Barriers to advance care planning: a qualitative study of seriously ill Chinese patients and their families.

BACKGROUND: Advance care planning (ACP) facilitates identification and documentation of patients' treatment preferences. Its goal aligns with that of palliative care - optimizing quality of life of seriously ill patients. However, concepts of ACP and palliative care remain poorly recognized in Chinese population. This study aims at exploring barriers to ACP from perspective of seriously ill patients and their family caregivers. METHODS: This is a qualitative study conducted in a Palliative Day Care Centre of Hong Kong between October 2016 and July 2017. We carried out focus groups and individual interviews for the seriously ill patients and their family caregivers. A semi-structured interview guide was used to explore participants' experiences and attitudes about ACP. Qualitative content analysis was adopted to analyze both manifest content and latent content. RESULTS: A total of 17 patients and 13 family caregivers participated in our study. The qualitative analysis identified four barriers to ACP: 1) limited patients' participation in autonomous decision making, 2) cognitive and emotional barriers to discussion, 3) lack of readiness and awareness of early discussion, and 4) unprepared healthcare professionals and healthcare system. CONCLUSIONS: Participations of seriously ill patients, family caregivers and healthcare workers in ACP initiation are lacking respectively. A series of interventions are necessary to resolve the barriers.

Functional muscle transfer and the variance of reinnervating axonal load: part I. The facial nerve.

BACKGROUND: Results of functional muscle transfer for the treatment of facial palsy vary. Surgical technique in such cases remains constant, with only the selected ramus of the buccal branch of the facial nerve changing. In this study, different-sized branches of the facial nerve were used to reinnervate a constant-sized muscle flap to see whether this might explain the spectrum of clinical results seen. METHODS: Twenty-four New Zealand White rabbits were divided into two groups of 12 animals. The rectus femoris muscle was raised as a free flap and transplanted to the cheek, after being coapted to a large (buccal) or small (marginal mandibular) branch of the facial nerve. Physiological testing of the flaps and histological examination of the muscle and motor nerve were undertaken. Half the animals from each group were euthanized at 6 months and the remaining at 9 months. In all cases, the contralateral rectus femoris muscle served as the control. RESULTS: Improved physiological results were noted in the groups reinnervated by the larger nerve at both time points. Significant improvement in force production was also noted between time points in the large nerve group. These results were confirmed by histological studies. CONCLUSION: Varying sizes of reinnervating axonal load may be responsible for the varied outcomes observed clinically and may also explain the phenomenon of late-onset tightening.

Functional muscle transfer and the variance of reinnervating axonal load: part II. Peripheral nerves.

BACKGROUND: Peripheral limb reconstruction using functional muscle transfer following injury or tumor resection has been widely reported in the literature. Such procedures often fail to deliver the physiologic contractile strength that might be hoped for in relation to the size of the transplanted muscle. Pure motor nerves of differing sizes were used to reinnervate a constant-sized muscle flap to see whether functional results could be improved in an experimental model analogous to clinical peripheral limb reconstruction. METHODS: Twenty-four New Zealand White rabbits were divided into two groups of 12 animals each. The rectus femoris muscle was raised as a free flap and transplanted back to the donor site orthotopically (coapted back to its original motor nerve) in the rectus femoris group or heterotopically (coapted to the larger motor nerve to the vastus lateralis-double the axonal load of the indigenous nerve) in the vastus lateralis group. Half the animals from each group were euthanized at 6 months, and the remaining animals were at 9 months. In all cases, the contralateral rectus femoris muscle served as a control. RESULTS: Physiologic assessment of the transplants for maximal tetanic contractural force was undertaken, together with immunohistochemical and histologic analysis of muscle and nerve tissue. Result analysis demonstrated that the double-sized nerve failed to produce significant improvements in physiologic outcome between the two groups at either the 6- or 9-month time point. The results were further endorsed by the histologic findings. CONCLUSION: Increasing the axonal load to a functional muscle transplant beyond that of its indigenous motor nerve does not improve outcome.

Amyloidosis masquerading as inflammatory bowel disease with a mass lesion simulating a malignancy.

Our patient, who was known to have multiple myeloma, presented with weight loss, rectal bleeding, and a barium enema study suggestive of a colitis with a mass lesion. Colonoscopy with biopsy revealed the mass to be large mucosal folds infiltrated with amyloidosis. Amyloidosis has been reported to mimick malignancy, mainly by tumorous deposits in the stomach and less commonly in the small and large bowels. Gastrointestinal surgery in patients with amyloidosis potentially may have undesirable consequences due to failure of anastomotic suture lines and subsequent sepsis (6, 11, 17, 18). The knowledge that amyloidosis may be associated with multiple myeloma and an appreciation of the wide range of gastrointestinal roentgenographic findings in patients with amyloidosis should prompt the clinician to obtain endoscopic and biopsy evaluation of these patients.

Transitional lumbosacral discs. probability of herniation.

The charts and roentgenograms of 200 patients operated upon for lumbar disc herniations were reviews. Among them, there were 42 persons in whom a lumbosacral transitional vertebra existed. The discs beneath these vertebra varied in appearance. A descriptive classification for the four disc types is proposed. In none of the 42 patients were there myelographic evidence of herniation of such a disc. In five instances, such disc were surgically inspected, and no protrusion was uncovered. Before transitional discs are operated upon, the proof of herniation should be incontrovertible.

"Skinny" upper gastrointestinal endoscopy--the initial diagnostic tool: a prospective comparison of upper gastrointestinal endoscopy and radiology.

One hundred twenty-five patients were prospectively evaluated with upper gastrointestinal "skinny" endoscopy and radiology. Seventy-five patients underwent endoscopic examination before barium studies, whereas 50 patients underwent radiologic examination before endoscopy. If superficial mucosal erosions are eliminated, the areas of greatest disagreement occurred in the postoperative stomach, the deformed antrum, and the deformed duodenal bulb. We conclude that 1) a barium meal is not a prerequisite to a complete endoscopic examination by a trained endoscopist, 2) a barium meal following an adequate endoscopic examination usually adds little new information, and 3) "skinny" endoscopic examination can be utilized as the initial and usually the only diagnostic test in most patients with upper gastrointestinal symptoms.