The key challenges of discussing end-of-life stroke care with patients and families: a mixed-methods electronic survey of hospital and community healthcare professionals.

BACKGROUND: Communication between professionals, patients and families about palliative and end-of-life care after stroke is complex and there is a need for educational resources in this area. METHODS: To explore the key learning needs of healthcare professionals, a multidisciplinary, expert group developed a short electronic survey with open and closed questions, and then distributed it to six UK multiprofessional networks and two groups of local clinicians. RESULTS: A total of 599 healthcare professionals responded. Educational topics that were either definitely or probably needed were: ensuring consistent messages to families and patients (88%); resolving conflicts among family members (83%); handling unrealistic expectations (88%); involving families in discussions without them feeling responsible for decisions (82%); discussion of prognostic uncertainties (79%); likely mode of death (72%); and oral feeding for 'comfort' in patients at risk of aspiration (71%). The free-text responses (n = 489) and 82 'memorable' cases identified similar themes. CONCLUSION: Key topics of unmet need for education in end-of-life care in stroke have been identified and these have influenced the content of an open access, web-based educational resource.

Detection and genetic characterization of diverse Bartonella genotypes in the small mammals of Singapore.

Bartonella species are arthropod-borne bacterial pathogens that infect numerous mammalian species. Small mammals play an important role as natural reservoirs of many Bartonella species, maintaining the greatest diversity of Bartonella described to date. Although Bartonella research has been conducted in Southeast Asia, no studies have been undertaken on small mammals in Singapore. Here, we report the detection and description of Bartonella in small mammals in Singapore during the period of November 2011 to May 2014. BartonellaDNA was detected in 20.8% (22/106) of small mammal spleens with a PCR amplifying the beta subunit of bacterial RNA polymerase (rpoB) gene. Commensal species Rattus norvegicus and Rattus tanezumi had the highest prevalence, 75% (3/4) and 34,5% (10/29), followed by Suncus murinus 30% (6/20), Tupaia glis 16,7% (1/6) and Mus castaneus 13.3% (2/15). Phylogenetic analysis of 18 rpoB gene sequences revealed five Bartonella genotypes circulating in the small mammals of Singapore. Bayesian tip-significance testing demonstrated strong structuring in the geographical signal, indicating that distribution of Bartonella species is correlated to the distribution of their hosts. Major deforestation and fragmentation in Singapore favour synanthropic species that traverse habitats and increase the possibility of spillover to incidental hosts.

High diversity of medically important gastrointestinal rodent-borne helminths in Singapore.

Small mammals are important reservoirs of zoonotic diseases and are definitive hosts for medically important parasitic helminths. Several rodent and shrew species are peridomestic, bringing them into close contact with both humans and the intermediate hosts that maintain the transmission cycle. Here, we screened DNA extracted from large intestine tissue homogenate from 108 individuals comprised of 10 species. We detected two species known to infect humans, Dicrocoelium dendriticum and Moniliformis moniliformis. We also report the first detection of a second Angiostrongylus species in Singapore. This study demonstrates the diversity of helminths that are parasitizing the small mammals in Singapore.

Identification of a Lineage D Betacoronavirus in Cave Nectar Bats (Eonycteris spelaea) in Singapore and an Overview of Lineage D Reservoir Ecology in SE Asian Bats.

Coronaviruses are a diverse group of viruses that infect mammals and birds. Bats are reservoirs for several different coronaviruses in the Alphacoronavirus and Betacoronavirus genera. They also appear to be the natural reservoir for the ancestral viruses that generated the severe acute respiratory syndrome coronavirus and Middle East respiratory syndrome coronavirus outbreaks. Here, we detected coronavirus sequences in next-generation sequence data created from Eonycteris spelaea faeces and urine. We also screened by PCR urine samples, faecal samples and rectal swabs collected from six species of bats in Singapore between 2011 and 2014, all of which were negative. The phylogenetic analysis indicates this novel strain is most closely related to lineage D Betacoronaviruses detected in a diverse range of bat species. This is the second time that coronaviruses have been detected in cave nectar bats, but the first coronavirus sequence data generated from this species. Bat species from which this group of coronaviruses has been detected are widely distributed across SE Asia, South Asia and Southern China. They overlap geographically, often share roosting sites and have been witnessed to forage on the same plant. The addition of sequence data from this group of viruses will allow us to better understand coronavirus evolution and host specificity.

Can intensity of long-term follow-up for survivors of childhood and teenage cancer be determined by therapy-based risk stratification?

OBJECTIVE: To determine the feasibility of therapy-based, risk-stratified follow-up guidelines for childhood and teenage cancer survivors by evaluating adverse health outcomes in a survivor cohort retrospectively assigned a risk category. DESIGN: Retrospective cohort study. SETTING: Tertiary level, single centre, paediatric cancer unit in South East Scotland. PARTICIPANTS: All children and teenagers diagnosed with cancer (<19 years) between 1 January 1971 and 31 July 2004, who were alive more than 5 years from diagnosis formed the study cohort. Each survivor was retrospectively assigned a level of follow-up, based on their predicted risk of developing treatment-related late effects (LEs; levels 1, 2 and 3 for low, medium and high risk, respectively). Adverse health outcomes were determined from review of medical records and postal questionnaires. LEs were graded using the Common Terminology Criteria for Adverse Event, V.3. RESULTS: 607 5-year survivors were identified. Risk stratification identified 86 (14.2%), 271 (44.6%) and 250 (41.2%) as levels 1, 2 and 3 survivors, respectively. The prevalence of LEs for level 1 survivors was 11.6% with only one patient with grade 3 or above toxicity. 35.8% of level 2 survivors had an LE, of whom 9.3%, 58.8%, 18.5%, 10.3% and 3% had grades 1, 2, 3, 4 and 5 toxicity, respectively. 65.2% of level 3 survivors had LE, of whom 5.5% (n=9), 34.4% (n=56), 36.2% (n=59), 22.1% (n=36) and 1.8% (n=3) had grades 1, 2, 3, 4 and 5 toxicity, respectively. CONCLUSIONS: Therapy-based risk stratification of survivors can predict which patients are at significant risk of developing moderate-to-severe LEs and require high-intensity long-term follow-up. Our findings will need confirmation in a prospective cohort study that has the power to adjust for all potentially confounding variables.

Survivors of childhood cancer lost to follow-up can be re-engaged into active long-term follow-up by a postal health questionnaire intervention.

UNLABELLED: Lifelong long-term follow-up (LTFU) is recommended for all survivors of childhood cancer. National guidelines recommend risk-stratified levels of follow-up by a multidisciplinary team, in an age-appropriate environment. Many survivors do not participate in long-term follow-up. OBJECTIVE: To re-engage childhood cancer survivors lost to follow-up in late effects programmes by means of postal questionnaire. POPULATION AND METHODS: Retrospective cohort study of all children (<19 years) diagnosed with cancer in a single institution in the UK between 1971 and 2003. All lost to follow-up survivors (not seen in clinic >2 years) were sent a postal health and well-being questionnaire. RESULTS: 831 patients were diagnosed with childhood cancer between 1971 and 2003, with 575 long-term survivors (overall survival rate 69%). Information was available on 550 survivors (males 290 (53%), median age (range) at review 18.8 (5.4-44.2) years and at diagnosis 5.0 (0.0-18.8) years, and disease free survival (range) was 10.8 (1.0-37.4) years. Of the 550 survivors, 256 (46%) were lost to follow-up. 99 (39%) of lost to follow-up survivors returned completed postal questionnaires (58% female). 45% of responders reported at least one late effect, 36% mild-moderate, and 8% severe-life threatening. 19% reported two or more late effects. 74% of all childhood cancer survivors are now in active follow-up. CONCLUSIONS: Almost half (46%) of all long-term survivors of childhood cancer are lost to follow-up, Postal follow-up is an effective means of re-engaging more than one third of survivors of childhood cancer in active long-term follow-up, half of whom had at least one late effect.

Brain dysfunction following 'awake' craniotomy, brain mapping and resection of glioma.

The rationale for 'awake' resective brain tumour surgery and brain mapping is that the amount of tumour removed is optimized, and risks of damage to adjacent eloquent brain minimized by intraoperative patient assessments. Both goals are generally attained, but occasionally patients may have iatrogenic postoperative deficits. Five such cases (20%) are described from a consecutive series of 25 awake craniotomies. These patient fell into three distinct clinical categories; those (n = 2) who developed sensory-motor deficits that were recognized intraoperatively; those (n = 2) who had deficits that were apparent only on postoperative testing; and one patient who developed a sudden deficit with no warning. The former four patients had deficits that recovered within weeks to months (16%), but the latter one (4%) was left with a severe focal motor disability. These cases highlight both the benefits and limitations of awake craniotomy and intraoperative assessment. Although sensory-motor deficits can be recognized early, some high-level neurological functions may not be readily assessed intraoperatively and vascular catastrophes may occur without warning. The pathophysiological basis of these iatrogenic neurological deficits, and techniques to minimize such problems are discussed.

Use of the Arizona Battery for Communication Disorders of Dementia in the UK.

The Arizona Battery for Communication Disorders of Dementia (ABCD) (Bayles & Tomoeda, 1993) was given to groups of young and old normal subjects and to subjects with moderate Alzheimer's disease in the UK. Very few significant differences were found between their raw scores and those of the original standardisation sample in the USA, which makes the ABCD an appropriate test to use in the UK. Although some subjects commented on several of the test stimuli, cultural differences in pictures and vocabulary did not produce notable effects on test performance and so alterations to test materials are not required for the test to be used in the UK.

Place of residence by age, ethnicity, and level of retardation of the mentally retarded/developmentally disabled population of California.

California's data on their mentally retarded/developmentally disabled population, the largest set in the United States, were accessed to determine residency of clients by age, ethnicity, and level of retardation. Data on the desired variables were available for over 59,000 of the 64,000 clients in the records. Despite claims of excess institutional population and the availability of residential alternatives, 52.5% of all persons resided in their natural homes; small family care units held 14.2% of the population and institutions, 12.8%, these being the second and third among the eight types of residences identified by the state. The proportion of the population in the natural home decreased with age and level of retardation, dropping precipitously among profoundly and severely impaired persons. Anglo-white families kept fewer (44%) at home than did blacks, Latinos, and other ethnic groups combined.

Trends in maladaptive behavior of mentally retarded persons placed in community and institutional settings.

Changes in maladaptive behavior of retarded individuals referred and placed in institutional vs. community settings were examined. The results demonstrated that no significant time trend was present for either the institutional or community groups, regardless of clients' age and level of retardation. Placement, level of retardation, and age, however, were related to overall prevalence of maladaptive behavior among the individuals.