Assessing the validity of the clinician-rated distress thermometer in palliative care.

BACKGROUND: The distress of patients suffering from a terminal illness can lead to a state of despair and requests for euthanasia and assisted suicide. It is a major challenge for palliative care workers. The Distress Thermometer (DT) is recommended by the National Comprehensive Cancer Network as a means of more easily assessing distress. It is available as a Self-assessment reported Distress Thermometer, but for a wider use in palliative care it should also be implemented in the form of a clinician-reported outcome (clinRO). Clinicians need to rate patient's distress when the patient is not able to do so (subject that cannot be addressed, defensive patient…). The primary aim of the quantitative study was to assess the validity of the Clinician-Rated Distress Thermometer in palliative care. METHOD: The assessments were performed by teams working in three palliative care centres. The primary endpoint was concordance between the patient and clinicians' responses via Lin's concordance coefficient. Eligible patients were aged 18 years or older, suffering from a severe disease in the palliative phase, and with a sufficient level of awareness to consent to participate in the study. A total of 51 patients were recruited, 55% were male, with a mean age of 65.8 years [39-90 years]. RESULTS: Three hundred sixty-four clinician-Rated Distress Thermometer and 467 Self-Reported Distress Thermometer were performed. Only 364 of the 467 Self-Reported Distress Thermometer were used for the study, as investigators did not systematically ask the patient to give an account of his distress. Concordance between patient and clinician responses: The Lin's concordance coefficient with a threshold (alpha) of 5% was 0.46 [0.38; 0.54]. At the first assessment, it was 0.61 [0.44; 0.79]. The Cohen's kappa coefficient was 0.52, with a concordance rate of 79.6%. The sensitivity was 82.9% [66.4-93.4] and the specificity 71.4% [41.9-91.6]. CONCLUSION: The first assessment gave the best results in terms of concordance between Clinician-Rated DT and Self-Reported DT. In the next assessments, the Clinician-Rated DT were less consistent with the patients' Self-Reported DT.

IPADAM "Pharmaceutical interventions on the issue of pharmaceutical records and self-medication" quanti survey in 482 French pharmacies.

OBJECTIVES: This study aims to: (i) quantify the number of pharmaceutical interventions (PIs) linked to spontaneous requests for the two oral target molecules, ibuprofen and pseudoephedrine (ii) analyse the causes and proposed solutions (iii) quantify the number of registrations in the patient's pharmaceutical record and identify the various causes of non-registration. METHODS: The study was conducted over a 2 weeks' period in the months of February and April 2014 in 482 pharmacies affiliated to the training supervisor associations of 8 French Faculties of Pharmacy. Data regarding spontaneous requests for the target molecules was collected, with due respect to a patient care flow chart at the pharmacy, by incorporating the systematic proposal for registration of the medication in the patient's pharmaceutical record. Each PI was the subject of a notification made with reference to a standardized grid. RESULTS: A total of 12,160 dispensations were made over the two weeks of the study. Overall 815 of them gave rise to an PI (6.7%), justified in almost half of the cases by a contraindication. The alternative proposed by the dispensing pharmacist was accepted in more than 9 out of 10 cases. In half of the cases, the dispensing pharmacist had access to the patient's French healthcare card; more than 2/3 of the dispensations thus led to the registration of the medication in the patient's pharmaceutical record. CONCLUSION: The pairing of the two tools, these being the notification grid and the pharmaceutical record, aims to maximize dispensation security while patients are being guided in their approach to self-medication.

[IPADAM quali study. Intervention of the Pharmacist in the Issue of Self-medication: Experience of pharmacy team focus groups and patients' perceptions]. / IPADAM quali « Interventions Pharmaceutiques À propos du Dossier pharmaceutique et de l'AutoMédication ¼ : expérience des équipes officinales et ressenti des patients.

OBJECTIVES: This study had two main aims: (i) document the experience of community pharmacists receiving a spontaneous request for ibuprofen and oral pseudoephedrine, and their use of pharmaceutical records, and (ii) explore patients' perceptions of pharmaceutical records and pharmaceutical interventions. METHODS: The study was conducted over two weeks between February and April 2014 in 482 community pharmacies and 8 French faculties of pharmacy. It was based on data collected by pharmacy team focus groups during patient telephone interviews using standardized question grids. Textual and thematic analyses were made of the patient responses. RESULTS: Four pharmacy team focus groups carried out 49 telephone interviews. Examination of the practice of the groups showed that pharmaceutical interventions, although incompletely registered, are performed on a daily basis and enhance the value of the pharmacist's function. Analysis of the telephone interviews also showed the importance of the advisory role of the pharmacist in dispensing an optional medical prescription. The thematic analysis of the results identified a positive response of patients to pharmaceutical interventions if made by their regular pharmacist and accompanied by explanatory information. The focus groups and patients agreed that pharmaceutical records were not consulted often enough. CONCLUSION: This study underlines the need for greater safety in the use of optional medical prescription drugs. Promoting responsible self-medication in compliance with proper use should include systematic reference to a PR and informed dialogue with the patient.

A pancreatic extract-enriched diet improves the nutritional status of aged rats.

Correction of the malnourished state, particularly common and severe in elderly people, is often unsuccessful. To improve the efficiency of realimentation, we evaluated the nutritional effect of a pancreatic extract (PE)-enriched diet in malnourished aged rats. Sprague-Dawley male rats were randomly assigned to 6 groups as follows: 1 group of control rats had free access to the diet for 12 wk (C group) and 5 groups were 50% food restricted for the same period. One food-restricted group was then killed (R group) and the 4 remaining groups were refed for 1 wk using a standard diet enriched either with two different doses of a pancreatic extract (2.4 or 4.8 g/d in PE1 and PE2 groups, respectively) or with an isonitrogenous casein hydrolysate (CH1 and CH2 groups, respectively). Profound alterations induced by food restriction (FR) were moderately corrected by refeeding, except nitrogen balance, which was reestablished in rats refed all diets (P: < 0.01 vs. R). Supplementation of the food ration with a pancreatic extract clearly improved recovery. Indeed, body weight gain, both jejunal and ileal trophicity [jejunum: total height, PE2: 849 +/- 45 microm vs. CH2: 768 +/- 17 microm (P: < 0.05); protein content, PE2: 69.9 +/- 5.7 mg vs. CH2: 56.4 +/- 4.8 mg (P: < 0.01)] and nonspecific immune response in terms of H2O2 production by polymorphonuclear neutrophils and tumor necrosis factor alpha (TNF-alpha) by macrophages (PE2, 20.7 +/- 4.7 vs. CH2, 8.7 +/- 2.3, P: < 0.05) were improved in rats fed PE2. A pancreatic extract could improve the efficiency of realimentation in malnourished aged rats.

[Required procedure for nominal data files processing in biomedical research]. / Procédure à mettre en aeuvre pour le traitement informatique des données nominatives dans le cadre de la recherche biomédicale.

To date, biomedical research using nominal data files for the data collection, data acquisition or data processing has had to comply with 2 French laws (Law of December, 20, 1988, modified, relating to the protection of patients participating in biomedical research, and the Law of January, 6, 1978, completed by the Law of July 1, 1994 n degrees 94-548, chapter V bis). This later law dictates rules not only for the establishment of nominal data files, but also confer individual rights to filed persons. These regulations concern epidemiological research, clinical trials, drug watch studies and economic health research. In this note, we describe the obligations and specific general and simplified procedure required for conducting biomedical research. Included in the requirements are an information and authorization procedure with the local and national consultative committees on data processing in biomedical research (CCTIRS, Comité Consultatif sur le Traitement de l'Information en Recherche Biomédicale, and CNIL, Commission Nationale Informatique et Libertés).

Aging: a barrier to renutrition? Nutritional and immunologic evidence in rats.

BACKGROUND: Previous reports suggest that correcting the malnourished state is more difficult in elderly people than in younger ones and that protein requirements may be higher in elderly than in younger adults. OBJECTIVE: The aim of this study was to establish whether malnourished old rats respond to protein-supplemented nutritional repletion as do young adult rats. DESIGN: Adult (3 mo old) and old (22 mo old) rats were submitted to dietary restriction programs that induced similar metabolic and nutritional alterations. Malnourished adult and old rats were then killed (R groups) or refed for 1 wk with a high-protein diet (HPD; 23% protein) or a very-high-protein diet (VHPD; 27% protein). Control groups at both ages were fed ad libitum throughout the experiment. Effects of food repletion were evaluated in terms of protein metabolism, intestinal histomorphometry, and nonspecific immune status. RESULTS: In adult rats, HPD sufficed to increase body weight and restore basal values of liver weight and protein content (P: < 0.01 compared with the R adult group), nitrogen balance (P: < 0.01 compared with the R adult group), and hydrogen peroxide production by polymorphonuclear neutrophils and monocytes (P: < 0.01 compared with the R group); VHPD had no supplementary effect except on nitrogen balance. In old rats, HPD was less effective and greater benefit was observed with VHPD in terms of body weight gain (10%; P: < 0.01 compared with the old group fed HPD), albuminemia, muscle weight and protein content, plasma arginine concentration, and hydrogen peroxide production by stimulated polymorphonuclear neutrophils and monocytes compared with the old R group (P: < 0.01). CONCLUSION: Aging is a significant variable affecting the response to nutritional support.

Comparative study of glycine, alanine or casein as inert nitrogen sources in endotoxemic rats.

Pharmacological effects of dietary amino acids (AA) and peptides must be compared to an isonitrogenous control that is as inert as possible. To establish a rationale for the choice of such a control, potential metabolic and nutritional effects of three currently used nitrogenous controls (glycine, alanine, and casein) were evaluated in an endotoxemic rat model that has well-defined alterations in AA and protein metabolism. Five-week-old male Sprague-Dawley rats (113 +/- 1 g) were randomly assigned to four groups and received at d 0 an intraperitoneal injection of endotoxin (3 mg/kg). After withdrawal of food for 24 h, the rats were enterally refed for 48 h with a liquid diet (Osmolite((R))) supplemented with 0.19 g N. kg(-1). d(-1) in the form of glycine [lipopolysaccharide (LPS)-GLY group], alanine (LPS-ALA group) or casein (LPS-CAS group). One group (LPS group) received only Osmolite((R)). Plasma, two skeletal muscles, the liver and the intestine were then removed. Body and tissue weights and tissue protein contents did not differ among the four groups. Intestine histomorphometry showed no significant difference among groups. Jejunal hydrolase activities were significantly affected by the nitrogenous supplementations, but no effect was observed in the ileum. Only limited significant effects were observed on plasma and tissue-free AA concentrations, except for an accumulation of glycine in the plasma and tissues from the LPS-GLY group, compared to other groups. Overall, whereas glycine as a nitrogenous control should be used with care, either alanine or casein may be used as the "placebo," with the choice depending on the study to be performed.

Severe dietary restriction initiated in aged rats: evidence for poor adaptation in terms of protein metabolism and intestinal functions.

BACKGROUND: Protein energy malnutrition is a common finding in elderly people, increasing morbidity and mortality in aged inpatients. Investigations need to be developed to counteract malnutrition-induced alterations early and to avoid potential irreversible lesions. The aim of this experimental study was to evaluate time-response to severe dietary restriction (DR) initiated in aged rats in terms of protein metabolism and digestive trophicity. MATERIALS AND METHODS: After the acclimatization period, 22-month-old male rats were randomized into six groups: three control groups, fed ad libitum for 3, 6 or 12 weeks with a standard diet and three corresponding dietary-restricted groups fed for the same periods with only 50% of the spontaneous intake. Intestinal mucosa, liver and skeletal muscles (soleus, extensor digitorum longus and tibialis anterior muscle) were removed when the rats were killed. RESULTS: DR induced dramatic body weight loss (up to 50% of initial body weight after 12 weeks DR). Protein metabolism was affected in terms of nitrogen balance (P < 0.01) and protein content, in particular at the splanchnic level. Morphometrically, the intestine structure was altered after 12 weeks of DR (P < 0.01), and this atrophy was correlated with malabsorption of mannitol (P < 0. 01). Ileal hydrolase activities were decreased throughout the 12 weeks of DR. CONCLUSIONS: Aged rats clearly exhibit a defect of adaptation to long-term DR initiated at an advanced age. Severe DR leads to malnutrition, which becomes of major importance after 12 weeks, in particular at the intestine level. Hence, application of these experimental results to elderly, malnourished people may contribute to a better knowledge of denutrition-induced disorders.

Protein metabolism in rats during long-term dietary restriction: influence of aging.

BACKGROUND: Protein depletion is frequent in the elderly, but the underlying mechanisms are not yet fully understood. In particular, it is unknown whether there is a defect of adaptation to a restriction of food intake in the elderly. This study was performed to compare the effects of 6-week dietary restriction (DR) on protein metabolism in both adult and aged rats. METHODS: Adult (3-month-old) and aged (22-month-old) rats were acclimatized for 2 weeks and then fed a standard diet for 6 weeks, either ad libitum (control adult [C(Adult)] and aged [C(Aged)] rats) or with only 50% of the average intake of the second week of acclimatization (restricted adult [R(Adult)] and aged [R(Aged)] rats). Protein metabolism, in terms of tissue protein content, nitrogen balance, and 3-methylhistidine (3-MH) urinary excretion, was evaluated. RESULTS: C(Adult) rats gained 30.4% of initial weight, whereas the body weight (BW) of C(Aged) rats was maintained. DR induced a rapid decrease in BW during the first 2 weeks in R(Adult) rats, but afterward BW remained stable. In R(Aged) rats, BW loss was linear during the 6 weeks and significantly higher than for R(Adult) rats (p<.01). In both restricted groups, muscle protein content was moderately affected by DR, whereas DR induced a marked decrease in visceral protein content. Nitrogen balance was decreased by DR but stayed positive in R(Adult) rats, whereas it became null in R(Aged) rats. CONCLUSIONS: In terms of protein metabolism, aged rats adapted less efficiently than adult rats to a long-term dietary restriction.

Can a glutamate-enriched diet counteract glutamine depletion in endotoxemic rats?

The study evaluated whether a glutamate-enriched diet would restore glutamine tissue pools and maintain tissue trophicity in endotoxemic rats. For this purpose, young male Sprague-Dawley rats received an intraperitoneal injection of lipopolysaccharide (LPS) from Escherichia coli at 3 mg/kg body weight. After 24 hours of food deprivation, the rats were enterally refed for 48 hours using Osmolite enriched with glutamate at 4 g/kg/d (LPS-Glu group, n = 7) or glycine isonitrogenous to glutamate (LPS-Gly group, n = 7). A control group (healthy group, n = 7) had free access to a standard rodent diet. Tissue weights and protein contents were significantly lower in both LPS-treated groups than in the healthy group. No plasma or tissue accumulation of glutamate was observed except in the liver. Glutamine concentrations were increased in the jejunum, liver, and plasma in the LPS-Glu group versus the other two groups (P < 0.05). Conversely, they were depleted in muscles of the endotoxemic groups versus the healthy group (P < 0.05). Villus height was significantly greater in the LPS-Glu group than in the LPS-Gly group in the jejunum (P < 0.05), but not in the ileum. In conclusion, a glutamate-enriched diet administered enterally to endotoxemic rats can counteract glutamine depletion in the splanchnic area but not in muscles. In addition, glutamate displayed a trophic effect restricted to the jejunum.