Management of bleeding in palliative care patients in the general internal medicine ward: a systematic review.

BACKGROUND: Palliative care patients, those suffering from at least one chronic lifelong medical condition and hospice care patients, those with a life expectancy less than 6 months, are regularly hospitalised in general internal medicine wards. By means of a clinical case, this review aims to equip the internist with an approach to bleeding in this population. Firstly, practical advice on platelet transfusions will be provided. Secondly, the management of bleeding in site-specific situations will be addressed (from the ENT/pulmonary sphere, gastrointestinal - urogenital tract and cutaneous ulcers). Finally, an algorithm pertaining to the management of catastrophic bleeding is proposed. METHODS: Electronic databases, including EMBASE, Pubmed, Google Scholar and the Cochrane Library were studied as primary resources, in association with local guidelines, to identify papers exploring platelet transfusions and alternative management of site-specific bleeding in palliative care patients. RESULTS: Haemorrhagic complications are frequent in palliative care patients in the internal medicine ward. Current guidelines propose a therapeutic-only platelet transfusion policy. Nonetheless, prophylactic and/or therapeutic transfusion remains a physician-dependent decision. Site-specific therapeutic options are based on expert opinion and case reports. While invasive measures may be pertinent in certain situations, their application must be compatible with patient goals. Catastrophic bleeding requires caregivers' comforting presence; pharmacological management is secondary. CONCLUSION: Literature is lacking regarding management of bleeding in the palliative care population hospitalised in an acute medical setting. Recommendations are of limited quality, the majority based on case reports or expert opinion. Further studies, exploring for example the impact on patient quality of life, are desirable to improve the management of this frequently encountered complication.

[The transition of palliative care from the hospital to the ambulatory care of the general practitioner: the experience in the canton of Fribourg]. / Soins palliatifs: de l'hôpital de soins aigus au cabinet du praticien. L'expérience fribourgeoise.

Thanks to medical progress, the life expectancy of a majority of severely ill patients has greatly improved. The fact that these patients will live longer with their disease encourages new solutions to respond to the challenges of care continuity, coordination, interprofessional and interinstitutional collaboration. Palliative care represents a chain management based on the involvement of every professional in acute care hospitals, palliative care units, nursing homes and private homes. The collaboration among the different players as well as their education are essential elements linked to the quality of care, to the quality of life for both patients and their relatives.

Everolimus versus mycophenolate mofetil in heart transplantation: a randomized, multicenter trial.

In an open-label, 24-month trial, 721 de novo heart transplant recipients were randomized to everolimus 1.5 mg or 3.0 mg with reduced-dose cyclosporine, or mycophenolate mofetil (MMF) 3 g/day with standard-dose cyclosporine (plus corticosteroids ± induction). Primary efficacy endpoint was the 12-month composite incidence of biopsy-proven acute rejection, acute rejection associated with hemodynamic compromise, graft loss/retransplant, death or loss to follow-up. Everolimus 1.5 mg was noninferior to MMF for this endpoint at month 12 (35.1% vs. 33.6%; difference 1.5% [97.5% CI: -7.5%, 10.6%]) and month 24. Mortality to month 3 was higher with everolimus 1.5 mg versus MMF in patients receiving rabbit antithymocyte globulin (rATG) induction, mainly due to infection, but 24-month mortality was similar (everolimus 1.5 mg 10.6% [30/282], MMF 9.2% [25/271]). Everolimus 3.0 mg was terminated prematurely due to higher mortality. The mean (SD) 12-month increase in maximal intimal thickness was 0.03 (0.05) mm with everolimus 1.5 mg versus 0.07 (0.11) mm with MMF (p < 0.001). Everolimus 1.5 mg was inferior to MMF for renal function but comparable in patients achieving predefined reduced cyclosporine trough concentrations. Nonfatal serious adverse events were more frequent with everolimus 1.5 mg versus MMF. Everolimus 1.5 mg with reduced-dose cyclosporine offers similar efficacy to MMF with standard-dose cyclosporine and reduces intimal proliferation at 12 months in de novo heart transplant recipients.

[Breaking bad news: "EPICES", a French style as a learning method]. / Annonce de mauvaises nouvelles: une pointe d'EPICES dans l'apprentissage.

Breaking bad news is a daily task for doctors and nurses. These health professionals may feel powerless to achieve this task and to deal with the emotions that arise in the patient when they are doing so. The interdisciplinary approach and a specific training are essential resources to feel more comfortable in this context. "EPICES", the French translation of the mnemonic acronym "SPIKES", of Buckman, gives a guide for this sensitive practice.

Intermittent claudication: From its risk factors to its long-term prognosis in men. The Quebec Cardiovascular Study.

BACKGROUND: The natural history of intermittent claudication, from its risk factors to its cardiovascular prognosis, has been reported in few prospective studies. OBJECTIVE: To assess incident intermittent claudication, as well as its risk factors and long-term prognosis in men. METHODS: A random sample of 4376 men 35 to 64 years of age from Quebec City (Quebec), who were free of cardiovascular disease (CVD), was evaluated in 1974 for CVD risk factors and followed until 1998. To assess the prognosis, the event rates between 1985 and 1998 were computed among men with incident claudication without other CVD, incident survivors of a first myocardial infarction (MI) without other CVD and men free of CVD between 1974 and 1985. RESULTS: From 1974 to 1998, 300 men developed intermittent claudication. Tobacco consumption, high systolic blood pressure and diabetes at least doubled the adjusted RR (aRR) of intermittent claudication. In 1985, there were 80 claudicants, 2868 men free of CVD and 68 survivors of a first MI. During the 13-year follow-up, a new CVD occurred in 48.8% of the claudicants, in 18.9% of men without CVD (aRR 2.08; 95% CI 1.48 to 2.90) and in 45.6% of MI survivors (aRR compared with claudicants 1.12; 95% CI 0.69 to 1.79). There was also no significant difference between claudicants and MI survivors for fatal CVD, nonfatal CVD and total mortality. CONCLUSIONS: Men with intermittent claudication are at high risk for CVD that may be equivalent to men with previous MI.

Pulmonary recruitment protocol for organ donors: a new strategy to improve the rate of lung utilization.

Because lung transplantation is the only effective therapy for terminal respiratory failure, the demand for donor lungs has increased steadily. However, the number of donors has remained fairly constant over the years, which results in an increasing duration of waiting for lung transplantation. To overcome the lack of organs, various strategies have been developed by transplant centers including use of marginal donors. To increase the lung utilization rate in multiorgan donors, we implemented a simple lung recruitment protocol involving a brief period of controlled sustained inflation. In 2005, the lung utilization rate in the transplant program at our institution was only 20% in multiorgan donors. With the lung recruitment protocol, the rate of lung utilization for transplantation increased to 33%, in 2006, 24% in 2007, and 24% in 2008. Following the lung recruitment protocol, the arterial oxygen tension/fraction of inspired oxygen ratio increased to greater than 15% in more than 40% of donors. We were able to improve gas exchange sufficiently that as many as two-thirds of the lungs were suitable for transplantation. During the protocol, no complications were reported, and no patient became hemodynamically unstable, precluding organ procurement. We believe that optimization of multiorgan donor management with simple interventions may improve oxygenation, reducing the number of inadequate donor lungs and increasing the overall donor pool and organ availability.

Palliative care education in Swiss undergraduate medical curricula: a case of too little, too early.

Palliative medicine education is an important strategy in ensuring that the needs of terminally ill patients are met. A review was conducted in 2007 of the undergraduate curricula of all five of Switzerland's medical schools to identify their palliative care-related content and characteristics. The average number of mandatory hours of palliative care education is 10.2 h (median 8 h; range 0-27 h), significantly short of the 40 h recommended by the European Palliative Care Association's Education Expert Group. The median time allocated to designated palliative care blocks is 3 h (range 0-8 h). Most of the education occurs before the clinical years, and there are no mandatory clinical rotations. Three schools offer optional clinical rotations but these are poorly attended (<10% of students). Although a number of domains are covered, ethics-related content predominates; 21 of a total of 51 obligatory hours (41%). Communication related to palliative care is largely limited to 'breaking bad news'. In two of the schools, the teaching is done primarily by palliative care physicians and nurses (70% or more of the teaching). In the others, it is done mostly by educators in other clinical specialties and ethics (approximately 90% of the teaching). These findings show significant deficiencies.

The response of a Swiss university hospital's palliative care consult team to assisted suicide within the institution.

In January 2006 the Centre Hospitalier Universitaire Vaudois (CHUV), a large university hospital in Lausanne, Switzerland, became the first hospital in Switzerland to allow assisted suicide (AS) in exceptional cases within its walls. However, euthanasia is illegal. This decision has posed several ethical and practical dilemmas for the hospital's palliative care consult service. To address these, the team embarked on a formal process of open dialogue amongst its members with the goal of identifying a collective response and position. This process involved meetings every 4 to 6 weeks over the course of 10 months. An iterative process unfolded. One of the principal dilemmas relates to finding a balance between the team's position against AS and the patient's autonomy and the institution's directive. Although all team members expressed opposition to AS, there were mixed opinions as to whether or not the team members should be present during the act if requested so by patients. Some thought this could be misinterpreted as complicity in the act and could send out mixed messages to the public and other health professionals about palliative care. Others felt that the team's commitment to nonabandonment obliged them to be present even if they did not provide the drug or give any advice or assistance. The implications of nonabandonment are explored, as are several other questions such as whether or not the teams are obliged to provide detailed information on AS when requested by patients.

[Competencies in palliative care: what should the physicians be able to do?]. / Compétences en soins patiatifs: que faut-il savoir faire en tant que médecin?

Palliative patients (patients with progressive incurable illnesses) have a number of needs, early and late in their illness trajectories. This article highlights some of the most important competencies required by physicians to address these needs. They cover a broad spectrum of domains and include pain and symptom management, communication, disclosure, prognostication, and psychological, social and spiritual needs. All physicians, generalists and specialists alike, should possess the basic competencies but should also recognize that some patients, especially those not responding to initial strategies, require timely referrals to specialized palliative care teams.

The development of measures of community capacity for community-based funding programs in Canada

Improving community capacity for influencing actions on the determinants of health is an immediate outcome of many Public Health Agency of Canada-funding community-based programs. Despite the importance of this outcome, it has been difficult to measure and describe the contribution of funding programs to improving community capacity. This paper reports on a study conducted to develop and establish the psychometric properties of scales that measure community capacity to address health issues in the context of federally funded community-based programs. A literature review and national think tank with 21 experts informed the development of the first draft of the scales that outlined nine key domains of community capacity. Two focus groups with community practitioners provided information on the face and content validity and general usability of this draft instrument. The revised instrument was sent for pilot testing to 114 community organizations. Qualitative and quantitative analyses were performed to assess the validity, reliability and usability of the instrument. Twenty-nine organizations returned a completed instrument (25 per cent response rate). Principal Component Analysis confirmed scale unidimensionality for eight multi-item scales: all of the component loadings were considered good with all scales loading between 0.60 and 0.92. Scale internal consistency was also considered high with alphas between 0.72 and 0.86 for six of these eight scales. Spearman's correlations were significant for the remaining two multi-item scales (composed of two items each), indicating that the two items for each scale were significantly correlated to each other. One scale could not be analyzed quantitatively, as it contained only a single item. Triangulation of qualitative and quantitative results found consistency in interpretations of scale response sets. Feedback on the instrument indicated interest in using it for project planning and evaluation. Psychometric analyses and triangulation provided evidence of the construct validity and reliability of the instrument. The final instrument covers 9 domains and has a total of 26 items, each with a four-point rating scale and a section for qualitative contextual comments. The instrument provides quantitative and qualitative information on community capacity within the context and scope of community-based funding programs. (AU)

Tumor de Frantz: presentación de un caso / Frantz's tumor: report of a case

El tumor papilar sólido-quístico de páncreas es una neoplasia muy poco frecuente y de origen incierto. Suele afectar a mujeres jóvenes, cursa con escasa sintomatología y es considerado en general como una neoplasia de bajo grado de malignidad. Su tratamiento es quirúrgico, presentando un excelente pronóstico tras resección completa incluso si existen metástasis. Presentamos el caso de una paciente de 14 años de edad diagnosticada de una neoplasia localizada en cola de páncreas que correspondía a un tumor de Frantz. Analizamos las características biológicas y ultraestructurales de estos tumores, sus formas de presentación y las pruebas complementarias recomendadas para su diagnóstico.

Solid-cystic-papillary tumor of pancreas is an uncommon neoplasm and unknown origin. It generally occurs in young women, the symptomatology is limited and is considered a low-grade malignant tumor. Treatment is surgical and the prognosis is usually good after complete resection, even if metastatic dissemination exists. We report a case of a 14-years-old woman diagnosed of a neoplasm in the tail of the pancreas which could be classified as Frantz's tumor. We analyze the biological and ultrastructural characteristics of these tumors, their forms of presentation and the recommended explorations for the diagnostic.

Hematomas espontáneos de la pared abdominal / Spontaneous Hematomas of the abdominal wall

Introducción: El hematoma espontáneo de la pared abdominal (HEPA) es una entidad de aparición infrecuente y de difícil diagnóstico debido a la similitud clínica con otros procesos agudos. Suele aparecer en pacientes que siguen tratamiento anticoagulante y se caracteriza por su forma de presentación brusca como dolor abdominal agudo. La cirugía puede evitarse en la mayoría de los casos si se diagnostica correctamente mediante pruebas de imagen. Observaciones clínicas: Presentamos 12 casos de HEPA tratados en nuestro Servicio entre los años 1999 y 2005, y realizamos una revisión de esta entidad en cuanto a etiología, factores desencadenantes, diagnóstico y tratamiento. Conclusión: El tratamiento del HEPA debe ser conservador, reservando la cirugía para aquellos casos que presenten deterioro hemodinámico por sangrado activo.

Introduction: Spontaneous hematoma of the abdominal wall is infrequent and difficult to diagnose due to its clinical similarity with other acute processes. It is usually associated with patients undergoing anticoagulant therapy and is characterized for its form of abrupt presentation like acute abdominal pain. Surgery can be avoided in most patients if hematoma is correctly diagnosed by imaging tests. Clinical observations: We present 12 cases of spontaneous hematoma of the abdominal wall from 1999 through 2005 and we review the etiology, precipitating factors, diagnosis and treatment of this clinical entity. Conclusion: Treatment of spontaneous hematoma of abdominal wall must be preservative, reserving the surgery for those cases that present hemodynamic compromise by persistent hemorrhage.

Age and duration of follow-up as modulators of the risk for ischemic heart disease associated with high plasma C-reactive protein levels in men.

BACKGROUND: Plasma C-reactive protein (CRP) levels recently have been identified as an emerging risk factor for ischemic heart disease (IHD). However, whether plasma CRP levels predict an increased risk for future IHD beyond traditional risk factors has yet to be evaluated in a large prospective, population-based study. METHODS: The association between elevated plasma CRP levels and the risk for future IHD was investigated in the prospective, population-based cohort of 2037 IHD-free middle-aged men from the Quebec Cardiovascular Study. During a 5-year follow-up, 105 first IHD events were recorded. Baseline plasma CRP levels were measured using a highly sensitive assay. RESULTS: High plasma CRP concentrations (equal to or above vs below the median level of 1.77 mg/L) were associated with a significant 1.8-fold increase in IHD risk (95% confidence interval [CI], 1.2-2.7). This association remained significant after adjustment for lipid risk factors but not when the simultaneous contribution of nonlipid traditional risk factors was taken into account. Multivariate analyses indicated that CRP level predicted short-term risk for IHD (events that occurred < or =2 years after the baseline evaluation), but not long-term risk (>2 years). Moreover, high plasma CRP levels predicted an increased risk for IHD, independent of any other confounder, in younger (< or =55 years) but not in older (>55 years) individuals. CONCLUSION: Plasma CRP levels may provide independent information on IHD risk only in younger middle-aged men and in the case of IHD events that may occur relatively soon after the baseline evaluation.

Total cholesterol/HDL cholesterol ratio vs LDL cholesterol/HDL cholesterol ratio as indices of ischemic heart disease risk in men: the Quebec Cardiovascular Study.

BACKGROUND: Total cholesterol (TC)/high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C)/HDL-C ratios are used to predict ischemic heart disease risk. There is, however, no consensus on which of these 2 indices is superior. The objective of the present study was to present evidence that the LDL-C/HDL-C ratio may underestimate ischemic heart disease risk in overweight hyperinsulinemic patients with high triglyceride (TG)-low HDL-C dyslipidemia. METHODS: A total of 2103 middle-aged men in whom measurements of the metabolic profile were performed in the fasting state were recruited from 7 suburbs of the Quebec metropolitan area. RESULTS: The relationship of LDL-C/HDL-C to TC/HDL-C ratios was examined among men in the Quebec Cardiovascular Study classified into tertiles of fasting TG levels. For any given LDL-C/HDL-C ratio, the TC/HDL-C ratio was higher among men in the top TG tertile (>168 mg/dL [>1.9 mmol/L]) than in men in the first and second TG tertiles. Adjustment of the TC/HDL-C ratio for LDL-C/HDL-C by covariance analysis generated significant differences in average TC/HDL-C ratios among TG tertiles (P<.001). Greater differences in features of the insulin resistance syndrome (insulinemia, apolipoprotein B, and LDL size) were noted across tertiles of the TC/HDL-C ratio than tertiles of the LDL-C/HDL-C ratio. CONCLUSION: Variation in the TC/HDL-C ratio may be associated with more substantial alterations in metabolic indices predictive of ischemic heart disease risk and related to the insulin resistance syndrome than variation in the LDL-C/HDL-C ratio.

Comparison of various electrophoretic characteristics of LDL particles and their relationship to the risk of ischemic heart disease.

BACKGROUND: Several cross-sectional studies and 3 prospective, nested, case-control studies have indicated that individuals with small, dense low density lipoprotein (LDL) particles are at increased risk for ischemic heart disease (IHD). However, whether LDL particle size is an independent risk factor for future IHD events remains controversial. The objective of the present study was to further analyze the cardiovascular risk associated with various electrophoretic characteristics of LDL particles in men. METHODS AND RESULTS: LDL particles were characterized by polyacrylamide gradient gel electrophoresis (PAGGE) in a cohort of 2034 men of the Quebec Cardiovascular Study. All men were initially free of IHD and were followed up for a period of 5 years, during which 108 first IHD events were recorded. Among all LDL characteristics investigated by PAGGE, including LDL peak particle size, the cholesterol concentration in LDL particles with a diameter smaller than 255 A showed the strongest association with the risk of IHD (relative risk=4.6 in men in the third vs first tertile of the distribution, P<0.001). Multivariate logistic and survival models indicated that the relationship between LDL cholesterol levels in particles with a diameter <255 A and IHD risk was independent of all nonlipid risk factors and of LDL cholesterol, high density lipoprotein cholesterol, triglyceride, and lipoprotein(a) levels. CONCLUSIONS: Results from this large, population-based, prospective study suggest that further characterization of LDL particles by PAGGE, in addition to the traditional lipid profile, may improve our ability to predict IHD events in men.

Transplant coronary artery disease: a novel model independent of cellular alloimmune response.

BACKGROUND: Allograft coronary atherosclerosis (TxCAD) is the leading cause of death after the first year after transplantation. TxCAD is believed to be a form of chronic rejection of the cardiac allografts. This study was undertaken to determine whether TxCAD could develop in the absence of a cellular alloimmune response. METHODS AND RESULTS: Inbred lean Zucker rats (>26 generations) served as donors and recipients of the cardiac grafts. Donor hearts were explanted at 60 or 90 days. Explanted hearts were processed for coronary artery histological analysis. Cytokine expression was determined by reverse transcription-polymerase chain reaction, and the presence of T cells within the explanted hearts was evaluated by immunohistochemistry. Forty-six transplantations were made, and TxCAD developed in all but one of the transplanted hearts. Overall, one third of the vessels examined were affected by TxCAD, and in roughly half of these vessels, the disease was severe. Native hearts were free of atherosclerosis. Interleukin-2 was absent from the transplanted hearts, and T cells were present in minimal amounts (<1 per low-power field). CONCLUSIONS: TxCAD developed in the absence of a cellular alloimmune response in these genetically similar donors and recipients. The observed TxCAD was significant and comparable to what is found in rat allografting models.

A prospective, population-based study of low density lipoprotein particle size as a risk factor for ischemic heart disease in men.

BACKGROUND: The current interpretation of the increased risk of ischemic heart disease (IHD) associated with reduced low density lipoprotein (LDL) particle size is based entirely on data derived from relatively small case-control studies, with a lack of evidence from large, prospective, population-based cohort data. OBJECTIVES: To investigate the association between LDL particle size and incident IHD on the basis of data from the entire population-based, prospective cohort of men from the Quebec Cardiovascular Study. PATIENTS AND METHODS: Analyses were conducted in a cohort of 2057 men who were all initially free of IHD, and who were followed up over a five-year period, during which 108 first IHD events (myocardial infarction, angina or coronary death) were recorded. LDL particle size was measured by nondenaturing gradient gel electrophoresis. RESULTS: Cox proportional hazards analysis indicated that the relationship between LDL particle size and the risk of future IHD events was not linear. Men with an LDL particle size less than 256.0 A had a significant 2.2-fold increase in the five-year rate of IHD (P<0.001) compared with men having an LDL particle size greater than 256.0 A. Multivariate and subgroup analyses indicated that small, dense LDL particles predicted the rate of IHD independent of LDL cholesterol, triglycerides, high density lipoprotein (HDL) cholesterol, apolipoprotein B and the total cholesterol to HDL cholesterol ratio. Finally, the magnitude of the increase in IHD risk attributed to lipid risk factors was modulated to a significant extent by variations in LDL particle size. CONCLUSIONS: The present study provides the first large scale, population-based, prospective evidence supporting the hypothesis that small, dense LDL particles may be associated with an increased risk of IHD. The results also suggest that information on LDL diameter may improve the ability to predict IHD risk accurately over traditional lipid variables.

A smoking reduction and cessation program with registered nurses: findings and implications for community health nursing.

A smoking reduction and cessation program was implemented with registered nurses in 3 Canadian provinces. Nurses (n = 117) participated in either an 8-week group or self-directed program using a resource specifically designed for nurses. Questionnaires were administered prior to and at the end of the 8-week interventions and at 6 and 12 months postintervention. Statistically significant changes at 8 weeks in nurses' smoking practices were found on the number of nurses continuing to smoke, mean number of cigarettes smoked, and movement in the stage of behavioral change. Attrition and variation in patterns of quitting over the 12-month study period made assessing participants' longer term outcomes difficult. This study highlights the complexity of assisting nurses to quit smoking and of implementing and evaluating a program based on accepted community health models of practice.