Daniel J. Brauner

Effect of the Omnibus Reconciliation Act 1987 on Antipsychotic Prescribing in Nursing Home Residents

Objective: To determine the impact of OBRA 87 on antipsychotic prescribing in a 485‐bed nursing home.

Effects of active and inactive phospholipase D2 on signal transduction, adhesion, migration, invasion, and metastasis in EL4 lymphoma cells.

The phosphatidylcholine-using phospholipase D (PLD) isoform PLD2 is widely expressed in mammalian cells and is activated in response to a variety of promitogenic agonists. In this study, active and inactive hemagglutinin-tagged human PLD2 (HA-PLD2) constructs were stably expressed in an EL4 cell line lacking detectable endogenous PLD1 or PLD2. The overall goal of the study was to examine the roles of PLD2 in cellular signal transduction and cell phenotype. HA-PLD2 confers PLD activity that is activated by phorbol ester, ionomycin, and okadaic acid. Proliferation and Erk activation are unchanged in cells transfected with active PLD2; proliferation rate is decreased in cells expressing inactive PLD2. Basal tyrosine phosphorylation of focal adhesion kinase (FAK) is increased in cells expressing active PLD2, as is phosphorylation of Akt; inactive PLD2 has no effect. Expression of active PLD2 is associated with increased spreading and elongation of cells on tissue culture plastic, whereas inactive PLD2 inhibits cell spreading. Inactive PLD2 also inhibits cell adhesion, migration, and serum-induced invasion. Cells expressing active PLD2 form metastases in syngeneic mice, as do the parental cells; cells expressing inactive PLD2 form fewer metastases than parental cells. In summary, active PLD2 enhances FAK phosphorylation, Akt activation, and cell invasion in EL4 lymphoma cells, whereas inactive PLD2 exerts inhibitory effects on adhesion, migration, invasion, and tumor formation. Overall, expression of active PLD2 enhances processes favorable to lymphoma cell metastasis, whereas expression of inactive PLD2 inhibits metastasis.

The Effects of Public Reporting on Physical Restraints and Antipsychotic Use in Nursing Home Residents with Severe Cognitive Impairment

To assess whether reductions in physical restraint use associated with quality reporting may have had the unintended consequence of increasing antipsychotic use in nursing home (NH) residents with severe cognitive impairment.

Phytohemagglutinin induced proliferation by aged lymphocytes: reduced expression of high affinity interleukin-2 receptors and interleukin-2 secretion.

Human lymphocytes from elderly and young donors were cultured with phytohemagglutinin. Cultures from two groups of aged donors, recruited respectively from our ambulatory clinic and a nursing home, incorporated less tritiated thymidine (3H-TdR) and secreted less interleukin-2 than did young donors. Furthermore, as determined for the first time by a radioligand binding receptor assay, the aged lymphoblasts possessed significantly fewer high affinity IL-2 receptors per cell. Despite a decrease in the number of high affinity receptor cells the dissociation constant (Kd) was comparable for the three groups. It was also shown that the amounts of soluble IL-2 receptors that were released into the supernatants by mitogen stimulated cells did not differ for the aged and young donors. These data suggest that defects in IL-2 production and high affinity IL-2 receptor generation may both be responsible for immune deficiency in the elderly.

The voices of the medical record

The medical record, as a managerial, historic, and legal document, serves many purposes. Although its form may be well established and many of the cases documented in it ‘routine’ in medical experience, what is written in the medical record nevertheless records decisions and actions of individuals. Viewed as an interpretive ‘text’, it can itself become the object of interpretation. This essay applies literary theory and methodology to the structure, content, and writing style(s) of an actual medical record for the purpose of exploring the relationship between the forms and language of medical discourse and the daily decisions surrounding medical treatment. The medical record is shown to document not only the absence of a consistent treatment plan for the patient studied but also a breakdown in communication between different health professionals caring for that patient. The paper raises questions about the kind of education being given to house staff in this instance. The essay concludes with a consideration of how such situations might be more generally avoided.

Charting the Chart—An Exercise in Interpretation(s)

The multiauthored article is standard in the medical sciences, where the politics of the laboratory and the academy often loom larger than the singularity of the argument or grace of its execution. The following paper, however, depends upon the singularity of each of its authors and hails the individual grace of their arguments. Although collaborative, this paper is primarily collective, composed of unique readings of the same document. In its array of individual viewpoints and interpretations, it underscores the collective nature of the entries that constitute the single entity identified as the chart. As the record of one patients hospitalization is really a diverse collection of individual voices as well as professional interactions or viewpoints, so the responses of these readers are unique to each ones personal and professional backgrounds.1 —Suzanne Poirier, Ph.D., Literature2

Moral reasoning and Alzheimer's care: Exploring complex weavings through narrative

Abstract This article reports on selected results of an inquiry-guided study in which we used literature and autobiography to challenge current rationalist perspectives on the use of formal services by caregivers of Alzheimers sufferers. Starting with Gilligan s concepts of two basic forms of moral reasoning—justice versus care-based—we interpreted the moral reasoning about caregiving expressed in four novels: Diary of a Good Neighbor, Memory Board, Memento Mori, and The Other Side. Although we found Gilligans dichotomous framework not directly applicable, we did find ample evidence of the salience of moral reasoning to questions of who should care and on what basis. We also found that stories, as they are woven from threads of family history, social position and mores, as well as ideas about intimate love, religion, and autonomy, reveal the interconnectedness of so-called private choices to the social ideologies that constrain and shape these choices.

Reconsidering Default Medicine

By creating an alternative treatment orderFcomfort feeding only (CFO)FPalecek and colleagues have taken an important step toward improving the care of persons with advanced dementia and rectifying the problem of continued overuse of percutaneous enteral gastrostomy (PEG) feeding tubes. By intentionally changing the usual advance directive scenario, the authors suggest the possibility of improving care for gravely ill and dying patients, but this possibility cannot be fully realized unless we also examine the advance directive paradigm in which the CFO operatesFand that Palecek and colleagues do not challenge. If we can then apply this knowledge to move beyond the current paradigm, we could transform care for the legions of patients who suffer from the default application of burdensome, inefficacious therapies because of the contingencies of custom.

The Role of Severe Dementia in Nursing Home Report Cards.

Health care report cards are intended to improve quality, but there may be considerable heterogeneity in who benefits. In this article, we examine the intended and unintended effects of quality reporting for nursing home residents with severe dementia relative to other residents, using a difference-in-differences design to examine selected reported and unreported quality measures. Our results indicate that prior to public reporting, nursing home residents with severe dementia were at significantly higher risk of poor outcomes on most reported quality measures. After public reporting was initiated, outcomes for nursing home residents with severe dementia did not consistently improve or worsen. We see no evidence that individuals with severe dementia are being avoided by nursing homes, despite their potential negative impact on quality scores, but we do find an increase in coding of end-stage disease. Additional risk-adjustment, stratification, or additional quality measures may be warranted.

Deciding for Others: Limitations of Advance Directives, Substituted Judgment, and Best Interest

Advance directives do not always resolve questions about the best care for patients who no longer have decision-making capacity; physicians and patient surrogates can take alternative approaches to arrive at the best care decision. Virtual Mentor is a monthly bioethics journal published by the American Medical Association.