Palliative care physicians' experiences of end-of-life communication: A focus group study.

The aim of this study was to explore palliative home care physicians' experiences regarding end-of-life breakpoint communication (BPC). This is a qualitative study where focus group interviews were conducted and analysed using qualitative content analysis. The results show that the participants saw themselves as being responsible for accomplishing BPC, and they were convinced that it should be regarded as a process of communication initiated at an early stage, i.e. proactively. However, BPC was often conducted as a reaction to the patient's sudden deterioration or sometimes not at all. The barriers to achieving proactive BPC included physicians' uncertainty regarding the timing of BPC, primarily due to difficulties in prognostication in terms of time of death, and uncertainty as to what BPC should include and how it should best be approached. Furthermore, there was insufficient documentation regarding previous BPC, which impeded proactive BPC. Although our study shows that physicians are ambitious when it comes to the communication of information to patients and families, there is a need for further training in how to conduct BPC and when to initiate the BPC process. Furthermore, there should be documentation that different professionals can access as this would appear to facilitate a proactive BPC process.

Increasing the number of patients receiving information about transition to end-of-life care: the effect of a half-day physician and nurse training.

INTRODUCTION: Honest prognostication and information for patients are important parts of end-of-life care. This study examined whether an educational intervention could increase the proportion of patients who received information about the transition to end-of-life (ITEOL care). METHOD: Two municipalities (in charge of nursing homes) and two hospitals were randomised to receive an interactive half-day course about ITEOL for physicians and nurses. The proportion of patients who received ITEOL was measured with data from the Swedish Register of Palliative Care (SRPC). Patients were only included if they died an expected death and maintained their ability to express their will until days or hours before their death. Four hospitals and four municipalities were assigned controls, matched by hospital size, population and proportion of patients receiving ITEOL at baseline. RESULTS: The proportion of patients in the intervention group who received ITEOL increased from 35.1% (during a 6-month period before the intervention) to 42% (during a 6-month period after the intervention). The proportion in the control group increased from 30.4% to 33.7%. The effect of the intervention was significant (p=0.005) in a multivariable model adjusted for time, age, gender and cause of death. CONCLUSION: More patients at end-of-life received ITEOL after an educative half-day intervention directed to physicians and nurses.

Regional changes in cerebral blood flow oxygenation can indicate global changes in cerebral blood flow during coronary artery occlusion in juvenile pigs.

Near infrared spectroscopy (NIRS) is a widely employed method for assessment of regional cerebral oxygenation (RcStO2). RcStO2 values are expected to vary with changes in the relative amount of oxyhaemoglobin. The present experimental study aimed to assess the response of RcStO2 to controlled alterations of carotid blood flow (CQ). Landrace pigs were anesthetized followed by surgical preparation. Cyclic variations in cardiac output were accomplished by intermittently occluding the main stem of the left coronary artery. A flow measurement probe for assessing CQ was placed around the left carotid artery. One NIRS probe was placed on the left ipsilateral forehead to assess regional cerebral oximetry. Simultaneous registration of CQ and RcStO2 was conducted. There was a strong correlation for variation in CQ and RcStO2 signal values. Based on coherence analysis the fraction of power of the RcStO2 that was coherent with the CQ signal reached 0.84 ± 0.12 (P < 0.05) for frequencies lower than 0.1 Hz. The agreement of the sample-to-sample co-variation, as assessed by the Pearson correlation coefficient, was 0.83 ± 0.08 (P < 0.05). One explanatory component for variations in cerebral oxygenation verified by NIRS should be attributed to variations in the cerebral blood flow.

Surgical nurses' attitudes towards caring for patients dying of cancer - a pilot study of an educational intervention on existential issues.

This is a randomised controlled pilot study using a mixed methods design. The overall aim was to test an educational intervention on existential issues and to describe surgical nurses' perceived attitudes towards caring for patients dying of cancer. Specific aims were to examine whether the educational intervention consisting of lectures and reflective discussions, affects nurses' perceived confidence in communication and to explore nurses' experiences and reflections on existential issues after participating in the intervention. Forty-two nurses from three surgical wards at one hospital were randomly assigned to an intervention or control group. Nurses in both groups completed a questionnaire at equivalent time intervals: at baseline before the educational intervention, directly after the intervention, and 3 and 6 months later. Eleven face-to-face interviews were conducted with nurses directly after the intervention and 6 months later. Significant short-term and long-term changes were reported. Main results concerned the significant long-term effects regarding nurses' increased confidence and decreased powerlessness in communication, and their increased feelings of value when caring for a dying patient. In addition, nurses described enhanced awareness and increased reflection. Results indicate that an understanding of the patient's situation, derived from enhanced awareness and increased reflection, precedes changes in attitudes towards communication.

Milrinone and levosimendan during porcine myocardial ischemia -- no effects on calcium overload and metabolism.

BACKGROUND: Although inotropic stimulation is considered harmful in the presence of myocardial ischaemia, both calcium sensitisers and phosphodiesterase inhibitors may offer cardioprotection. We hypothesise that these cardioprotective effects are related to an acute alteration of myocardial metabolism. We studied in vivo effects of milrinone and levosimendan on calcium overload and ischaemic markers using left ventricular microdialysis in pigs with acute myocardial ischaemia. METHODS: Anaesthetised juvenile pigs, average weight 36 kg, were randomised to one of three intravenous treatment groups: milrinone 50 µg/kg bolus plus infusion 0.5 µg/kg/min (n = 7), levosimendan 24 µg/kg plus infusion 0.2 µg/kg/min (n = 7), or placebo (n = 6) for 60 min prior to and during a 45 min acute regional coronary occlusion. Systemic and myocardial haemodynamics were assessed, and microdialysis was performed with catheters positioned in the left ventricular wall. (45) Ca(2+) was included in the microperfusate in order to assess local calcium uptake into myocardial cells. The microdialysate was analysed for glucose, lactate, pyruvate, glycerol, and for (45) Ca(2+) recovery. RESULTS: During ischaemia, there were no differences in microdialysate-measured parameters between control animals and milrinone- or levosimendan-treated groups. In the pre-ischaemic period, arterial blood pressure decreased in all groups while myocardial oxygen consumption remained stable. CONCLUSIONS: These findings reject the hypothesis of an immediate energy-conserving effect of milrinone and levosimendan during acute myocardial ischaemia. On the other hand, the data show that inotropic support with milrinone and levosimendan does not worsen the metabolic parameters that were measured in the ischaemic myocardium.

Palliative chemotherapy during the last month of life.

BACKGROUND: This study analyses the potential discriminative characteristics for patients with incurable cancer who received palliative chemotherapy during their last month of life. PATIENTS AND METHODS: The study includes all patients with epithelial cancer treated with palliative chemotherapy who died in 2008 in northern Sweden. Demographic parameters and care utilization data were registered. Data were analyzed using nonparametric methods. RESULTS: Of 374 included patients, 87 (23%) received chemotherapy during the last month of life. These patients had a significantly shorter survival time from first palliative treatment to death, were admitted more frequently to hospital, more often lacked a documented decision to cease treatment, and died less frequently at home. CONCLUSIONS: The results indicate covariations between palliative chemotherapy treatments in the last month of life and unfavorable patient outcomes. As almost one of four patients with incurable cancer received their last round of palliative chemotherapy <31 days before death, there is a potential for improved routines.

Parents' experiences of having an asymptomatic child diagnosed with hypertrophic cardiomyopathy through family screening.

BACKGROUND: Hypertrophic cardiomyopathy is hereditary and the commonest medical cause of sudden death in childhood and adolescence, which is the reason for recommending screening in children with an affected parent. A diagnosis of hypertrophic cardiomyopathy implies lifestyle modifications, restrictions that may bring profound changes to the affected individual and impacts on the whole family. OBJECTIVE: To describe parents' experiences of how the diagnosis of hypertrophic cardiomyopathy in their child affects daily life. METHOD: Twelve parents with asymptomatic children diagnosed with hypertrophic cardiomyopathy through family screening were interviewed 12-24 months after the diagnosis. Analysis was conducted with qualitative content analysis. RESULTS: Parents described the immediate reaction of shock, grief, and injustice but were also grateful that the child was still asymptomatic. The diagnosis caused a significant change in lifestyle for most families due mainly to restrictions of sports activities. Parents had to adapt to the new life and develop strategies to protect their child. Death became a reality causing feelings of vulnerability. Regular medical check-ups and access to the liaison nurse were described as important factors of reassurance. CONCLUSIONS: Parents experienced early diagnosis as positive in a long-term perspective. The main changes perceived were ascribed to lifestyle modifications. Parents with athletic children experienced the lifestyle modifications as more severe. They strived to create a new life where they could feel secure and have faith in the future, and emphasised the need of regular follow-up and support from health care professionals as "mental pain relief", which helped them achieve a new state of normality.

Spouses' experiences of a cardiac arrest at home: an interview study.

INTRODUCTION: In case of out-of-hospital cardiac arrest (OHCA) influence of a bystander spouse is decisive for the chance of survival. AIM: To describe spouses' experiences of witnessing their partners' cardiac arrest at home, focusing on the time before the event and when it happened. METHODS: Interviews with fifteen spouses were recorded and transcribed verbatim. Qualitative content analysis was conducted. RESULTS: In the domain entitled "Time before cardiac arrest", four themes emerged in the analysis process: "Lack of early warning signs", "Difficulty interpreting early warning signs", "Interpreting signs in the light of previous illness" and "Denial of serious illness". In the domain entitled "The cardiac arrest event", three themes emerged: "Perceiving the seriousness", "Being unable to influence" and "Doing what is in one's power". The emergency call services' (ECS) ability to instruct and help the spouses to do what they can becomes evident in these themes. CONCLUSION: Spouses who experienced OHCA demonstrated a lack of confidence in or ability to interpret early warning signs and symptoms. This lack of confidence also extended to the process of cardiopulmonary resuscitation (CPR). The support from the ECS and CPR training was acknowledged as helpful and important. Further research is required to determine which interventions can improve people's ability to intervene as early as possible.

Significant improvement in quality of life of patients with incurable cancer after designation to a palliative homecare team.

The aims of this study were to describe and compare quality of life before and after designation to a palliative homecare team in patients with different cancer diagnoses and to identify pre-designation predictors of post-designation global quality of life. We measured patients' quality of life 1 week before designation and 11 days (median time) after with the Assessment of Quality of life at the End of Life (Axelsson & Sjödén 1999). Of 163 eligible patients 63 participated without attrition. Patients' quality of life improved in the physical, psychological, medical and global areas. Six items significantly improved: hours recumbent during the day (P = 0.009), nausea (P = 0.008), anxiety (P = 0.007), getting hold of staff (P = 0.000), received care (P = 0.003) and global quality of life (P = 0.023). Depression/low in mood (r = 0.55) and meaningfulness (r = 0.70) associated to global quality of life. Furthermore, pain (P = 0.028) and meaningfulness (P = 0.028) predicted global quality of life. In the existential area, it is important to further explore how meaningfulness is associated to and predicts global quality of life.

Caregivers' perceptions about terminally ill family members' quality of life.

Caregivers' perceptions on terminally ill family members' quality of life is rarely described. The aim of this study was to describe caregivers' perceptions about terminally ill family members' quality of life when suffering from cancer. Four caregivers participated in repeated focus group, and the data were analysed using qualitative content analysis. The findings were presented through five themes: 'living a normal life', 'being relieved from burdens', 'having a sense of belonging', 'being a symbol of incurable illness' and 'having a sense of dignity'. We found that to manage daily life it was significant to keep up a normal life and participate in social life. One new insight in this study was that caregivers contributed to an extending understanding to the term meaning in which the sense of belonging was fundamental. An obstacle for the sense of belonging was illuminated as the visible signs of incurable illness that stigmatized the ill person, and influenced the dignity. This study highlights the importance of supportive actions from significant others and healthcare professionals for terminally ill family members' quality of life.

Optimisation in fluoroscopy.

Optimisation of radiation protection in fluoroscopy is important since the procedure could lead to relatively high absorbed doses both in patients and personnel resulting in acute radiation injury. Optimisation procedures include adjustment of the fluoroscopy equipment such as exposure factors as well as proper use of automatic brightness control and pulsed fluoroscopy. It is also important to gain the benefits of image processing and the higher sensitivity of flat panel detectors as compared to image intensifier-TV systems.Proper positioning of the patient with respect to detector and X-ray tube is of fundamental importance to image quality and radiation dose to the patient. Both image quality and radiation dose are also affected by the methodology used with parameters such as magnification factor, increased filtration, use of last-image-hold and the use of a grid.There is a direct relation between patient dose and the absorbed dose to the personnel since this is mostly due to scattered radiation from the patient. If the correct methodology and the correct radiation protection devices are used, the absorbed dose to the personnel could be minimised to acceptable levels even for those working with complex procedures.In order to have an organised review of all aspects of optimisation, it is recommendable to have an active quality system at the department. This system should define responsibilities and tasks for persons involved.

Reduction of absorbed dose in storage phosphor urography by significant lowering of tube voltage and adjustment of image display parameters.

PURPOSE: To investigate whether image quality in storage phosphor urography can be maintained when the X-ray tube voltage is significantly lowered to give a lower patient dose. MATERIAL AND METHODS: Initial phantom studies were used to establish exposure settings at 53 kV that gave signal-to-noise ratios for contrast media structures equivalent to those obtained at the reference kilovoltage of 69 kV. Dose area product and image quality, assessed by image quality criteria and visual grading, were then recorded for 44 patients drawn at random to be examined by either the standard or modified technique. RESULTS: Absorbed dose could be reduced by more than 30% without any significant change in image quality in manually controlled exposures and by 13% in exposures controlled by AEC. CONCLUSION: It might be possible to lower the tube voltage in digital examinations involving contrast media as a means of lowering patient dose. The image display parameters need to be adjusted to maintain image quality.

Digital skeletal radiography. Reduction of absorbed dose by adaptation of exposure factors and image processing.

PURPOSE: The possibility to reduce the absorbed dose to the patient by increase of tube potential while maintaining the same exposure to the image plate and sufficient image quality in skeletal radiography has been investigated. MATERIAL AND METHODS: Image processing parameters were adjusted to account for an increase in tube potential by 20 kV. Revision of image processing parameters was based on measurements with phantoms constructed to simulate the histogram shape recorded for clinical images. Image quality was evaluated both using image quality criteria and visual grading analysis. Energy imparted was calculated from measurement of the kerma-area-product. RESULTS AND CONCLUSION: Energy imparted was reduced by 20-30% using the modified technique with increased kV. All images were considered of accurate quality for diagnosis and the difference in image quality score was marginal. There was, however, a significant shift towards lower grades for the "high kV" technique using visual grading analysis.

The potential of inductively coupled plasma mass spectrometry detection for high-performance liquid chromatography combined with accurate mass measurement of organic pharmaceutical compounds.

Quantification of unknown components in pharmaceutical, metabolic and environmental samples is an important but difficult task. Most commonly used detectors (like UV, RI or MS) require standards of each analyte for accurate quantification. Even if the chemical structure or elemental composition is known, the response from these detectors is difficult to predict with any accuracy. In inductively coupled plasma mass spectrometry (ICP-MS) compounds are atomised and ionised irrespective of the chemical structure(s) incorporating the element of interest. Liquid chromatography coupled with inductively coupled plasma mass spectrometry (LC/ICP-MS) has been shown to provide a generic detection for structurally non-correlated compounds with common elements like phosphorus and iodine. Detection of selected elements gives a better quantification of tested 'unknowns' than UV and organic mass spectrometric detection. It was shown that the ultrasonic nebuliser did not introduce any measurable dead volume and preserves the separation efficiency of the system. ICP-MS can be used in combination with many different mobile phases ranging from 0-100% organic modifier. The dynamic range was found to exceed 2.5 orders of magnitude. The application of LC/ICP-MS to pharmaceutical drugs and formulations has shown that impurities can be quantified below the 0.1 mol-% level.

MDM2 and p53 in childhood acute lymphoblastic leukemia: higher expression in childhood leukemias with poor prognosis compared to long-term survivors.

In previous studies the authors have found increased expression of p53 and MDM2 proteins in leukemic cells in a majority of children eligible for bone marrow transplantation (BMT) due to relapse or prognostically unfavorable features. In this study the immunohistochemical expression of p53, MDM2, and p21Cip1 was investigated in bone marrow samples from the time of diagnosis in 30 children with acute lymphoblastic leukemia (ALL) surviving disease-free at least 5 years. This group was compared with 15 advanced ALL patients, admitted for BMT. In 7 of the BMT patients orginal diagnostic marrow samples were also available for analysis. Four out of 30 ALL patients in the relapse-free group expressed p53 in the original leukemic cell population, while 8/15 advanced ALL patients did before BMT (p = .014). Four out of 30 cases in the relapse-free group expressed MDM2, while 10/15 in the BMT group did (p = .0011). In retrospect, MDM2 overexpression at the time of diagnosis was also more common (p = .0098) in the BMT group as well as p53 overexpression (p = .054) compared to nonrelapsed patients.

Pharmacokinetic and toxicity profile of a phosphorothioate oligonucleotide following inhalation delivery to lung in mice.

Antisense oligonucleotides are currently being investigated for the treatment of a variety of diseases. Antisense drugs are being administered primarily by parenteral injection. To explore more convenient patient delivery methods, we have characterized the tissue kinetics and tolerability of an inhaled aerosol formulation of a phosphorothioate oligonucleotide in mice. Concentrations of oligonucleotide in bronchioalveolar lavage fluid, plasma, and tissue and immunohistochemical localization were used to assess deposition and pharmacokinetic parameters. Significant concentrations of oligonucleotide in lung, as well as systemic tissues, were measured following a pulmonary dose of 12 mg/kg. Doses as low as 1-3 mg/kg also produced significant concentrations of oligonucleotide (>50 microg oligonucleotide per gram of tissue), and these were maintained in the lung with a halflife of 20 hours or greater. Oligonucleotide was localized to bronchiolar epithelium and alveolar epithelium and endothelium. Toxicity was mild at the 12 mg/kg level and minimal to absent at doses of 3 mg/kg or below. Based on a favorable pharmacokinetic profile and a relative lack of toxicity, inhalation delivery appears to be a therapeutic option for antisense oligonucleotides.

Studies related to the scale-up of high-cell-density E. coli fed-batch fermentations using multiparameter flow cytometry: effect of a changing microenvironment with respect to glucose and dissolved oxygen concentration.

Multiparameter flow cytometric techniques developed in our laboratories have been used for the "at-line" study of fed-batch bacterial fermentations. These fermentations were done at two scales, production (20 m(3)) and bench (5 x 10(-3) m(3)). In addition, at the bench scale, experiments were undertaken where the difficulty of achieving good mixing (broth homogeneity), similar to that found at the production scale, was simulated by using a two-compartment model. Flow cytometric analysis of cells in broth samples, based on a dual-staining protocol, has revealed, for the first time, that a progressive change in cell physiological state generally occurs throughout the course of such fermentations. The technique has demonstrated that a changing microenvironment with respect to substrate concentration (glucose and dissolved oxygen tension [DOT]) has a profound effect on cell physiology and hence on viable biomass yield. The relatively poorly mixed conditions in the large-scale fermentor were found to lead to a low biomass yield, but, surprisingly, were associated with a high cell viability (with respect to cytoplasmic membrane permeability) throughout the fermentation. The small-scale fermentation that most clearly mimicked the large-scale heterogeneity (i.e., a region of high glucose concentration and low DOT analogous to a feed zone) gave similar results. On the other hand, the small-scale well-mixed fermentation gave the highest biomass yield, but again, surprisingly, the lowest cell viability. The scaled-down simulations with high DOT throughout and locally low or high glucose gave biomass and viabilities between. Reasons for these results are examined in terms of environmental stress associated with an ever-increasing glucose limitation in the well-mixed case. On the other hand, at the large scale, and to differing degrees in scale-down simulations, cells periodically encounter regions of relatively higher glucose concentration.

A comparison of analogue and digital techniques in upper gastrointestinal examinations: absorbed dose and diagnostic quality of the images.

This study was performed to investigate whether patient exposure and diagnostic quality of the image is significantly influenced by the introduction of digital image acquisition techniques. Evaluation was performed for three different techniques (analogue, analogue fluoro + digital radiography, digital) in examination of the upper gastrointestinal tract. The evaluation was done from data acquired in three different departments. Patient exposure was recorded as KERMA-area product (KAP) and the individual patient readings were normalised to a standard size patient. Image quality was assessed using visual grading with a reference image. The recorded KAP values were significantly higher (22.3 Gycm2) for the fully digital technique compared to the others (analogue 6.8 Gycm2, analogue + digital 3.6 Gycm2). This was due mostly to an increased number of exposures. The diagnostic quality of the image was, however, also regarded to be slightly lower for the technique giving the lowest patient dose with the smallest number of exposures (analogue + digital). The digital examination technique, as used in this study, thus resulted in significantly higher patient dose without any significant gain in diagnostic quality of the image.

Laser-induced incandescence for soot particle size measurements in premixed flat flames.

Measurements of soot properties by means of laser-induced incandescence (LII) and combined scattering-extinction were performed in well-characterized premixed ethylene-air flames. In particular, the possibility of using LII as a tool for quantitative particle sizing was investigated. Particle sizes were evaluated from the temporal decay of the LII signal combined with heat balance modeling of laser-heated particles, and these sizes were compared with the particle sizes deduced from scattering-extinction measurements based on isotropic sphere theory. The correspondence was good early in the soot-formation process but less good at later stages, possibly because aggregation to clusters began to occur. A critical analysis has been made of how uncertainties in different parameters, both experimental and in the model, affect the evaluated particle sizes for LII. A sensitivity analysis of the LII model identified the ambient-flame temperature as a major source of uncertainty in the evaluated particle size, a conclusion that was supported by an analysis based on temporal LII profiles.