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.

Artificial nutrition and hydration in the last week of life in cancer patients. A systematic literature review of practices and effects.

BACKGROUND: The benefits and burdens of artificial nutrition (AN) and artificial hydration (AH) in end-of-life care are unclear. We carried out a literature review on the use of AN and AH in the last days of life of cancer patients. MATERIALS AND METHODS: We systematically searched for papers in PubMed, CINAHL, PsycInfo and EMBASE. All English papers published between January 1998 and July 2009 that contained data on frequencies or effects of AN or AH in cancer patients in the last days of life were included. RESULTS: Reported percentages of patients receiving AN or AH in the last week of life varied from 3% to 53% and from 12% to 88%, respectively. Five studies reported on the effects of AH: two found positive effects (less chronic nausea, less physical dehydration signs), two found negative effects (more ascites, more intestinal drainage) and four found also no effects on terminal delirium, thirst, chronic nausea and fluid overload. No study reported on the sole effect of AN. CONCLUSIONS: Providing AN or AH to cancer patients who are in the last week of life is a frequent practice. The effects on comfort, symptoms and length of survival seem limited. Further research will contribute to better understanding of this important topic in end-of-life care.

Photochemotherapy of oral lichen planus. A controlled study.

Photochemotherapy with 8-methoxypsoralen and long-wave ultraviolet light (PUVA) has become a useful alternative in dermatologic therapy. PUVA therapy has been successfully used in the treatment of severe psoriasis and cutaneous lichen planus. The aim of this investigation was to use PUVA in the treatment of oral lichen planus (OLP). Eighteen patients with long-standing, bilateral, and severe OLP of the buccal mucosa participated in the investigation. A dose of 0.6 mg/kg 8-methoxypsoralen was administered orally 2 hours before long-wave ultraviolet light irradiation was done. The patients were randomly assigned to treatment of the left or right side of the buccal mucosa. The irradiation therapy was given 12 times at intervals of 2 to 3 days, and the patients received a total average dosage of 16.5 J/cm2. The results showed that 13 treated sites compared with six control sites responded significantly favorable to PUVA therapy. Two patients dropped out because of side effects that were similar to those seen after whole-body irradiation PUVA treatment. The follow up times was 12 months. The conclusion of this study is that PUVA seems to be effective in the treatment of OLP and should be considered in severe cases of OLP.

A longitudinal investigation of the individual consistency of plaque levels in adults.

The present investigation was designed to determine the individual variation of plaque levels in adults over a period of 3 months. The participants were 20 healthy subjects, 11 men and 9 women, with a mean age of 42.3 +/- 7.3(SD) years. Plaque area was determined with a computerized image analysis system and expressed as percentage of tooth area (P% Index). The scoring procedures were carried out three times (tests 1, 2, and 3) at an interval of 4 weeks. After each test all plaque was removed. All subjects were instructed to maintain their personal oral hygiene habits during the study. The results showed no significant differences for the means of P% Index between tests 1, 2, and 3 in the whole mouth, upper and lower jaws, right and left sides, or each tooth surface. The intraindividual plaque levels for individual tooth surfaces were closely correlated between tests 1, 2 and 3. The intraindividual plaque level was consistent in tests 1, 2, and 3 with standard deviations within subjects ranging from 1.1% to 6.2%. This study suggests that individual plaque levels seem to be consistent on the basis of tooth surface over a certain period of time. Individual plaque control should be more directed towards tooth surfaces with comparably high plaque accumulation within the mouth for significant reduction of the overall plaque levels.

Antiserum directed against chromogranin A and B (CAB) is a useful marker for peptide hormone-producing endocrine cells and tumors.

Certain proteins, such as the chromogranins, have a ubiquitous occurrence in nearly ail peptide hormone-producing cells. To date, little is known about their functional role as structural proteins, precursors of bioactive peptides, or enzymes. Such proteins may serve as markers for endocrine cells and tumors. In the present study, we have used an antiserum that recognizes both chromogranin A and B (CAB) to demonstrate peptide hormone-producing endocrine cells and tumors in humans. The antiserum demonstrated endocrine cells all along the gastrointestinal tract, most of the islet cells, the adrenomedullary cells, the thyroid C cells, scattered endocrine cells in the respiratory tract, and numerous cells in the adenohypophysis. The CAB-positive cells outnumbered those storing chromogranin A as studied in the intestines and the anterior pituitary. An array of different peptide hormone-producing tumor cells were also CAB-positive, including several types of islet cell tumors, gastric, intestinal, and bronchial carcinoids, medullary thyroid carcinomas, and pheochromocytomas. Thus, the CAB antiserum may help identify peptide hormone-producing cells and tumors.

Pseudomonas 3 beta-hydroxysteroid dehydrogenase. Primary structure and relationships to other steroid dehydrogenases.

The 3 beta-hydroxysteroid dehydrogenase of Pseudomonas testosteroni commercially available was purified by an FPLC step and submitted to sequence determination by peptide analysis. The structure obtained reveals a 253-residue polypeptide chain, with an N-terminal, free alpha-amino group, and a low cysteine content. Comparisons with other hydroxysteroid dehydrogenases recently characterized reveal distant similarities with prokaryotic and, to some extent, also eukaryotic forms of separate specificities. Residue identities with a Streptomyces 20 beta-hydroxysteroid dehydrogenase are 35% and distributed over the entire molecule, whereas residue identities with the mammalian 17 beta-hydroxysteroid dehydrogenase only constitute 20%, and are essentially limited to the N-terminal and central parts, Nevertheless, all these enzymes exhibit a conserved tyrosine residue (position 151 in the present enzyme) noted as possibly having a functional role in some members of this protein family. Combined, the results establish the prokaryotic 3 beta-hydroxysteroid dehydrogenase as belonging to the family of short-chain alcohol dehydrogenases, reveal that the hydroxysteroid dehydrogenases are no more closely related than dehydrogenases with other enzyme activities within the family (e.g. glucose, ribitol, hydroxyprostaglandin dehydrogenases), show several of the mammalian hydroxysteroid dehydrogenases to have subunits of longer size with different patterns of similarity than those of the prokaryotic family members characterized, and define important segments of the coenzyme-binding region for this enzyme group.

Characterization of the murine corticosteroid binding globulin: variations between mammalian forms.

Corticosteroid binding globulin (CGB) from term-pregnant mouse serum was isolated and characterized by peptide analysis after treatment with CNBr and Lys-specific protease, respectively. Amino acid sequence analysis of six segments, covering 189 of 383 positions in different regions of the protein, showed unexpectedly low overall homology (60%) to the indirectly deduced human amino acid sequence previously reported. However, some segments displayed a greater resemblance to their human counterparts. Differences were observed in at least two of six potential glycosylation sites. The nature of electrophoretic CBG variants and their immunological properties are described.

Activation of rat liver microsomal glutathione transferase by limited proteolysis.

The activity of rat liver microsomal glutathione transferase is increased by limited tryptic proteolysis; the membrane-bound and purified forms of the enzyme are activated about 5- and 10-fold respectively. The cleavage sites that correlate with this activation were determined by amino acid sequence analysis to be located after Lys-4 and Lys-41. Differences in the relative extent of cleavage at these two sites did not consistently affect the degree of activation. Thus the data support the conclusion that cleavage at either site results in activation. The trypsin-activated enzyme was compared with the form activated with N-ethylmaleimide, which modifies Cys-49. These two differently activated forms were found to have similar kinetic parameters, which differ from those of the unactivated enzyme. The relatedness of the two types of activation is also demonstrated by the observation that microsomal glutathione transferase fully activated by N-ethylmaleimide is virtually resistant to further activation by trypsin. This is the case despite the fact that the N-ethylmaleimide-activated enzyme is much more susceptible to trypsin cleavage at Lys-41 than is the untreated enzyme. The latter observation indicates that activation with N-ethylmaleimide is accompanied by a conformational change involving Lys-41.

Re- and allotransplantation of teeth--an experimental study in monkeys.

In each of six monkeys one of the permanent lateral incisors with uncompleted root development was replanted. At the same time the contralateral incisors in four of the monkeys were allotransplanted by pairs. The remaining two contralateral incisors served as controls. After 4 weeks and 4 months, respectively, three monkeys were decapitated and the upper lateral incisors with adjacent periodontal tissue were examined histologically. The replanted teeth in five cases had a vital pulp. In the sixth case, however, the replanted incisor exhibited pulpitis and partial necrosis of the pulp. The periodontal membrane had a normal histologic appearance. In two cases a small area of arrested root resorption was observed. With the allotransplanted teeth the histologic appearance was altered. After 4 weeks a pronounced inflammatory reaction was observed in both the pulpal tissue and the periodontal membrane. The pulp was in most cases necrotic, and marked root resorption was observed. Most of the allotransplanted teeth were resorbed and replaced by an irregular hard tissue that resembled osteoid, which in many cases was connected with the tooth remnants by ankylosis. These results indicate that allotransplanted teeth, in contrast to replanted teeth, exhibit the characteristic features of an allograft rejection, including an inflammatory reaction and resorption.

A standardized meal stimulation test of the endocrine pancreas for early detection of pancreatic endocrine tumors in multiple endocrine neoplasia type 1 syndrome: five years experience.

Forty-nine members of 6 families with multiple endocrine neoplasia type 1 (MEN 1) were investigated with a standardized meal stimulation test to detect the presence of pancreatic endocrine tumors. Fifteen age-matched subjects and 4 patients with primary hyperparathyroidism also were studied. Serum pancreatic polypeptide (PP), gastrin, and insulin as well as plasma glucagon and somatostatin concentrations were determined before and during the test meal. Patients with demonstrable pancreatic endocrine tumors had significantly increased mean basal and peak serum PP (P less than 0.001) and gastrin (P less than 0.001) responses to the meal compared with healthy family members and normal subjects. Seven of 12 MEN 1 patients with parathyroid and pituitary disease but no demonstrable pancreatic endocrine tumors had exaggerated PP and/or gastrin responses to the meal; 4 of them developed pancreatic endocrine tumors, detected by abdominal computerized tomography, 0.5-4 yr later. None of the healthy members of the MEN 1 families or the patients with primary hyperparathyroidism had responses different from those of the normal subjects. Our experience with the meal stimulation test indicates that an elevated basal or exaggerated serum PP and/or gastrin response is an earlier sign of pancreatic involvement in the MEN 1 trait than is abdominal computerized tomography.

The effect of 20 Mg omeprazole daily on serum gastrin, 24-h intragastric acidity, and bile acid concentration in duodenal ulcer patients.

Serum gastrin, 24-h intragastric acidity, and bile acid concentrations were measured during physiologic conditions in 10 patients with duodenal ulcer disease. Omeprazole, 20 mg daily, for 8 days reduced acidity by greater than or equal to 99% in six patients and by 47-54% in four patients. The degree of acid reduction was related to the area under the plasma omeprazole concentration time curve (AUC). Serum gastrin levels were not significantly increased by omeprazole. Intragastric bile acid concentrations were increased by omeprazole, but this seems to be of little importance for the healing of duodenal ulcers.

Measles virus hemagglutinin. Removal of the initiator methionine in the mature protein, and evidence for further processing to produce a 'ragged' end.

Measles virus hemagglutinin has been isolated by immunoadsorption. The total composition of the protein and its N-terminal amino acid sequence give data matching the structure indirectly deduced from cDNA. However, direct analysis of the hemagglutinin also shows that the mature protein is proteolytically processed and has a partly heterogeneous N-terminus. The initiator Met is removed, and non-stoichiometrically also the second residue.

Isolation and characterization of variant IGF-1 as well as IGF-2 from adult human brain.

The forms of somatomedin present in the adult human brain have been characterized in this study. Two peptides were purified by acidification, size exclusion chromatography, affinity chromatography, FPLC and HPLC. Structural analysis identified these peptides as the variant form of IGF-1 with a truncated N-terminal region earlier isolated from human fetal brain and IGF-2. The presence of the truncated IGF-1 variant and IGF-2 in the human CNS suggests their role as neuropeptides.

Replantation of avulsed teeth after long extra-alveolar periods.

In 11 patients, 18 teeth, with extra-alveolar periods ranging from 6 h to 48 days were replanted after root-filling with chloroform resin and guttapercha. After observation periods from 1 to 7 years, only 1 tooth was lost (after 5 years), but the remaining 17 teeth were clinically well functioning. All teeth were ankylotic and subjected to replacement resorption of various extent. Inflammatory root resorption and periradicular osteitis were not observed. Marginal bone loss up to 5 mm was noticed, but was accompanied by gingival retraction and thus pathological periodontal pockets (5 mm) were not observed. Consequently, teeth replanted after long extra-alveolar periods (even several days) can function for many years and thus postpone prosthetic treatment.

Elevated serum levels of pancreatic polypeptide are related to impaired glucose handling in inflammatory states.

Glucose handling and insulin secretion were studied in patients with inflammatory connective tissue diseases and correlated to circulating levels of immunoreactive pancreatic polypeptide (PP). The patients had normal fasting serum levels of insulin and normal insulin response to intravenous glucose loading. Ten of 16 patients had an impaired glucose tolerance, defined as a K rate of less than one. The basal PP levels, which were elevated in half of the patients, were inversely correlated to the K values but showed no relationship to basal or maximum insulin levels. The degree of the impaired glucose handling in the patients was related to the degree of the inflammatory activity as defined by acute-phase reactants. Elevated PP levels may be partly responsible for impaired glucose tolerance in inflammatory states either as an inhibitor of peripheral insulin activity or as an inhibitor of hypersecretion of insulin, needed to overcome decreased tissue sensitivity for insulin.

Transluminal angioplasty for renovascular hypertension complicated by pregnancy.

Percutaneous transluminal angioplasty was successfully used in the treatment of renovascular hypertension that resulted from fibromuscular hyperplasia in a 26-year-old woman who was four weeks' pregnant. The patient's BP normalized immediately. She had a normal pregnancy that terminated in the delivery of a full-term normal child. Two and a half years after the procedure, she remained normotensive without taking antihypertensive medication. Percutaneous transluminal angioplasty may be useful in the treatment of renal artery stenosis complicated by hypertension and pregnancy, where the inherent risk of toxemia endangers the life of the mother and fetus.

Abnormal pancreatic polypeptide response to intravenous glucose in uraemics. A possible mechanism behind impaired glucose tolerance in uraemia.

Glucose handling and insulin secretion were studied in chronic haemodialysis patients and correlated with circulating levels of immunoreactive pancreatic polypeptide (PP). No correlation was found between the elevated basal levels of PP and K-rate or the maximum insulin response after a single intravenous injection of glucose. Fifty-three per cent of the patients had a normal glucose tolerance defined as a K-rate more than 1. This group of uraemics had a tendency to an exaggerated insulin response compared with the controls but no significant changes of serum-PP levels after a glucose stimulus were observed. In contrast, uraemic patients with a K-rate less than 1 and normal insulin response, showed significant increases of serum-PP at 4 and 6 min after glucose administration. Among all uraemic patients we found a significant inverse correlation between the K-rate and the early PP response (P less than 0.05) and a significant positive correlation between the K-rate and early insulin response (P less than 0.05). PP release in response to acute hyperglycaemia may be one mechanism behind impaired glucose handling in uraemics, either by reducing peripheral insulin activity or by preventing insulin secretion sufficient to overcome the decreased tissue sensitivity to insulin.

Elevated serum immunoglobulin E in bronchial carcinoma: its relation to the histology and prognosis of the cancer.

Total IgE and specific IgE antibodies against six common allergens were measured in the sera of 217 unselected patients with bronchial carcinoma. Their median total IgE level was significantly increased as compared to the median levels found in two control populations consisting of 246 individuals representing the adult general population and 143 patients with benign pulmonary disorders. The frequency of serological atopy, i.e., the presence of specific IgE antibodies, was also significantly increased in the cancer population as compared to the controls. In contrast, the incidence of possible clinical atopy was about five times higher in the general population than in the cancer group. Patients with bronchial carcinoma typed as adenocarcinoma had the best prognosis and also had nonelevated IgE levels in contrast to patients with bronchial carcinoma typed as squamous cell carcinoma, small or large cell carcinoma. The favourable prognosis with nonelevated IgE levels also was demonstrated in patients with squamous cell carcinoma. It is suggested that the elevated IgE levels in bronchial carcinoma reflect impaired cellular immunity.

Participation of antral somatostatin in the local regulation of gastrin release.

In anaesthetized pigs gastrin release was stimulated by irrigation of the antrum with bicarbonate and by instillation of a meat extract. The concentration of gastrin and somatostatin was measured by radioimmunoassay both in the antral and peripheral venous blood. The increase in gastrin was coupled to a significant decrease in somatostatin immunoreactivity as measured in the antral venous blood both during instillation of alkali and meat extract. In peripheral blood, the differences were much less evident and not statistically significant. It is speculated that the decrease in release of antral somatostatin during alkalinization and instillation of meat extract is the primary event which is followed by a diminished inhibition of gastrin liberation. Thus, the present data support the hypothesis that antral somatostatin participates in the local regulation of gastrin release.