Communicating do-not-resuscitate orders with a computer-based system

BACKGROUND: Do-not-resuscitate (DNR) orders for critically ill patients are frequently miscommunicated between attending physicians, house staff, and nurses. A computer-based system was developed to improve the communication of a procedure-specific DNR order form. METHODS: Concordance of understanding of patients' DNR status was measured with the use of unstructured DNR orders (period 1), procedure-specific DNR order forms (period 2), and procedure-specific DNR order forms administered with a computer-based communication system (period 3). The 3 components of the DNR order assessed were (1) the clinical events to which the DNR order applied, (2) whether the DNR order withheld all elements of cardiopulmonary resuscitation, and (3) whether other treatments were to be withheld. RESULTS: For the 147 patients, the computer-based system in period 3 (n = 71) improved concordance for attending physicians and nurses or residents for all 3 of the DNR components compared with period 1 (n = 40) and some of the DNR components compared with period 2 (n = 36). Concordance was "substantial" or "almost perfect" as measured by the K statistic during period 3. The proportion of agreement for the composite of all 3 components of the DNR order increased during each period (P<.001, period 3 vs period 1). Overall agreement between all caregivers for the composite DNR order also improved from period 1 (22.2%) to period 2 (47.8%) and period 3 (61.9%; P<.001 vs period 1). Errors in order entry were detected by physicians because of the computer system and corrected in 9.9% of DNR orders in period 3. Progress note documentation of DNR status did not improve during period 3. The procedures of period 3 were considered acceptable by the physician and nursing staff. CONCLUSION: A computer-based system combined with a procedure-specific DNR order form improves communication of patients' DNR status in a critical care setting.     

Selective reduction of GluR2 protein in adult hippocampal CA3 neurons following status epilepticus but prior to cell loss

Kainic acid (KA) induces status epilepticus and delayed neurodegeneration of CA3 hippocampal neurons. Downregulation of glutamate receptor 2 (GluR2) subunit mRNA [the alpha-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid (AMPA) subunit that limits Ca2+ permeability] is thought to a play role in this neurodegeneration, possibly by increased formation of Ca2+ permeable AMPA receptors. The present study examined early hippocampal decreases in GluR2 mRNA and protein following kainate-induced status epilepticus and correlated expression changes with the appearance of dead or dying cells by several histological procedures. At 12 h, in situ hybridization followed by emulsion dipping showed nonuniform decreases in GluR2 mRNA hybridization grains overlying morphologically healthy-appearing CA3 neurons. GluR1 and N-methyl-D-aspartate receptor mRNAs were unchanged. At 12-16 h, when little argyrophilia or cells with some features of apoptosis were detected by silver impregnation or electron microscopy, single immunohistochemistry with GluR2 and GluR2/3 subunit-specific antibodies demonstrated a pattern of decreased GluR2 receptor protein within CA3 neurons that appeared to predict a pattern of damage, similar to the mRNA observations. Double immunolabeling showed that GluR2 immunofluorescence was depleted and that GluR1 immunofluorescence was sustained in clusters of the same CA3 neurons. Quantitation of Western blots showed increased GluR1:GluR2 ratios in CA3 but not in CA1 or dentate gyrus subfields. Findings indicate that the GluR1:GluR2 protein ratio is increased in a population of CA3 neurons prior to significant cell loss. Data are consistent with the "GluR2 hypothesis" that reduced expression of GluR2 subunits will increase formation of AMPA receptors permeable to Ca2+ and predict vulnerability to a particular subset of pyramidal neurons following status epilepticus.     

Infective endocarditis complicated with rapidly progressive glomerulonephritis: a case report

Despite a general national decline in criminal activities in the 1990s, juvenile criminal offenses continue to increase, (including violent, property, and delinquency acts). In addition increased numbers of children are being held in juvenile jails. It is all but impossible for pediatric health providers to think that "their patients" and "their practices" are immune from the epidemic of crime that affects and is caused by "just kids."     

Exploring Privacy Management on Facebook: Motivations and Perceived Consequences of Voluntary Disclosure

This study examined the perceived motivations and consequences of voluntary disclosure of Facebook active users using a survey administered to college students in a public‐speaking course. College‐age students who took the survey were motivated to use Facebook because they perceived their relationships improved with friends and family, although using Facebook could become negatively habit forming. The research suggests that users of Facebook use it more for disclosing to distant friends rather than to close friends, which is divergent from most early disclosure research that equates disclosure with intimacy. This research utilizes Communication Privacy Management Theory for the theoretical framework.     

The authorship dilemma: alphabetical or contribution?

Scientific communities have adopted different conventions for ordering authors on publications. Are these choices inconsequential, or do they have significant influence on individual authors, the quality of the projects completed, and research communities at large? What are the trade-offs of using one convention over another? In order to investigate these questions, we formulate a basic two-player game theoretic model, which already illustrates interesting phenomena that can occur in more realistic settings. We find that contribution-based ordering leads to a denser collaboration network and a greater number of publications, while alphabetical ordering can improve research quality. Contrary to the assumption that free riding is a weakness of the alphabetical ordering scheme, when there are only two authors, this phenomenon can occur under any contribution scheme, and the worst case occurs under contribution-based ordering. Finally, we show how authors working on multiple projects can cooperate to attain optimal research quality and eliminate free riding given either contribution scheme.     

The Relations Between Contextual Risk, Earned Income, and the School Adjustment of Children From Economically Disadvantaged Families.

This longitudinal study examined the relations between multiple risk indexes representing contextual adversity, income-to-needs ratios, and the elementary school adjustment of children from economically disadvantaged families. The results provide evidence for volatility in family circumstances over 2-year intervals from preschool to 5th grade, for relations between the contextual risk indexes and change in externalizing behavior, and for relations between the income-to-needs ratios and change in academic competence. The results also show differences in the timing of the effects. Little evidence was found for persistence effects. Theoretical implications concern conceptualizations of the diverse and dynamic nature of the family circumstances experienced by disadvantaged children. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Protein kinase C regulates a vesicular class of calcium channels in the bag cell neurons of aplysia

Protein kinase C (PKC) acutely increases calcium currents in Aplysia bag cell neurons by recruiting calcium channels different from those constitutively active in the plasma membrane. To study the mechanism of PKC regulation we previously identified two calcium channel alpha1-subunits expressed in bag cell neurons. One of these, BC-alpha1A, is localized to vesicles concentrated primarily in somata and growth cones. We used antibodies to BC-alpha1A to analyze its expression in the bag cell neurons of juvenile Aplysia at a developmental stage at which PKC-sensitive calcium currents have previously been shown to be low. We find that vesicular BC-alpha1A staining is generally reduced in juvenile bag cell neurons but that its expression level can vary among juvenile animals. In 17 bag cell clusters examined, the percentage of neurons that displayed punctate alphaBC-alpha1A staining ranged from 0 to 85%. Sampling of calcium currents from cells of the same clusters by whole cell patch-clamp techniques revealed that the PKC-sensitive calcium current density is significantly correlated with the degree of vesicular staining. In contrast, no correlation of basal calcium current levels with aBC-alpha1A staining was found. These results strongly suggest that BC-alpha1A, a member of the ABE-subfamily of calcium channels, carries the PKC-sensitive calcium current in bag cell neurons. They are consistent with a model in which PKC recruits channels from the vesicular pool to the plasma membrane.     

Insulin-like growth factor binding protein production in human follicular thyroid carcinoma cells

OBJECTIVE: The study investigated the value of using national or regional data bases to examine care in a specific hospital. DATA SOURCES: The following data sources were included: (1) the results of the 1992 HCFA analysis of the index hospital for patients hospitalized in fiscal year 1990; (2) the 1989 Medicare Provider Analysis and Review (MEDPAR) file; and (3) clinical information from bypass surgery patients in Wisconsin and from the index hospital. PRINCIPAL FINDINGS: The assessment of the mortality rates in the index hospital for all conditions combined and for CABG patients differed depending on what data base was used and how the data were analysed. The national data were most useful in establishing that the coding practices for all patients and the mortality rate for intra-aortic balloon patients differed between the index hospital and other hospitals. The regional clinical data base for bypass surgery patients was used to establish that the high mortality rates for intra-aortic balloon patients were due to patient selection. CONCLUSIONS: National claims data must be analysed carefully before applying results to an individual hospital. Even a careful analysis is more for raising questions about care at a specific hospital rather than for reaching definitive conclusions.