The Nordic Specialist Course in Palliative Medicine: evaluation and experiences from the first course 2003-2005.

BACKGROUND AND AIMS: Palliative medicine is not recognized as a medical specialty in any of the five Nordic countries, but there is a great need for physicians with specialty qualifications to serve on an increasing number of palliative care services. The Associations for Palliative Medicine in the five countries agreed to develop a common Nordic course on a specialty level. RESULTS: A theoretical training course in six modules in two years was developed, based on the British palliative medicine curriculum and including a limited research project and a written exam. Twenty-two out of 30 students completed the first course as scheduled in 2005, and five more have obtained their course diploma later. The evaluation from the students showed very satisfactory personal experiences and subjective learning outcomes, and a positive influence on the overall development of palliative care in the respective countries. CONCLUSION: The Nordic Specialist Course in Palliative Medicine has proved a successful Nordic collaboration and may form the basis for a full specialist training programme.

Attitudes of Danish doctors and nurses to palliative and terminal care.

BACKGROUND: The WHO definitions of palliative care have been adopted in Denmark and implemented in The National Guidelines from 1999, but service developments have been very slow and not according to the recommendations. Attitudes to palliative care of Danish doctors and nurses may in part account for this. OBJECTIVE: To assess the attitudes to issues related to palliative care of doctors and nurses in a Danish county hospital and the related primary care services. DESIGN: Cross-sectional survey using a mailed, self-administered questionnaire answered anonymously. PARTICIPANTS: Nurses and doctors employed in a county hospital in Denmark, homecare nurses and general practitioners from the related primary care services. OUTCOME MEASURES: The responses from the groups were compared by chi2 statistics (where ordinal variables with chi2 for trend). Data were analysed using SPSS 10.0. RESULTS: 347 responded, response rate 76%. Eighty-one per cent of all respondents were currently caring for terminally ill patient(s), 94% had done so within the last six months. Hospital doctors see more terminally ill patients than GPs (P = 0.002). Comparison of doctors (both hospital and GPs) with nurses showed that nurses were more likely to definitely agree that palliative/terminal care was a rewarding part of their work (61% 'definitely agree' versus 30%), and they were less likely to prefer to leave care of these patients to others (4% 'definitely/probably agree' versus 9%). Nurses reflected more on existential matters (80% 'definitely/probably agree' versus 63%) and were more likely to agree that dealing with a dying patient made them aware of their own feelings regarding death (97% 'definitely/probably agree' versus 80%). Only 7% of all respondents reported 'being an active member of a religious community'. Ninety-two per cent of all respondents agreed that doctors play a key role in reducing the suffering of dying patients, but 59% of nurses versus 9% of doctors 'definitely/probably agree' that 'it is primarily the task of nurses to deal with patients reactions to death'. There were significant differences between hospital doctors and GPs, with the former less likely to agree that palliative and terminal illness is rewarding, more likely to leave care of dying patients to others, and more likely to 'probably' or 'definitely agree' that it is more satisfying to work with patients who will improve. Home care nurses reflected more on existential matters than their hospital colleagues, and were more likely to 'definitely agree' that palliative/terminal care is rewarding. Differences between groups seemed to be due to profession (doctor versus nurse) and setting (hospital versus community) rather than age or gender. CONCLUSION: These findings suggest that in Denmark nurses demonstrate more positive attitudes to the care of palliative/terminally ill patients than doctors, and that attitudes amongst doctors and nurses working in the community are more positive than those of the colleagues in hospitals. There is currently little education in the principles and practice of palliative care in Denmark. These findings will inform the development of appropriate palliative care education for doctors and nurses working both in the hospital and in the community in Denmark. They also raise the possibility that part of the inertia in the development of palliative care in Denmark is related to the lack of education and, in particular, to the need of support for doctors and nurses providing terminal care so they are enabled to be more reflective on the care they currently provide. There is evidence that education in palliative care can change health professionals' attitudes to palliative and terminal care, and this now needs to be investigated in Denmark.

Bone marrow fibrosis and disease activity in multiple myeloma monitored by the aminoterminal propeptide of procollagen III in serum.

Simple bone marrow fibrosis is seen in 10-30% of multiple myeloma (MM) patients. We investigated the incidence and characteristics of the bone marrow stromal alterations, in order to characterize the collagens involved by immunohistochemistry, and to evaluate the use of serum aminoterminal propeptide of type III procollagen (PIIINP) as a marker of marrow fibrogenesis and disease activity in MM. 34 consecutive patients with newly diagnosed MM were included prospectively, and followed for 12-30 months. Compared with the findings in 15 normal individuals we found increased interstitial deposits of collagen III in 48% of MM patients, whereas deposits of collagen I were not increased. Interstitial fibrosis appeared to be restricted to areas of severe plasma cell infiltration, but it could also have a more dispersed presentation in the severely infiltrated marrow. There was a high co-distribution of collagen III fibrils and reticulin fibres. Serum PIIINP levels were elevated in most patients, and in the follow-up study serum PIIINP showed a good correlation with the response to treatment. Patients with resistant or progressive disease had continually elevated levels of PIIINP. In most patients with responsive disease serum PIIINP normalized, and we observed no relapses in patients who had normal serum PIIINP levels. Other patients who responded to treatment by reduced M-component level, but had persistently elevated serum levels of PIIINP, had either early relapses or developed progression of osteolytic lesions in spite of unchanged M-component levels. Therefore an elevated serum PIIINP during treatment might indicate an active malignant clone. Serum PIIINP does not simply follow the M-component, but gives further information of potential therapeutic value.

[Atypical mycobacteria. Disseminated infection in patients with hematologic diseases]. / Atypiske mykobakterier. Dissemineret infektion hos hoematologiske patienter.

During the last decade interest in atypical mycobacteria (AM), especially Mycobacterium avium complex (MAC) has been intense, as a large number of AIDS patients develop disseminated infection with MAC. Disseminated infection has also been reported in other immunocompromised patients, but in much fewer cases. Among haematological diseases hairy cell leukemia (HCL) and chronic myelogenous leukemia (CML) seem to predispose to disseminated AM infection. We review 53 cases of disseminated AM infection in haematological patients reported in the literature, 39 with HCL, ten CML, and four other haematological diseases, and a review of possible treatment is given. The prognosis seems to depend on the course of the underlying haematological disease, and we conclude that early diagnosis and treatment of the infection is of great importance. Blood and bone marrow should therefore be cultivated for mycobacteria in such patients with persistent fever of unknown cause, and in cases with negative cultures and elevated serum values of alkaline phosphatase liver biopsy should be considered.

[Disseminated Mycobacterium avium infection in three patients with hematologic diseases]. / Dissemineret Mycobacterium avium-infektion hos tre haematologiske patienter.

We report three cases of disseminated Mycobacterium avium complex infection in immunocompromised haematological patients. We conclude that in haematological patients with longlasting fever of unknown cause Mycobacterium avium complex infection should be considered and the relevant cultures from blood and bone marrow should be done.

Abnormal bone turnover in monoclonal gammopathy of undetermined significance: analyses of type I collagen telopeptide, osteocalcin, bone-specific alkaline phosphatase and propeptides of type I and type III procollagens.

The main difference between monoclonal gammopathy of undetermined significance (MGUS) and multiple myeloma (MM) is the presence of lytic bone destructions in the latter. About 20% of MGUS patients develop MM, and histomorphometric studies have shown disturbed bone turnover rates in some of these patients. This study was performed in order to evaluate whether serum analyses of the C-terminal telopeptide of type I collagen (ICTP), as a reflector of bone degradation, and of osteocalcin, bone-specific alkaline phosphatase (bAP) and the C-terminal propeptide of type I procollagen (PICP), as markers of bone formation, might give information on disturbances of bone metabolism in MGUS. Furthermore, serum N-terminal propeptide of procollagen III (PIIINP) might give information on disturbances in collagen III metabolism in the bone marrow. In the 35 patients examined, serum ICTP was elevated in 12 patients (34%), serum PIIINP elevated in 6 patients (17%), serum osteocalcin elevated in 11 patients (31%), serum bAP elevated in 6 patients (17%), and serum PICP elevated in 4 patients (11%). Serum ICTP correlated significantly with PIIINP (r = 0.72, p < 0.001), and with serum osteocalcin (r = 0.57, p < 0.001) and serum bAP (r = 0.51, p = 0.002). These findings indicate disturbances of bone turnover and affected collagen metabolism in some MGUS patients. Follow-up observation may reveal any prognostic value of these findings.

Assessment of bone involvement in patients with multiple myeloma using bone densitometry.

To evaluate the use of dual energy X-ray absorptiometry (DXA) in multiple myeloma (MM) we performed a prospective study of 34 patients with newly diagnosed MM. Most patients had advanced disease and all but two patients had osteolytic bone destructions and/or pathological fractures. Bone mineral content (BMC) and bone mineral density (BMD) of the lumbar spine (L1-L4) and hip were measured using a Hologic QDR-1000 scanner. Collapsed vertebrae were not excluded from analysis. Data from 289 healthy Danish volunteers aged 21-79 yr were used for calculation of Z-scores. Lumbar spine BMC (Z-score -0.46 +/- 0.23, p = 0.05) and lumbar spine BMD (Z-score -0.56 +/- 0.23, p = 0.02) were significantly reduced in MM patients, whereas no reduction was seen in hip BMC or BMD. Collapsed vertebrae had marked reduced BMD (Z-score -1.34 +/- 0.22, p < 0.001), as had non-fractured vertebrae in the same individuals (Z-score -1.42 +/- 0.25, p < 0.001). Lumbar spine BMD correlated with radiologically assessed bone morbidity (r -0.37, p = 0.03) and stronger with the incidence of vertebral fractures (r -0.64, p < 0.001). Thus, osteopenia of the back is common in multiple myeloma and correlates with an increased incidence of fractures. DXA may identify subjects with increased risk of vertebral fractures for more intensive chemotherapeutic or anti-resorptive treatment.

[Systemic mastocytosis with eosinophilia]. / Systemisk mastocytose med eosinofili.

A 67-year old female patient presented with marked eosinophilia in the peripheral blood. The patient had asymptomatic systemic mastocytosis which she had probably had for many years. At the time of diagnosis, the eosinophilia had already produced symptoms of cardiac insufficiency. The patient was treated with prednisone and hydroxyurea which reduced the eosinophil count. In spite of treatment cardiac symptoms progressed, the patient developed atrial flutter, and died in pulmonary oedema. The autopsy showed fibrotic changes in the heart as seen in the fibrotic end stage of Löeffler's endomyocardial disease. The possible reasons for eosinophilia in the patient are discussed.

[Subacute thyroiditis in Parvovirus B19 infection]. / Subakut thyreoiditis ved Parvovirus B19-infektion.

In a 32-year-old women with clinical and scintigraphic signs of thyroiditis, serological screening showed positive IgG and IgM titres against Parvovirus B19 (PB19). Subacute thyroiditis has not previously been reported following PB19 infection. The present case suggests that subacute thyroiditis may be caused by PB19 infection. Further screening is necessary to establish whether this infection is more frequently associated with subacute thyroiditis than previously thought.