A Quantitative Framework Classifying the Palliative Care Workforce into Specialist and Generalist Components.

BACKGROUND: Early referral to palliative care (PC) services has been shown to improve quality of life in advanced cancer. However, limitations in trained PC workforce raise issues with the sustainability of delivering PC with early PC referral. Classifying PC into generalist and specialist components could be one approach to sustainable PC delivery models but a quantitative guide for this classification is presently lacking in the literature. OBJECTIVE: To undertake a retrospective examination of clinical data obtained from a PC benchmarking project to develop a quantitative framework guiding classification of PC services into specialist and generalist components. DESIGN: A descriptive retrospective study of data from 2726 hospitalized inpatients under the care of a tertiary consultative PC service over a 2-year period was conducted. Daily categorical symptom, overall psychological and social distress scores at the start and end of 3392 palliative care episodes as well as the number of visits made by the PC team to patients were extracted for analysis. RESULTS: More than 50% of patients had symptom, overall psychological or social distress scores of nil or mild severity at episode start and end. Approximately 20% of all 2726 patients accounted for approximately half of all visits made by the team regardless of the reasons for review. This patient percentage minority had more PC episodes starting with moderate or severe pain. These findings suggest a Pareto-like distribution in the occurrence of moderate/severe PC problems and the intensity of PC input. CONCLUSIONS: Large-scale clinical data supports the use of a Pareto-based quantitative framework for a workforce comprising of mainly generalist PC staff supported by smaller numbers of PC specialists.

Trajectory of quality of life for poor prognosis stage 5D chronic kidney disease with and without dialysis.

BACKGROUND: Renal replacement therapy (RRT) has not always been shown to benefit end-stage renal failure patients who are elderly or have multiple comorbidities in terms of survival or symptom control. Conservative management may be a viable alternative offering comparable health-related quality of life. METHODS: This is a prospective observational study of 101 patients who reached an estimated glomerular filtration rate of 8-12 ml/min and were either ≥75 years old or had an age-adjusted Charlson Comorbidity Index ≥8. Patients were all initially on conservative management; 38 later commenced renal replacement therapy while the rest remained conservatively managed. The Kidney Disease Quality of Life-Short Form was assessed at baseline and various scheduled time points over 24 months. The mixed model methodology was used to estimate the quality of life patterns and adjust for covariates. RESULTS: In the conservative management group, the Physical Component Summary and Mental Component Summary scores were stable and showed no significantly different trajectories from the RRT group (both p > 0.05). Though RRT was associated with an improvement in the Cognitive Function Scale score, it was also associated with worse scores on the Effect of Kidney Disease and Burden of Kidney Disease Scale scores. CONCLUSIONS: RRT does not improve health-related quality of life of end-stage kidney failure patients who are elderly or have a high comorbidity burden.

Measurement properties of the Chinese Version of the Kidney Disease Quality of Life-Short Form (KDQOL-SF™) in end-stage renal disease patients with poor prognosis in Singapore.

CONTEXT: The Kidney Disease Quality of Life (KDQOL™) instrument is widely used to assess care of end-stage renal disease (ESRD) patients. OBJECTIVES: This study aimed to demonstrate the measurement properties of the Chinese (simplified characters) version of the KDQOL-Short Form™ (KDQOL-SF™) in ethnic Chinese ESRD patients in Singapore. METHODS: Seventy-eight new ESRD patients, initially conservatively managed, were interviewed and followed-up; 31 later commenced dialysis. Quality of life (with the KDQOL-SF), Karnofsky Performance Status, and estimated glomerular filtration rate (eGFR) were assessed at 0, 3, 6, 9, 12, 18, and 24 months. Nonparametric statistics were used to assess correlation and changes. RESULTS: The patterns of descriptive summary and floor and ceiling effects were similar to those reported in the original English version. Most of the kidney disease-targeted scales and the generic scales of the KDQOL-SF demonstrated 1) criterion validity in terms of correlation with objectively measured and/or subjectively rated variables, 2) convergent/divergent validity in terms of correlation patterns between kidney disease-targeted and generic scales, and 3) responsiveness to change in terms of difference before and after dialysis, except for Work Status. Internal consistency reliability was satisfactory, but that for the Work Status scale was too low (alpha=0.32) and for two other kidney disease-targeted scales, Sexual Function and Dialysis Staff Encouragement, was too high (1.0). CONCLUSION: Most of the scales in the Chinese version of the KDQOL-SF were valid and achieved internal consistency reliability, except for the Work Status scale. Also, the internal consistency reliability of two disease-targeted scales was too high, suggesting room for reduction of some items to reduce burden on respondents.

[Observation on the protective effect of preventive acupuncture and moxibustion on uterus in ovariectomized rats].

OBJECTIVE: To observe the effect of preventive acupuncture and moxibustion of "Guanyuan" (CV 4) on uterus in ovariectomized (OVX) rats. METHODS: A total of 80 female SD rats were randomly divided into 5 groups: normal control, sham-operation (sham), model, preventive acupuncture (PA) and preventive moxibustion (PM) groups, with 16 cases in each. PA (with the needle retained for 20 min after insertion) and PM (one moxa-cone/rat) were applied to "Guanyuan" (CV 4) separately before ovariectomy, two times a week, 4 weeks altogether. Then, ovariectomy was performed on rats of model, PA and PM groups. Uterus tissue was taken under anesthesia for homogenate (10 rats/group) or sectioning (5-6 microm, 6 rats/group). Uterus estradiol (E2), progestone (P) were detected with radioimmunoassay; superoxide dismutase (SOD), nitric oxide synthase (NOS), and malondialdehyde (MDA) were assayed with immunoturdidimetry. Partial uterus slices were stained with H & E method for observing morphological changes, or stained with immunohistochemical method or with in situ hybridization method for displaying estrogen receptor (ER)-alpha and ER-alpha mRNA expression separately. RESULTS: After ovariectomy, the rat's uterus presented obvious squamous metaplasia, hyperplasy, and thickening of the endomembrane, decrease in glands and blood vessels and increase in fibrous connective tissue, etc; while the situation was evidently better in PA and PM groups. In comparison with normal control group, E2, P contents and SOD, NOS activities of uterus tissue in model group decreased significantly (P < 0.01), while MDA in model group increased evidently (P < 0.01). Compared with model group, uterus P content in PA and PM groups increased obviously (P < 0.05), while uterus MDA decreased apparently (P < 0.01). Compared with normal control group, the expression of ER-alpha and ER-alpha mRNA in model group was downregulated markedly (P < 0.01); after PA and PM, both ER-alpha and ER-alpha mRNA expression increased obviously (P < 0.01). No significant differences were found between PA and PM groups in the above mentioned 7 indexes (P > 0.05). CONCLUSION: Preventive acupuncture and moxibustion of CV4 can postpone the structural degeneration of uterus in OVX rats, which may be related to their effects in modulating the secretion of uterus E2 and P, upregulating the expression of ER-a and ER-alpha mRNA, and improving the anti-oxidative ability.

[Experimental study on changes of expressions of ER-alpha and ER-alpha mRNA in different hypothalamic nuclei and the effect of "preventive acupuncture and moxibustion" in ovariectomy rats].

OBJECTIVE: To explore the mechanism of "preventive acupuncture and moxibustion" for regulating hypothalamic function in ovariectomy rats. METHODS: Thirty female SD rats, aged 3.5 months, were randomly divided into normal group, sham operation group, ovariectomy model group, preventive acupuncture group and preventive moxibustion group. After "preventive acupuncture and moxibustion" were previously given to the preventive acupuncture group and the preventive moxibustion group for one month, respectively. At the same time, ovarietomy was made in the preventive acupuncture group, the preventive moxibustion group and the ovariectomy model group. For the sham operation group, only a little fat around the ovary was removed without ovariectomy, and nothing was not applied to the normal group. Immunohistochemical and in situs hybridization methods were used to investigate changes of expressions of ER-alpha and ER-alpha mRNA in paraventricular nucleus, supraoptic nucleus and arcuate nucleus. RESULTS: In the model group the expressions of ER-alpha and ER-alpha mRNA in paraventricular nucleus and the expression of ER-alpha mRNA in supraoptic nucleus increased significantly (P<0.01), but the expression of ER-alpha dropped significantly in both supraoptic nucleus and arcuate nucleus (P<0.01). After preconditioning with acupuncture or moxibustion, the expression of ER-alpha mRNA in paraventricular nucleus significantly reduced (P<0.05), and the expression of ER-alpha had no significant change (P>0.05); the expression of ER-alpha in supraoptic nucleus and arcuate nucleus significantly increased (P<0.01 or P<0.05), and the expression of ER-alpha mRNA in paraventricular nucleus had no significant change (P>0.05). CONCLUSION: "Preventive acupuncture and moxibustion" at "Guanyuan" (CV 4) have an effect on the expressions of ER-alpha and ER-alpha mRNA in different hypothalamic nuclei in ovariectomy rats, which possibly is one of the ways for modulating the hypothalamic activity.