoperations. Short term and intermediate results of laparoscopic antireflux procedures appear comparable to those obtained with the procedures performed via a laparotomy. Whether this is also true for the long term outcome will have to be shown by the follow-up of the large series of laparoscopic antireflux procedures that have been performed in the recent years. Before these data are available, one should be careful not to widen the indications for antireflux surgery just because the procedure can now be performed laparoscopically.     

Influences of morphine on the ventilatory response to isocapnic hypoxia

BACKGROUND: The ventilatory response to hypoxia is composed of the stimulatory activity from peripheral chemoreceptors and a depressant effect from within the central nervous system. Morphine induces respiratory depression by affecting the peripheral and central carbon dioxide chemoreflex loops. There are only few reports on its effect on the hypoxic response. Thus the authors assessed the effect of morphine on the isocapnic ventilatory response to hypoxia in eight cats anesthetized with alpha-chloralose-urethan and on the ventilatory carbon dioxide sensitivities of the central and peripheral chemoreflex loops. METHODS: The steady-state ventilatory responses to six levels of end-tidal oxygen tension (PO2) ranging from 375 to 45 mmHg were measured at constant end-tidal carbon dioxide tension (P[ET]CO2, 41 mmHg) before and after intravenous administration of morphine hydrochloride (0.15 mg/kg). Each oxygen response was fitted to an exponential function characterized by the hypoxic sensitivity and a shape parameter. The hypercapnic ventilatory responses, determined before and after administration of morphine hydrochloride, were separated into a slow central and a fast peripheral component characterized by a carbon dioxide sensitivity and a single offset B (apneic threshold). RESULTS: At constant P(ET)CO2, morphine decreased ventilation during hyperoxia from 1,260 +/- 140 ml/min to 530 +/- 110 ml/ min (P < 0.01). The hypoxic sensitivity and shape parameter did not differ from control. The ventilatory response to carbon dioxide was displaced to higher P(ET)CO2 levels, and the apneic threshold increased by 6 mmHg (P < 0.01). The central and peripheral carbon dioxide sensitivities decreased by about 30% (P < 0.01). Their ratio (peripheral carbon dioxide sensitivity:central carbon dioxide sensitivity) did not differ for the treatments (control = 0.165 +/- 0.105; morphine = 0.161 +/- 0.084). CONCLUSIONS: Morphine depresses ventilation at hyperoxia but does not depress the steady-state increase in ventilation due to hypoxia. The authors speculate that morphine reduces the central depressant effect of hypoxia and the peripheral carbon dioxide sensitivity at hyperoxia.     

Surgical approaches to the acetabulum

This article presents a concise outline of the indications, surgical techniques, and approaches to the acetabulum: Kocher-Langenbeck approach, ilioinguinal approach, iliofemoral approach, combined approaches, extended iliofemoral approach, and the triradiate approach. No one surgical appproach is ideal for all fractures of the acetabulum. The type of approach used is determined by the fracture pattern and condition of the soft tissues in the area under consideration.     

A mathematical expression to describe the ventilatory response to hypoxia and hypercapnia

Analytical techniques using multiple-exposure roentgenograms were employed to investigate surgical repositioning of either the femoral or the tibial attachment of the medial collateral ligament. The motion of the femoral attachment of the ligament with respect to the tibial attachment was used to compute the changes in length of the borders of the ligament for normal knees and for knees with repositioned attachments. The results support the conclusion that when advancement of the medial collateral ligament is utilized in the treatment of medial instability, optimization is accomplished by distal and anterior advancement with the knee in 30 degrees of flexion. Femoral displacement (proximal realignment) or tibial displacement at knee-flexion angles greater than 45 degrees is not recommended.