Predicting macular hole closure with ocriplasmin based on spectral domain optical coherence tomography.

PurposeTo assess the preoperative features of patients with idiopathic macular hole (IMH) and vitreomacular adhesion (VMA) treated with ocriplasmin (OCP) that can predict successful closure.MethodData were prospectively collected on all patients with IMH treated with OCP in three British ophthalmic centres. Several preoperative variables were recorded including the IMH base diameter (BD), minimum linear diameter (MLD), and VMA width measured on spectral domain optical coherence tomography. Several other IMH indices were derived including a 'width factor', defined as the BD minus the MLD in µm. The occurrence of VMA release and hole closure were used as the main outcome measures.ResultsThirty-three patients in total with IMH were treated with OCP. Two patients developed rhegmatogenous retinal detachment and were excluded. The mean age of the remaining 31 patients was 71 years, and 71% were female. VMA release occurred in 19 of the 31 (61%) patients and macular hole closure in 11 (35%). Width factor was the most predictive feature for closure on multivariate analysis. The deviance R(2) was 67% (P<0.001). An IMH with a width factor of <60 µm had a 95% certainty of closure, whereas if >290 µm then there was less than a 5% chance of closure. Neither VMA width nor MLD alone was associated with VMA release or closure.ConclusionsPatients with macular holes where the BD was close in size to the MLD had an improved probability of closure than holes with wider base configurations.

Goldmann tonometer calibration: a national survey.

INTRODUCTION: Recent studies suggest that Goldmann tonometers can rapidly develop calibration errors (CEs) in clinical use and routine checks are necessary to ensure accuracy. PURPOSE: To determine current practice regarding CE checks in the United Kingdom and assess the views of senior nursing staff in charge of running ophthalmology outpatient clinics as to whom they feel to be responsible for CE checks. METHODS: Every ophthalmology unit with training recognition in England, Northern Ireland, Scotland, and Wales was contacted. Senior nurses responded to a structured telephone questionnaire regarding local tonometer calibration practice and their views regarding who is responsible for CE checks. A total of 155 eye units were identified and contacted. The response rate was 100%. RESULTS: CEs were checked for daily in 8 units (5.2%), weekly in 20 units (12.9%), fortnightly in 1 unit (0.6%), monthly in 12 units (7.7%), trimonthly in 5 units (3.2%), biannually in 27 units (17.4%), and annually in 21 units (13.5%). CEs were either never checked or checked in a very random manner (no identifiable pattern) in 61 units (39.4%). Sixty-three (40.6%) of the respondents felt CE checks were a departmental responsibility, 48 (31.0%) felt it to be the doctor's responsibility, and 44 (28.4%) felt CE checks should be performed by the nursing staff. CONCLUSIONS: Our national survey suggests that very few units check their tonometers for CEs at intervals which ensure their accuracy. Our previous survey of doctors suggests that they believe nurses should check for CE, whereas the nursing staff believe CE checks are not their responsibility. This lack of communication between health-care professionals may lead to inaccurate tonometers being used in clinical practice. We suggest that every eye unit should have a protocol, which clearly identifies individuals responsible for checking for CEs at least on a monthly basis.

Death rattle: its impact on staff and volunteers in palliative care.

BACKGROUND: Hospice staff and volunteers frequently hear the sound of death rattle and offer explanations and reassurance to relatives and other patients. This paper describes our study into the impact of hearing the sound of death rattle on hospice staff and volunteers, part of our wider investigation into death rattle. METHODS: Seven focus group meetings were held, involving a total of 41 participants from medical, nursing, chaplaincy, housekeeping and volunteer backgrounds. Meetings were audio-taped and the transcripts analysed using thematic analysis. RESULTS: Most participants expressed negative feelings about hearing the sound of death rattle and felt that relatives were also distressed by it. Medical and nursing participants reported diverse views on why they intervene. Some acknowledged the influence of their own emotional response to the sound. Others felt that intervention was part of their professional role or that the existence of a therapeutic option made it necessary to intervene. CONCLUSION: Death rattle has a negative impact on staff and volunteers who work with dying patients. This effect may influence their decision to intervene when death rattle occurs. Doctors and nurses need to consider why, when and how they intervene and the consequences of that intervention.

Interventions for noisy breathing in patients near to death.

BACKGROUND: Noisy breathing (death rattle) occurs in 23 to 92% of people who are dying. The cause of death rattle remains unproven but is presumed to be due to an accumulation of secretions in the airways. It is therefore managed physically (repositioning and clearing the upper airways of fluid with a mechanical sucker) or pharmacologically (with anticholinergic drugs). OBJECTIVES: To describe and assess the evidence for the effectiveness of interventions used to treat death rattle in patients close to death. SEARCH STRATEGY: Randomised controlled trials (RCTs), before and after studies and interrupted time series (ITS) studies in adults and children with death rattle were sought by MEDLINE (1966 to 2007), EMBASE (1980 to 2007), CINAHL (1980 to 2007), the Cochrane Pain, Palliative and Supportive Care Trials Register and the Cochrane Central Register of Controlled Trials. In addition, the reference lists of all relevant trials and reports were checked and investigators who are known to be researching this area were contacted for unpublished data or knowledge of the grey literature. SELECTION CRITERIA: RCTs, controlled before and after studies and ITS reporting the outcome of pharmacological and non-pharmacological interventions for treating death rattle. DATA COLLECTION AND ANALYSIS: Data was extracted by two independent review authors and trials were quality scored. There was insufficient data to carry out an analysis. MAIN RESULTS: Thirty studies were identified, of which only one study met the inclusion criteria. This small study was a randomised placebo-controlled trial of the use of hyoscine hydrobromide in patients with death rattle. Hyoscine hydrobromide tended to reduce death rattle compared to placebo but this was not significant. A larger randomised study, comparing atropine, hyoscine butylbromide and scopolamine, is in progress. AUTHORS' CONCLUSIONS: There is currently no evidence to show that any intervention, be it pharmacological or non-pharmacological, is superior to placebo in the treatment of death rattle. We acknowledge that in the face of heightened emotions when death is imminent, it is difficult for staff not to intervene. It is therefore likely that the current therapeutic options will continue to be used. However, patients need to be closely monitored for lack of therapeutic benefit and adverse effects while relatives need time, explanation and reassurance to relieve their fears and concerns. There is a need for more well-designed multi-centre studies with objective outcome measures and the ability to recruit sufficient numbers.

Tonometer disinfection practice in the United Kingdom: a national survey.

PURPOSE: To assess current tonometer disinfection practice in the UK, and compare with published recommendations. METHODS: Every ophthalmology unit with training recognition in the UK was contacted (n=155). A senior nurse at each institution completed a telephone questionnaire regarding local tonometer disinfection practice. RESULTS: The response rate was 100%. Thirty-five units (23%) reported exclusive use of disposable tonometer heads and were excluded from further analysis. One hundred and twenty units (77%) used either reusable or a combination of reusable and disposable tonometer heads. Where reusable heads were used, 80 units (67%) immersed them in a chlorine-based solution such as sodium hypochlorite or sodium dichloroisocyanurate. Others used isopropyl alcohol (18 units), hydrogen peroxide (12 units), chloramine (5 units), chlorhexidine (4 units) and peracetic acid (1 unit). Where a chlorine-based agent was used, the concentration of available chlorine ranged from 125 to 30 000 p.p.m., with 50 units (63%) using a concentration of less than 5 000 p.p.m. (i.e., inadequate based on published recommendations). Where the tonometer head was immersed in disinfectant between patients (n=101), 29 units (29%) provided just one tonometer head per practitioner, making adequate soak time between patients unlikely. Every unit replenished the disinfectant at least daily, deemed sufficient for most agents. However, hydrogen peroxide solutions should be replenished twice daily, which did not take place in nine units. CONCLUSION: This survey reveals disparity between current tonometer disinfection practice and published international recommendations, with some institutions using practices that may render patients susceptible to transmissible infection.

The sound of death rattle I: are relatives distressed by hearing this sound?

BACKGROUND: Death rattle is the noisy, rattling breathing that occurs in many dying patients. Health professionals intervene because the sound is said to distress attendant relatives. We found no formal study to confirm or refute relatives' distress, so we decided to ask the relatives. METHOD: Face-to-face semi-structured interviews with 27 bereaved relatives to investigate their experience of terminal care and what their response had been to the sound of death rattle if this had occurred. Interview transcripts were subjected to thematic content analysis. RESULTS: We found that almost half of the 12 relatives who had heard the sound of death rattle had been distressed by it. The others were either neutral about the sound or found it a helpful signal of impending death. CONCLUSION: We confirmed that some relatives do find it distressing to hear the sound of death rattle. However, our expectation that relatives are universally disturbed by this sound was unfounded. There is no justification for a 'blanket' approach to therapeutic intervention when death rattle occurs. A better understanding is required of how relatives make sense of the sound of death rattle.

The sound of death rattle II: how do relatives interpret the sound?

BACKGROUND: In an earlier study, we found that some bereaved relatives (five out of 12 interviewed) found it distressing to hear the sound of death rattle, but the remainder did not. In this paper, we report a second study in which we explored how a different group of relatives interpreted the sound of death rattle when they heard it. METHOD: We conducted face-to-face semi-structured interviews with 25 bereaved relatives using the principles of grounded theory. RESULTS: Seventeen of the 25 bereaved relatives interviewed had heard the sound of death rattle. Ten relatives were distressed by the sound, but seven were not. Some relatives regarded the sound of death rattle as a useful warning sign that death was imminent. Their interpretation of the sound was influenced by the patient's appearance, being less concerned if the patient was not obviously disturbed. Relatives were distressed when they thought that the sound of death rattle indicated that the patient might be drowning or choking. These concerns were reinforced by seeing fluid dribble from the dying patient's mouth. CONCLUSION: This study confirms the previous finding that not all relatives are distressed by the sound of death rattle. It also demonstrates that relatives interpret the sound in a variety of ways, some matter of fact and some distressing. We suggest that effective communication is helpful in uncovering relatives' interpretation of death rattle and dispelling unwarranted fears.

Palliative care: a suitable setting for undergraduate interprofessional education.

Effective delivery of high-quality palliative care requires effective interprofessional teamworking by skilled health and social care professionals. Palliative care is therefore highly suitable for sowing the seeds of interprofessional teamworking in early professional education. This paper describes experiences of running undergraduate interprofessional workshops in palliative care for medical, nursing, social work, physiotherapy and occupational therapy students. These workshops are unusual in three respects: first, the involvement of family carers mean that these learning experiences are rooted in clinical reality; secondly, there is no attempt to 'tidy up' the story for the students; thirdly, unlike many undergraduate interprofessional programmes, these workshops have been sustained over several years. Evaluation of these workshops demonstrate that students value and enjoy the opportunity to work together; they find the experience moving, informative and interesting. Feedback from carers showed that they appreciated the opportunity to present their real-life experiences to students. Our evidence suggests that palliative care is a suitable subject for undergraduate interprofessional education.

'Someone to talk to' and 'pain control': what people expect from a specialist palliative care team.

This paper presents a qualitative analysis of a subsample of data from a larger investigation into general practitioner referrals to specialist palliative care services (SPCS). The aim was to identify the expectations and perceptions of patients with advanced cancer and their relatives. Twenty-nine individuals were interviewed (18 patients, 11 relatives). Qualitative analysis of the interview transcripts was undertaken using an approach based on interpretative phenomenological analysis. The results indicated that SPCS were perceived as providing psychosocial services, characterized as 'support' and 'someone to talk to'. SPCS were expected to have 'expertise in symptom control', particularly in relation to pain management. The study demonstrated that patients' and relatives' expectations of a referral to SPCS were of psychosocial support and symptom control. It is argued that the implications of this restricted view of SPCS may mean that other salient concerns are not raised by patients and relatives.

Impact of witnessing death on hospice patients.

In the three decades since the concept of "awareness" was introduced to describe the nature of communication between dying people and their carers, there has been a radical change in hospital policies and medical practice. It is now common for the majority of cancer patients to be given full information about their disease and prognosis. Hospices provide a model of care in which death and dying are dealt with in an open manner. While this approach has been welcomed by the majority of people, a minority might still prefer a more limited awareness. An inevitable part of hospice care is the exposure to, and awareness of, people who are dying. There is little empirical data that considers the impact of death on fellow patients. This pilot investigation compared psychological morbidity, perceptions of comfort and/or distress, and descriptions of a "good death" in hospice cancer patients who reported witnessing a fellow patient's death (n = 34) with patients who did not have this experience (n = 33). Patients were assessed using the Hospital Anxiety and Depression scale, an Events Checklist and a semi-structured interview. The results indicate that patients witnessing a death were significantly less depressed than those who did not. Awareness of dying was found to be both comforting and distressing, although overall patients reported more comforting than distressing events. A "good death" was defined by patients in terms of symptom control, including dying in their sleep, being pain free, quietness and dignity. Narratives were used to describe the meaning of a "good death". Quantitative and qualitative analyses have been undertaken to provide a complex interpretation of these issues.

Perceptions of a 'good' death: a comparative study of the views of hospice staff and patients.

The literature suggests that health professionals working in palliative care have developed an idealised concept of dying which has been labelled the 'good' death. This paper reports the results of a preliminary qualitative study which compared the concepts of a 'good' death used by patients and staff in a palliative care unit. Semistructured interviews designed to elicit perceptions of 'good' and 'bad' deaths were conducted with 18 patients and 20 health professionals. The transcribed interviews were content analysed. There were major differences between the views of patients and staff. The patients' descriptions of a "good' death were diverse and included: dying in one's sleep, dying quietly, with dignity, being pain free and dying suddenly. In comparison, staff characterised a "good' death in terms of adequate symptom control, family involvement, peacefulness and lack of distress, while a "bad' death was described as involving uncontrolled symptoms, lack of acceptance and being young. The findings suggest that patients and staff differ in their conceptualisations of a "good' death.

Occupational and environmental hygiene assessment of fumigations with methyl bromide.

Use of methyl bromide for pest control fumigation may result in adverse exposure to three populations: the actual fumigators; other workers not actually involved in the fumigation; and the general public in the vicinity. The risk of exposure of these three target populations in Switzerland was investigated. The methodology was a combination of occupational hygiene surveys, including a preliminary hazard analysis, with a comprehensive assessment of the safety and health systems in use based on the 'Management Oversight and Risk Tree' (MORT) method [Knox and Eicher, MORT User's Manual, Revision 2. DOE 76-45/4 (1983)]. The target populations most concerned depend on the type of fumigation. Fumigators risk severe accidental exposure although they usually wear personal protection devices. In soil and chamber fumigation, workers not involved in the fumigation may undergo high exposure (75-100 pm for 1 h), far greater than the usual time-weighted average and short-term occupational exposure limits (5-20 ppm range). Occupants of premises adjoining the fumigated buildings may also be exposed to significant concentrations (25-50 ppm for 0.1-2 h). Problems originate mainly from a lack of management controls, failure to apply an appropriate code of practice and the use of personnel who are not properly qualified and trained.

Control of pain in terminal cancer.

Many elderly patients with cancer neither expect nor seek good pain control. This stoicism often follows the experience of poor symptom control among relatives and friends in the past and may explain why the severity of pain may be underestimated by the clinician. In addition, when pain is identified, physicians may be apprehensive about the use of strong analgesic drugs and their side effects, so that pain control is poor. This paper describes the diagnosis, assessment, and management of cancer pain in the elderly and deals specifically with analgesic and other drugs for the control of pain. The methods described are effective in up to 87% of patients. Although side effects occur, they can be minimized by skillful prescribing, explanation and reassurance.

Molecular heterogeneity of pregnancy-specific beta 1-glycoprotein (SP1).

Ion-exchange chromatography has been used to isolate three separate forms of Pregnancy-Specific beta 1-Glycoprotein (SP1) from pooled, late-pregnancy human sera. Each of the three components was immunochemically identifiable as SP1, yet distinguishable from each other on the basis of rocket morphology resulting from rocket immunoelectrophoresis (RIE). The elution profile from DEAE Sephacel indicated that each component has an isoelectric point below pH 8.6, but suggested a different charge for each molecular species. Crossed immunoelectrophoresis (XIE) of pooled, late pregnancy serum suggested the presence of each component prior to physico-chemical treatment and showed the components to be characterised by alpha, beta or gamma electrophoretic mobility. The differences in rocket morphology suggested differing affinities for the antiserum, and a difference in molecular size, which was confirmed by gel filtration.

Pregnancy-specific beta 1-glycoprotein as a screening test for at-risk pregnancies.

A serum assay was performed on 605 women for pregnancy-specific beta 1-glycoprotein (SP-1) between 31 and 34 weeks' gestation. SP-1 was also estimated for 255 of these women between 15 and 20 weeks' gestation, coincidental with maternal serum alpha-fetoprotein (AFP) screening. A clinical classification of pregnancy outcome was constructed for ech group. SP-1 values at 31 to 34 weeks' gestation in pregnancies that resulted in the birth of a small-for-dates (SFD) infant were statistically different from those in normal pregnancies (p less than 0.001). A value of 100 mg per liter was chosen as a suitable discriminatory level at 31 to 34 weeks, below which SP-1 had a sensitivity of 64%, a predictive value of 24%, and defined a relative risk of 5.3 for SFD infants. These parameters compare favorably with published data on the use of human placental lactogen as a screening test. No statistical relationship was found between SP-1 values at 31 to 34 weeks and birth weight, placental weight, parity, or other abnormal pregnancy outcomes. SP-1 screening at 15 to 20 weeks' gestation showed no correlation with serum AFP or with other parameters studied.