Factors influencing communication and decision-making about life-sustaining technology during serious illness: a qualitative study.

OBJECTIVES: We aimed to identify factors influencing communication and decision-making, and to learn how physicians and nurses view their roles in deciding about the use of life-sustaining technology for seriously ill hospitalised patients and their families. DESIGN: The qualitative study used Flanagan's critical incident technique to guide interpretive description of open-ended in-depth individual interviews. SETTING: Participants were recruited from the medical wards at 3 Canadian hospitals. PARTICIPANTS: Interviews were completed with 30 healthcare professionals (9 staff physicians, 9 residents and 12 nurses; aged 25-63 years; 73% female) involved in decisions about the care of seriously ill hospitalised patients and their families. MEASURES: Participants described encounters with patients and families in which communication and decision-making about life-sustaining technology went particularly well and unwell (ie, critical incidents). We further explored their roles, context and challenges. Analysis proceeded using constant comparative methods to form themes independently and with the interprofessional research team. RESULTS: We identified several key factors that influenced communication and decision-making about life-sustaining technology. The overarching factor was how those involved in such communication and decision-making (healthcare providers, patients and families) conceptualised the goals of medical practice. Additional key factors related to how preferences and decision-making were shaped through relationships, particularly how people worked toward 'making sense of the situation', how physicians and nurses approached the inherent and systemic tensions in achieving consensus with families, and how physicians and nurses conducted professional work within teams. Participants described incidents in which these key factors interacted in dynamic and unpredictable ways to influence decision-making for any particular patient and family. CONCLUSIONS: A focus on more meaningful and productive dialogue with patients and families by (and between) each member of the healthcare team may improve decisions about life-sustaining technology. Work is needed to acknowledge and support the non-curative role of healthcare and build capacity for the interprofessional team to engage in effective decision-making discussions.

Mind the gap: Opportunities for improving end-of-life care for patients with advanced heart failure.

BACKGROUND: Patients with advanced heart failure (HF) experience progressive symptoms, decreased quality of life, and more frequent hospitalizations as they approach the end of life (EOL). Understanding patient perspectives and preferences regarding EOL issues is necessary to identify key opportunities for improving care. OBJECTIVE: To identify, from the patient's perspective, the major opportunities for improving EOL care for patients hospitalized because of advanced HF. METHODS: A cross-sectional survey of patient perspectives regarding EOL care was administered via interview of 106 hospitalized patients who had advanced HF in five tertiary care centres across Canada. The study compared which aspects of EOL care patients rated as 'extremely important' and their level of satisfaction with these aspects of EOL care to identify key opportunities for improvement of care. RESULTS: The greatest opportunities for improvement in EOL care were reducing the emotional and physical burden on family, having an adequate plan of care following discharge, effective symptom relief and opportunities for honest communication. The three most important issues ranked by patients were avoidance of life support if there was no hope for a meaningful recovery, communication of information by the doctor and avoidance of burden for the family. CONCLUSIONS: Advanced care planning that seamlessly bridges hospital and home must be standard care for patients who have advanced HF. Components must include coordination of care, caregiver support, comprehensive symptom management, and effective communication regarding HF and EOL issues.

Acceptability and uptake of a community-based flu immunisation programme.

OBJECTIVE: To evaluate a community based influenza immunisation programme in terms of patients' and primary care professionals' satisfaction and uptake of immunisation. DESIGN: Surveys were conducted which compared the experiences and opinions of groups of staff and patients who had experienced the programme with groups where general practice was responsible for immunisation arrangements. SETTING: Primary care. SUBJECTS: Patients eligible for influenza immunisation and general practice staff involved in providing immunisation. RESULTS: A good response was obtained from patients (82.2%:2,900) and general practices (83.3%:55). Patients from both programme and comparison groups reported high levels of satisfaction with flu immunisation arrangements. Preferences expressed tended to coincide with patients' experiences of arrangements. Around 40% of both groups desired information. A minority of unvaccinated patients (more programme patients than comparators) expressed difficulties in accessing clinics. There were both advantages and disadvantages for general practices involved in the programme. Although time consumed in giving injections was less for programme staff, they reported substantial time spent on programme-related administration and dealing with patients' queries. Programme figures indicate uptake of 53.8% (not including those vaccinated elsewhere). Survey results show that 58.5% of programme patients who responded were vaccinated. CONCLUSIONS: In light of recent Scottish Executive Health Department guidance, experiences of this programme may be of interest to those contemplating Local Development Schemes for flu immunisation. Findings highlight the dilemma between potential economies of scale and continuity of care for patients.

GFRalpha-4, a new GDNF family receptor.

GFRalpha-1, GFRalpha-2, and GFRalpha-3 constitute a family of structurally related, glycosyl-phosphatidylinosital-linked, cell surface proteins, two of which, GFRalpha-1 and GFRalpha-2, are components of the receptor complex for the neurotrophic factors GDNF and neurturin, respectively. By screening an embryonic chicken brain cDNA library with a GFRalpha-1 probe at low stringency, we isolated cDNAs encoding an additional member of the GFRalpha family, GFRalpha-4. The nucleotide sequence predicts a 431-amino-acid secreted protein that is more closely related to GFRalpha-1 and GFRalpha-2 than to GFRalpha-3. GFRalpha-4 mRNA is expressed in distinctive patterns in the brain and several other organs and tissues of the chicken embryo. Our findings extend the family of GFRalpha proteins and provide information about the tissues in which GFRalpha-4 may function during development.

Purification and characterization of catechol 1,2-dioxygenase from Rhodococcus rhodochrous NCIMB 13259 and cloning and sequencing of its catA gene.

A method was developed for the purification of catechol 1, 2-dioxygenase from Rhodococcus rhodochrous NCIMB 13259 that had been grown in the presence of benzyl alcohol. The enzyme has very similar apparent Km (1-2 microM) and Vmax (13-19 units/mg of protein) values for the intradiol cleavage of catechol, 3-methylcatechol and 4-methylcatechol and it is optimally active at pH9. Cross-linking studies indicate that the enzyme is a homodimer. It contains 0.6 atoms of Fe per subunit. The enzyme was crystallized with 15% (w/v) poly(ethylene glycol) 4000/0.33 M CaCl2/25 mM Tris (pH7.5) by using a microseeding technique. Preliminary X-ray characterization showed that the crystals are in space group C2 with unit-cell dimensions a=111.9 A, b=78.1 A, c=134.6 A, beta=100 degrees. An oligonucleotide probe, made by hemi-nested PCR, was used to clone the gene encoding catechol 1,2-dioxygenase (catA). The deduced 282-residue sequence corresponds to a protein of molecular mass 31539 Da, close to the molecular mass of 31558 Da obtained by electrospray MS of the purified enzyme. catA was subcloned into the expression vector pTB361, allowing the production of catechol 1,2-dioxygenase to approx. 40% of the total cellular protein. The deduced amino acid sequence of the enzyme has 56% and 75% identity with the catechol 1, 2-dioxygenases of Arthrobacter mA3 and Rhodococcus erythropolis AN-13 respectively, but less than 35% identity with intradiol catechol and chlorocatechol dioxygenases of Gram-negative bacteria.

Antibody mechanisms implicated in digestive disturbances following ingestion of soya protein in calves and piglets.

Serum antibody responses to ingested aqueous alcohol-extracted soya proteins were studied in thirty-six pre-ruminant calves. Characterization of this antibody showed it to be predominantly a complement-fixing IgG1 preciptin. No evidence of tolerance was seen; previously sensitized calves responded to reintroduction of a soya diet with marked increases in antibody levels. The soya antigen was shown to be resistant to proteolysis and, to a lesser degree, to the microbial action of rumen fluid. Biopsy studies showed that the feeding of soya protein resulted in morphological disturbances to the villi and lamina propria of the intestine. Physiological studies by Thirty-Vella loop perfusion in the pig showed that soya protein solutions resulted in significant inhibition of flow rates. The effect was only observed after previous sensitization with the soya antigen. This study shows the necessity of applying immunological criteria to the quality control of soya bean processing in order to ensure that the sensitizing agent is eliminated and the nutritional qualities of soya protein concentrates are optimized.

Correspondence (Infectiousness of neural cases)

While from the nature of things it is impossible to prove that patients whose lesions are of the bacteriologically negative, resistant type are under no circumstances able to trasmit leprosy, available evidence is against their being a source of danger to children, who are usually highly susceptible. With regard to the juvenile type, the frequency with which such cases suddenly develop widespread, bacteriologically positive lesions makes clear the necessity of keeping children suffering from this type of the disease under close observation, remembering the danger of their suddenly becoming actively infectious cases. THere is a tendency for advanced cutaneous-type cases to develop nerve lesions in the later stages of the disease. Patients seen at this stage are often classified as neural (properly, " secondary neural"). Routine bacteriological examination may at first fail to show Mycobacterium leprae, but repeated examination will often show clumps of acid-fast bacilli in the skin, nose or gums. Patients who have at one time suffered from widespread sutaneous leprosy with bacteriologically positive lesions should, even after the disease has become quiescent and arrested, be kept from close contact with healthy people and especially with children. Such contact should be permitted only when the disease has remained arrested for several years, when the patients have shown no signs of the disease on being subjected to the iodice test, and when all parts of the skin, nasal mucosa, gums, etc., have been carefully examined for bacteria and found negative. Reference is made to the use of the leprolin test in determining resistance to invasion by Myco. leprae and in judging the degree of danger of transmission of disease.