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Biomedical subjects

R S Morrison

Publications and source records attributed to R S Morrison.

At least 19 recordsLinked to original sources
PubMed2002

Cellular and molecular alterations in spinal cord injury patients with pressure ulcers: a preliminary report.

The study was designed to investigate the changes, both numerically and functionally, of the molecules critical to wound healing in spinal cord injury (SCI) patients. Spinal cord injury patients who demonstrated delayed healing of their pressure ulcers were used as study subjects. Age-matched healthy individuals served as controls. Adhesion molecule expression of the peripheral blood leukocytes, including lymphocytes and granulocytes, was measured by flow cytometric analysis. Binding capacity of the lymphocytes was evaluated using human umbilical cord vein endothelial cells (HUVECs) as the binding matrix. Samples from pressure ulcers of the patients were immunostained to define fibronectin, kalinin, beta4 integrin, alpha2beta1, alpha3beta1, alpha5beta1, and CD138 expression. Compared to healthy controls, there was decreased expression of CD11a, CD11b, CD18, CD49b, CD49c, CD49d, CD54, and CD8 in patients' lymphocyte populations and CD11a, CD18, CD49c, CD49d, and CD8 in patients' granulocyte populations. The binding capacity, expressed as percentage binding of the lymphocytes to the HUVEC matrix, was greatly diminished in the patients. There was markedly diminished immunohistochemical staining of fibronectin in pressure ulcers. These findings showed that delayed healing of pressure ulcers in SCI patients can be attributed to reduced adhesion molecule expression, impaired cell-cell interaction, and lack of extracellular matrix structural and functional protein.

Adult↗
PubMed2001

The inner life of physicians and care of the seriously ill.

Seriously ill persons are emotionally vulnerable during the typically protracted course of an illness. Physicians respond to such patients' needs and emotions with emotions of their own, which may reflect a need to rescue the patient, a sense of failure and frustration when the patient's illness progresses, feelings of powerlessness against illness and its associated losses, grief, fear of becoming ill oneself, or a desire to separate from and avoid patients to escape these feelings. These emotions can affect both the quality of medical care and the physician's own sense of well-being, since unexamined emotions may also lead to physician distress, disengagement, burnout, and poor judgment. In this article, which is intended for the practicing, nonpsychiatric clinician, we describe a model for increasing physician self-awareness, which includes identifying and working with emotions that may affect patient care. Our approach is based on the standard medical model of risk factors, signs and symptoms, differential diagnosis, and intervention. Although it is normal to have feelings arising from the care of patients, physicians should take an active role in identifying and controlling those emotions.

Critical Illness↗
PubMed2001

Mortality and locomotion 6 months after hospitalization for hip fracture: risk factors and risk-adjusted hospital outcomes.

CONTEXT: Hip fracture is a common clinical problem that leads to considerable mortality and disability. A need exists for a practical means to monitor and improve outcomes, including function, for patients with hip fracture. OBJECTIVES: To identify and compare the importance of significant prefracture predictors of functional status and mortality at 6 months for patients hospitalized with hip fracture and to compare risk-adjusted outcomes for hospitals providing initial care. DESIGN: Prospective study with data obtained from medical records and through structured interviews with patients and proxies. SETTING AND PARTICIPANTS: A total of 571 adults aged 50 years or older with hip fracture who were admitted to 4 New York, NY, metropolitan hospitals between August 1997 and August 1998. MAIN OUTCOME MEASURES: In-hospital and 6-month mortality; locomotion at 6 months; and adverse outcomes at 6 months, defined as death or needing assistance to ambulate, compared by hospital, adjusting for patient risk factors. RESULTS: The in-hospital mortality rate was 1.6%. At 6 months, the mortality rate was 13.5%, and another 12.8% needed total assistance to ambulate. Laboratory values were strong predictors of mortality but were not significantly associated with locomotion. Age and prefracture residence at a nursing home were significant predictors of locomotion (P =.02 for both) but were not significantly associated with mortality. Adjustment for baseline characteristics either substantially augmented or diminished interhospital differences in outcomes. Two hospitals had 1 outcome (functional status or mortality) that was significantly worse than the overall mean while the other outcome was nonsignificantly better than average. CONCLUSIONS: Mortality and functional status ideally should be considered both together and individually to distinguish effects limited to one or the other outcome. Hospital performance for these 2 measures may differ substantially after adjustment, probably because different processes of care are important to each outcome.

Activities of Daily Living↗
PubMed2001

High short-term mortality in hospitalized patients with advanced dementia: lack of benefit of tube feeding.

BACKGROUND: The influence of tube feeding on survival in hospitalized patients with advanced dementia is controversial. OBJECTIVE: To assess long-term survival in an inception cohort, incident tube feeding placement during the index hospitalization, and the influence of tube feeding on survival in this group of patients. SUBJECTS AND METHODS: Ninety-nine hospitalized patients with advanced dementia and an available surrogate decision maker were followed up through and after the index hospitalization for mortality and placement of a feeding tube. Other variables measured included advance directive status, presence of a long-term primary care physician, level of involvement of the surrogate decision maker, admitting diagnosis, prior hospitalizations, comorbidities, and diagnosis related group diagnostic category. RESULTS: A new feeding tube was placed in 50% (51/99) of the study patients during the index hospitalization, 31% (31/99) left the hospital without a feeding tube, and 17% (17/99) were admitted with a feeding tube already in place. By stepwise logistic regression analysis, predictors of new feeding tube placement included African American ethnicity (odds ratio, 9.43; 95% confidence interval, 2.1-43.2) and residence in a nursing home (odds ratio, 4.9; 95% confidence interval, 1.02-2.5). Median survival of the 99 patients was 175 days. Eighty-five (85%) survived the index hospitalization, and 28 (28%) were still alive at last follow-up, a range of 1.3 to 4.2 years after enrollment in the study. Tube feeding was not associated with survival (P =.90). An admitting diagnosis of infection was associated with higher mortality (odds ratio, 1.9; 95% confidence interval, 1.01-3.6). CONCLUSIONS: In this cohort of hospitalized patients with advanced dementia, risk of receiving a new feeding tube is high, associated with African American ethnicity, and prior residence in a nursing home, and has no measurable influence on survival. With or without a feeding tube, these patients have a 50% six-month median mortality.

Aged↗
PubMed2001

How prevalent are hospital-based palliative care programs? Status report and future directions.

In the United States, the majority of deaths occur in the hospital but the dying process there is at best unsatisfactory and more likely inadequate for both patients and caregivers. The development of hospital-based palliative care programs (HBPCPs) can vastly improve inpatient end-of-life care. This study is the first to examine the prevalence and characteristics of HBPCPs in the United States, thus providing a snapshot of the characteristics of these HBPCPs. It also serves as a baseline and benchmark against which future development and patterns of HBPCPs can be compared. Phase 1: Data were obtained from the American Hospital Association (AHA) 1998 Annual Survey, on the existence of end-of-life care (EOLC) and pain management (PM) services in U.S. hospitals. Phase 2: A focused survey further assessed programs in Phase 1 and was sent to all registered hospitals that responded affirmatively to the AHA survey questions as having either a PM service, an EOLC service, or both. In phase 1, 1,751 (36%) hospitals reported having a PM service and 719 (15%) had an EOLC service, for a total of 2,015 unique hospitals that had one or both. For Phase 2, 1,120 of 2,015 responded (56%). Of these, 337 (30%) hospitals reported having an HBPCP, and another 228 (20.4%) had plans to establish one. HBPCPs are most commonly structured as inpatient consultation service and hospital-based hospice. They tend to be based in oncology, general medicine, and geriatrics. We also assessed reasons for consultation, patient characteristics, and future development needs. These findings can help guide future funding, educational, and programming efforts in hospital-based palliative care.

Ambulatory Care↗
PubMed2001

Self-reported symptom experience of critically ill cancer patients receiving intensive care.

OBJECTIVE: To characterize the symptom experience of a cohort of intensive care unit (ICU) patients at high risk for hospital death. DESIGN: Prospective analysis of patients with a present or past diagnosis of cancer who were consecutively admitted to a medical ICU during an 8-month period. SETTING: Academic, university-affiliated, tertiary-care, urban medical center. PATIENTS: One hundred cancer patients treated in a medical ICU. INTERVENTION: Assessment of symptoms. MEASUREMENTS: Patients' self-reports of symptoms using the Edmonton Symptom Assessment Scale (ESAS), and ratings of pain or discomfort associated with ICU diagnostic/therapeutic procedures and of stress associated with conditions in the ICU. MAIN RESULTS: Hospital mortality for the group was 56%. Fifty patients had the capacity to respond to the ESAS, among whom 100% provided symptom reports. Between 55% and 75% of ESAS responders reported experiencing pain, discomfort, anxiety, sleep disturbance, or unsatisfied hunger or thirst that they rated as moderate or severe, whereas depression and dyspnea at these levels were reported by approximately 40% and 33% of responders, respectively. Significant pain, discomfort, or both were associated with common ICU procedures, but most procedure-related symptoms were controlled adequately for a majority of patients. Inability to communicate, sleep disruption, and limitations on visiting were particularly stressful among ICU conditions studied. CONCLUSIONS: Among critically ill cancer patients, multiple distressing symptoms were common in the ICU, often at significant levels of severity. Symptom assessment may suggest more effective strategies for symptom control and may direct decisions about appropriate use of ICU therapies.

Adult↗
PubMed2000

Pescadillo, a novel cell cycle regulatory protein abnormally expressed in malignant cells.

Using a culture model of glial tumorigenesis, we identified a novel gene that was up-regulated in malignant mouse astrocytes following the loss of p53. The gene represents the murine homologue of pescadillo, an uncharacterized gene that is essential for embryonic development in zebrafish. Pescadillo is a strongly conserved gene containing unique structural motifs such as a BRCA1 C-terminal domain, clusters of acidic amino acids and consensus motifs for post-translational modification by SUMO-1. Pescadillo displayed a distinct spatial and temporal pattern of gene expression during brain development, being detected in neural progenitor cells and postmitotic neurons. Although it is not expressed in differentiated astrocytes in vivo, the pescadillo protein is dramatically elevated in malignant human astrocytomas. Yeast strains harboring temperature-sensitive mutations in the pescadillo gene were arrested in either G(1) or G(2) when grown in nonpermissive conditions, demonstrating that pescadillo is an essential gene in yeast and is required for cell cycle progression. Consistent with the latter finding, DNA synthesis was only observed in mammalian cells expressing the pescadillo protein. These results suggest that pescadillo plays a crucial role in cell proliferation and may be necessary for oncogenic transformation and tumor progression.

Amino Acid Sequence↗
PubMed2000

p38 MAP kinase mediates bax translocation in nitric oxide-induced apoptosis in neurons.

Nitric oxide is a chemical messenger implicated in neuronal damage associated with ischemia, neurodegenerative disease, and excitotoxicity. Excitotoxic injury leads to increased NO formation, as well as stimulation of the p38 mitogen-activated protein (MAP) kinase in neurons. In the present study, we determined if NO-induced cell death in neurons was dependent on p38 MAP kinase activity. Sodium nitroprusside (SNP), an NO donor, elevated caspase activity and induced death in human SH-SY5Y neuroblastoma cells and primary cultures of cortical neurons. Concomitant treatment with SB203580, a p38 MAP kinase inhibitor, diminished caspase induction and protected SH-SY5Y cells and primary cultures of cortical neurons from NO-induced cell death, whereas the caspase inhibitor zVAD-fmk did not provide significant protection. A role for p38 MAP kinase was further substantiated by the observation that SB203580 blocked translocation of the cell death activator, Bax, from the cytosol to the mitochondria after treatment with SNP. Moreover, expressing a constitutively active form of MKK3, a direct activator of p38 MAP kinase promoted Bax translocation and cell death in the absence of SNP. Bax-deficient cortical neurons were resistant to SNP, further demonstrating the necessity of Bax in this mode of cell death. These results demonstrate that p38 MAP kinase activity plays a critical role in NO-mediated cell death in neurons by stimulating Bax translocation to the mitochondria, thereby activating the cell death pathway.

Apoptosis↗
PubMed2000

Development. p73--guilt by association?

It has been assumed that the new members of the p53 protein family, p63 and p73, would have the same job as p53, namely, forcing cells to die if they or their DNA is damaged. Now, as Morrison and Kinoshita explain in their Perspective, one particular form of p73 has been found to be a survival factor rather than a death factor for sympathetic neurons during development (Pozniak et al.).

Animals↗
PubMed2000

Survival in end-stage dementia following acute illness.

CONTEXT: Little is known about the prognosis of acutely ill patients with end-stage dementia or about the type of care that these patients receive. If their prognosis is poor, then emphasis should be placed on palliative care for these patients rather than on curative interventions. OBJECTIVES: To examine survival for patients with end-stage dementia following hospitalization for hip fracture or pneumonia and to compare their care with that of cognitively intact older adults. DESIGN: Prospective cohort study with 6 months of follow-up. SETTING AND PATIENTS: Patients aged 70 years or older who were hospitalized with hip fracture (cognitively intact, n=59; with end-stage dementia, n=38) or pneumonia (cognitively intact, n=39; with end-stage dementia, n=80) in a large hospital in New York, NY, between September 1, 1996, and March 1, 1998. MAIN OUTCOME MEASURES: Mortality, treatments directed at symptoms, and application of distressing and painful procedures in cognitively intact patients vs those with end-stage dementia. RESULTS: Six-month mortality for patients with end-stage dementia and pneumonia was 53% (95% confidence interval [CI], 41%-64%) compared with 13% (95% CI, 4%-27%) for cognitively intact patients (adjusted hazard ratio, 4.6; 95% CI, 1.8-11.8). Six-month mortality for patients with end-stage dementia and hip fracture was 55% (95% CI, 42%-75%) compared with 12% (95% CI, 5%-24%) for cognitively intact patients (adjusted hazard ratio, 5.8; 95% CI, 1.7-20.4). Patients with end-stage dementia received as many burdensome procedures as cognitively intact patients and only 8 (7%) of 118 patients with end-stage dementia had a documented decision made to forego a life-sustaining treatment other than cardiopulmonary resuscitation. Only 24% of patients with end-stage dementia and hip fracture received a standing order for analgesics. CONCLUSIONS: In this study, patients with advanced dementia and hip fracture or pneumonia had a very poor prognosis. Given the limited life expectancy of patients with end-stage dementia following these illnesses and the burdens associated with their treatment, increased attention should be focused on efforts to enhance comfort in this patient population. JAMA. 2000;284:47-52

Acute Disease↗
PubMed2000

The cause of delirium in patients with hip fracture.

OBJECTIVES: To ascertain the most common causes of delirium, to establish the initiation and timing of delirium, and to determine the duration of delirium in patients with hip fracture. METHODS: Five hundred seventy-one (88%) of 650 patients with hip fracture admitted to 4 New York City hospitals were prospectively interviewed on a daily basis, 5 days a week, with the Confusion Assessment Method for the presence of delirium. The patients were enrolled within 48 hours of admission. Their medical charts and the data collected by the study staff were reviewed and summarized. Two of us (R.S.M. and A.L.S.) reviewed the case summaries independently and assigned a cause based on a previously developed classification system, estimated the onset of the delirious episode, and determined whether the delirium had cleared, improved, or persisted at discharge. Subsequently, discrepancies in cause, timing of initiation, and mental status on discharge between the 2 physicians reviewers were discussed until consensus was reached. RESULTS: The prevalence of delirium was 9.5% (54/ 571; 95% confidence interval, 7.0-11.9). Seven percent of episodes were assigned a definite cause, 20% a probable cause, 11% a possible cause, and 61% were attributable to 1 or more comorbid conditions. Twenty-eight (53%) of 54 subjects developed delirium after surgery. The delirium had cleared or improved in 40 (74%) of 54 subjects at the time of discharge. CONCLUSIONS: Delirium in patients with hip fracture appears to be a different syndrome from that observed in patients who are otherwise medically ill; it also appears to follow a different clinical course. These results have important implications for the management of delirium in patients with hip fracture.

Aged↗
PubMed2000

"We don't carry that"--failure of pharmacies in predominantly nonwhite neighborhoods to stock opioid analgesics.

BACKGROUND: We have observed that many black and Hispanic patients receiving palliative care at a major urban teaching hospital are unable to obtain prescribed opioids from their neighborhood pharmacies. In this study, we investigated the availability of commonly prescribed opioids in New York City pharmacies. METHODS: We surveyed a randomly selected sample of 30 percent of New York City pharmacies to obtain information about their stock of opioids. For each pharmacy, U.S. Census estimates for 1997 were used to determine the racial and ethnic composition of the neighborhood (defined as the area within a 0.4-km [0.25-mile] radius of the pharmacy) and the proportion of residents who were more than 65 years old. Data on robberies, burglaries, and arrests involving illicit drugs in 1997 were obtained for the precinct in which each pharmacy was located. We used a generalized linear model to examine the relation between the racial or ethnic composition of neighborhoods and the opioid supplies of pharmacies, while controlling for the proportion of elderly persons at the census-block level and for crime rates at the precinct level. RESULTS: Pharmacists representing 347 of 431 eligible pharmacies (81 percent) responded to the survey. A total of 176 pharmacies (51 percent) did not have sufficient supplies of opioids to treat patients with severe pain. Only 25 percent of pharmacies in predominantly nonwhite neighborhoods (those in which less than 40 percent of residents were white) had opioid supplies that were sufficient to treat patients in severe pain, as compared with 72 percent of pharmacies in predominantly white neighborhoods (those in which at least 80 percent of residents were white) (P<0.001). CONCLUSIONS: Pharmacies in predominantly nonwhite neighborhoods of New York City do not stock sufficient medications to treat patients with severe pain adequately.

Analgesics, Opioid↗
PubMed2000

Absence of p53: no effect in a transgenic mouse model of familial amyotrophic lateral sclerosis.

Familial amyotrophic lateral sclerosis (ALS) has been linked in some families to dominantly inherited mutations in the gene encoding copper-zinc superoxide dismutase 1 (Cu-Zn SOD1). Transgenic mice expressing a mutant human Cu-Zn SOD1 (G93A) develop a dominantly inherited adult-onset paralytic disorder that replicates many of the clinical and pathological features of familial ALS. Increased p53 immunoreactivity has been reported in the motor cortex and spinal ventral horns of postmortem tissue from ALS patients. The nuclear phosphoprotein p53 is an important regulator of cellular proliferation, and increasing evidence supports the role of p53 in regulating cellular apoptosis. To assess the role of p53-mediated apoptosis in amyotrophic lateral sclerosis, mice deficient in both p53 alleles (p53-/-) were crossed with transgenic mice expressing the G93A mutant (G93A+), creating novel transgenic knockout mice. The animals (p53 +/+G93A+, p53+/-G93A+, p53-/-G93A+) were examined at regular intervals for cage activity, upper and lower extremity strength, and mortality. At 120 days from birth mice from each genotype were sacrificed, and L2-L3 anterior horn motor neurons were counted. There was no significant difference in time to onset of behavioral decline, mortality, or motor neuron degeneration between the different genotypes. Despite evidence that p53 plays an important role after acute neuronal injury, the current study suggests that p53 is not significantly involved in cell death in the G93A+ transgenic mouse model of familial ALS.

Amyotrophic Lateral Sclerosis↗
PubMed2000

A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture.

Advanced dementia patients may be at substantial risk for undetected or undertreated pain. To examine the treatment of pain following hip fracture, a prospective cohort study was conducted in an academic teaching hospital. Fifty-nine cognitively intact elderly patients with hip fracture and 38 patients with hip fracture and advanced dementia were assessed daily. The cognitively intact patients rated their pain on a numeric scale ranging from 0 (none) to 4 (very severe). Analgesics prescribed and administered were recorded and compared to hip fracture patients with advanced dementia. The advanced dementia patients received one-third the amount of morphine sulfate equivalents as the cognitively intact patients. Forty-four percent of cognitively intact individuals reported severe to very severe pain preoperatively and 42% reported similar pain postoperatively. Half the cognitively intact patients who experienced moderate to very severe pain were prescribed inadequate analgesia for their level of pain. Eighty-three percent of cognitively intact patients and 76% of dementia patients did not receive a standing order for an analgesic agent. These data reveal that a majority of elderly hip fracture patients experienced undertreated pain. The fact that advanced dementia patients received one-third the amount of opioid analgesia as compared to cognitively intact subjects-40% of whom reported severe pain postoperatively-suggests that the majority of dementia patients were in severe pain postoperatively. This study and others suggest that directed interventions to improve pain detection and alter physician prescribing practices in the cognitively impaired are needed.

Aged↗
PubMed2000

Palliative care consultations: how do they impact the care of hospitalized patients?

To provide a detailed description of the recommendations of a Palliative Care Service (PCS) and to describe the impact of these recommendations on the care of terminally ill patients in an academic medical center, we describe data from all consecutive patients referred by their attending physicians to the PCS of an academic teaching hospital over a 15-month period. All patients were seen within 24 hours of consultation request. Data were collected prospectively on the day of discharge or death. Attention was focused on six recommendations and their implementation: 1) discussion about prognosis and goals of care; 2) pursuing documentation of advance directives; 3) discussion about foregoing specific treatments and/or diagnostic interventions; 4) family and patient support; 5) discharge planning; and 6) symptom management. Over a 15-month period, we collected data on 325 patients. The most frequent diagnoses were cancer, dementia, and HIV disease. The patients were followed for a mean of 7.6 days. The average number of recommendations was 4.2 per patient and 91% of the recommendations were implemented (3.8 per patient). Recommendations increased to 5.3 per patient and the implementation rate increased to 97% (5.1 per patient) for the 44 patients transferred to the Palliative Care Unit (PCU). PCS consultations result in multiple recommendations with a very high implementation rate. The number of recommendations and the high implementation rate suggest a strong need for palliative care services within acute care hospitals.

Adult↗