Caregivers reluctance to use palliative care practices: Construction of a causal model

peer reviewedObjective To identify any reason for healthcare professionals to resist to provide palliative care and to understand the main interactions between these factors, in order to develop a further work project which could modify them. Definition of resistance The passivity or the unconscious refusal, to reproduce behaviours and/or acts corresponding to the basic principles of the palliative approach when facing palliative patients. Target group Healthcare professionals, i.e all professionals who take care of patients suffering from an advanced or incurable disease. These are doctors, nurses, nursing auxiliaries, and also physiotherapists, psychologists, home carers, etc. Family members of the patient or volunteers were excluded from the target group. Method The causal analysis consists in building a causality tree of a specific problem within a team. The presentation under the form of a tree allows the reading of the identified factors, from the closest to the most distant. The causal analysis is a time-consuming method, but it will form the basis of further work of our team. Result The obtained model is an orderly repertory of the factors which contribute to the cause of the problem. Conclusion The members of the analysis unit have shared their knowledge to create a tool. This tool will be used to determine actions in order to reduce directly or indirectly the resistance to provide palliative care.Objectif Cerner l’ensemble des facteurs de la résistance des soignants à pratiquer les soins palliatifs et appréhender les interactions principales entre ces facteurs dans le but de développer un projet de travail ultérieur, susceptible de les modifier. Définition de la résistance La passivité ou le refus inconscient, devant un patient « palliatif », à mettre en œuvre des attitudes et/ou des actes appris qui s’inscrivent dans les principes de base de l’approche palliative. Public cible Les soignants, c’est-à-dire l’ensemble des professionnels qui s’occupent des patients atteints d’une maladie grave ou incurable. Il s’agit des médecins, des infirmiers, des aides-soignantes mais aussi des kinésithérapeutes, des psychologues, des gardes à domicile, des aides familiales, etc. Sont exclus du public cible les membres de la famille du patient et les volontaires. Méthode L’analyse causale qui consiste à construire, en équipe, un arbre de causalité d’un problème spécifique. La présentation sous forme d’arbre permet la lecture des différents facteurs recensés, des plus proches aux plus éloignés. L’analyse causale est une méthode consommatrice de temps, mais elle va constituer le fondement du travail ultérieur de la Plate-forme. Résultat Le modèle obtenu est un répertoire ordonné des facteurs qui participent à la cause du problème. Conclusion Les membres de la cellule d’analyse ont mis leurs savoirs en commun pour créer un outil de référence. Cet outil servira à définir des actions pour modifier directement ou indirectement la résistance des soignants à appliquer les soins palliatifs

How to recognize a patient with palliative needs : a «surprise» question to prevent bad surprises.

editorial reviewedEarly discussion on palliative care with patients with advanced, progressive or terminal disease is difficult regardless patient's life expectancy. In Belgium, a Royal Decree sets the criteria to identify patients with palliative needs. For that purpose, the Palliative Care Indicators Tool (PICT) is proposed. This 3-step identification tool designed for physicians begins with the so-called surprise question, «Would you be surprised if your patient died in the next 6 to 12 months?». The second and third steps examine the fragility and incurability criteria, respectively. The surprise question intends to encourage the clinician to trust his/her intuition and to promote a reflection on patient's needs. The PICT facilitates communication between caregivers. Also, it makes possible early thinking about advanced care planning. Hence, it allows patients to receive palliative care in due time. In this paper, after reviewing the background of the surprise question, we shall examine the benefits and limitations of the surprise question.Parler de soins palliatifs précocement chez les patients lorsqu’ils se trouvent à un stade avancé ou terminal d’une maladie grave, évolutive, mettant en péril le pronostic vital, quelle que soit son espérance de vie, reste difficile. La loi belge s’est dotée en octobre 2018 d’un arrêté royal proposant le PICT (Palliative Care Indicators Tool). Cette échelle d’identification, conçue en 3 étapes, débute par la question surprise : «Seriez-vous surpris si votre patient venait à décéder dans les 6 à 12 prochains mois??». La deuxième étape et la troisième étape déterminent respectivement les critères de fragilité et d’incurabilité. La question surprise encourage le clinicien à faire confiance à son intuition et valorise une réflexion centrée sur les besoins du patient. L’utilisation de l’outil PICT peut faciliter la communication entre soignants, permettre d’aborder plus tôt la réflexion autour de la planification anticipée des soins et offrira ainsi aux patients des soins palliatifs en temps opportun. Cet article présente l’historique de la question surprise ainsi que ses avantages et ses limites.3. Good health and well-bein

y a-t-il une place pour la radiothérapie en fin de vie ?

peer reviewedPrès de 50 % des patients atteints d’un cancer bénéficient, à un moment de leur trajet de soins, d’une irradiation. Celle-ci peut être administrée avec une intention curative ou palliative, en fonction de l’extension de la maladie, de l’état général du patient et de sa volonté. Le but d’une irradiation palliative, sera de contrôler localement la tumeur ou la métastase et, donc, de ralentir l’évolution du cancer. La radiothérapie peut également être utile pour supprimer un symptôme et, ainsi, être un des traitements de confort en fin de vie. La dose totale, la dose par fraction ainsi que la technique d’irradiation sont adaptées à l’intention du traitement. Cet article passe en revue les principales indications d’irradiation en fin de vie

Education for a Future in Crisis: Developing a Humanities-Informed STEM Curriculum

In the popular imagination, science and technology are often seen as fields of knowledge production critical to social progress and a cooperative future. This optimistic portrayal of technological advancement also features prominently in internal discourses amongst scientists, industry leaders, and STEM students alike. Yet, an overwhelming body of research, investigation, and first-person accounts highlight the varying ways modern science, technology, and engineering industries contribute to the degradation of our changing environments and exploit and harm global low-income and marginalized populations. By and large, siloed higher-education STEM curricula provide inadequate opportunities for undergraduate and graduate students to critically analyze the historical and epistemological foundations of scientific knowledge production and even fewer tools to engage with and respond to modern community-based cases. Here, we describe the development of a humanities- and social sciences-informed curriculum designed to address the theory, content, and skill-based needs of traditional STEM students considering technoscientific careers. In essence, this course is designed to foster behavior change, de-center dominant ways of knowing in the sciences, and bolster self-reflection and critical-thinking skills to equip the developing STEM workforce with a more nuanced and accurate understanding of the social, political, and economic role of science and technology. This curriculum has the potential to empower STEM-educated professionals to contribute to a more promising, inclusive future. Our framework foregrounds key insights from science and technology studies, Black and Native feminisms, queer theory, and disability studies, alongside real-world case studies using critical pedagogies.Comment: 25 pages, 1 figure, 4 table

Clinical outcomes of 130 patients with primary and secondary lung tumors treated with Cyberknife robotic stereotactic body radiotherapy

Background: Authors report clinical outcomes of patients treated with robotic stereotactic body radiotherapy (SBRT) for primary, recurrent and metastatic lung lesions. Patients and methods: 130 patients with 160 lesions were treated with Cyberknife SBRT, including T1-3 primary lung cancers (54%), recurrent tumors (22%) and pulmonary metastases (24%). The mean biologically equivalent dose (BED10Gy) was 151 Gy (72–180 Gy). Median prescribed dose for peripheral and central lesions was 3x20 Gy and 3x15 Gy, respectively. Local control (LC), overall survival (OS), and cause-specific survival (CSS) rates, early and late toxicities are reported. Statistical analysis was performed to identify factors influencing local tumor control. Results: Median follow-up time was 21 months. In univariate analysis, higher dose was associated with better LC and a cut-off value was detected at BED10Gy ≤ 112.5 Gy, resulting in 1-, 2-, and 3-year actuarial LC rates of 93%, vs 73%, 80% vs 61%, and 63% vs 54%, for the high and low dose groups, respectively (p = 0.0061, HR = 0.384). In multivariate analysis, metastatic origin, histological confirmation and larger Planning Target Volume (PTV) were associated with higher risk of local failure. Actuarial OS and CSS rates at 1, 2, and 3 years were 85%, 74% and 62%, and 93%, 89% and 80%, respectively. Acute and late toxicities ≥ Gr 3 were observed in 3 (2%) and 6 patients (5%), respectively. Conclusions: Our favorable LC and survival rates after robotic SBRT, with low rates of severe toxicities, are coherent with the literature data in this mixed, non-selected study population

Clinical outcomes of 130 patients with primary and secondary lung tumors treated with Cyberknife robotic stereotactic body radiotherapy

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Increased IL-6 and TGF-beta(1) concentrations in bronchoalveolar lavage fluid associated with thoracic radiotherapy

peer reviewedaudience: researcherPURPOSE: To assess, in lung cancer patients, the effects of thoracic radiotherapy (RT) on the concentrations of transforming growth factor-beta(1) (TGF-beta(1)) and interleukin-6 (IL-6) in the bronchoalveolar lavage (BAL) fluid. METHODS AND MATERIALS: Eleven patients with lung cancer requiring RT as part of their treatment were studied. BAL was performed bilaterally before, during, and 1, 3, and 6 months after RT. Before each BAL session, the patient's status was assessed clinically using pulmonary function tests and an adapted late effects on normal tissue-subjective, objective, management, analytic (LENT-SOMA) scale, including subjective and objective alterations. The National Cancer Institute Common Toxicity Criteria were used to grade pneumonitis. The TGF-beta(1) and IL-6 levels in the BAL fluid were determined using the Easia kit. RESULTS: The TGF-beta(1) and IL-6 concentrations in the BAL fluid recovered from the irradiated areas were significantly increased by thoracic RT. The increase in TGF-beta(1) levels tended to be greater in the group of patients who developed severe pneumonitis. In the BAL fluid from the nonirradiated areas, the TGF-beta(1) and IL-6 concentrations remained unchanged. CONCLUSION: The observed increase in TGF-beta(1) and IL-6 concentrations in the BAL fluid recovered from the irradiated lung areas demonstrated that these cytokines may contribute to the process leading to a radiation response in human lung tissue

Patient-derived organoids and orthotopic xenografts of primary and recurrent gliomas represent relevant patient avatars for precision oncology

Patient-based cancer models are essential tools for studying tumor biology and for the assessment of drug responses in a translational context. We report the establishment a large cohort of unique organoids and patient-derived orthotopic xenografts (PDOX) of various glioma subtypes, including gliomas with mutations in IDH1, and paired longitudinal PDOX from primary and recurrent tumors of the same patient. We show that glioma PDOXs enable long-term propagation of patient tumors and represent clinically relevant patient avatars that retain histopathological, genetic, epigenetic, and transcriptomic features of parental tumors. We find no evidence of mouse-specific clonal evolution in glioma PDOXs. Our cohort captures individual molecular genotypes for precision medicine including mutations in IDH1, ATRX, TP53, MDM2/4, amplification of EGFR, PDGFRA, MET, CDK4/6, MDM2/4, and deletion of CDKN2A/B, PTCH, and PTEN. Matched longitudinal PDOX recapitulate the limited genetic evolution of gliomas observed in patients following treatment. At the histological level, we observe increased vascularization in the rat host as compared to mice. PDOX-derived standardized glioma organoids are amenable to high-throughput drug screens that can be validated in mice. We show clinically relevant responses to temozolomide (TMZ) and to targeted treatments, such as EGFR and CDK4/6 inhibitors in (epi)genetically defined subgroups, according to MGMT promoter and EGFR/CDK status, respectively. Dianhydrogalactitol (VAL-083), a promising bifunctional alkylating agent in the current clinical trial, displayed high therapeutic efficacy, and was able to overcome TMZ resistance in glioblastoma. Our work underscores the clinical relevance of glioma organoids and PDOX models for translational research and personalized treatment studies and represents a unique publicly available resource for precision oncology

Subnational mapping of HIV incidence and mortality among individuals aged 15–49 years in sub-Saharan Africa, 2000–18 : a modelling study

Background: High-resolution estimates of HIV burden across space and time provide an important tool for tracking and monitoring the progress of prevention and control efforts and assist with improving the precision and efficiency of targeting efforts. We aimed to assess HIV incidence and HIV mortality for all second-level administrative units across sub-Saharan Africa. Methods: In this modelling study, we developed a framework that used the geographically specific HIV prevalence data collected in seroprevalence surveys and antenatal care clinics to train a model that estimates HIV incidence and mortality among individuals aged 15–49 years. We used a model-based geostatistical framework to estimate HIV prevalence at the second administrative level in 44 countries in sub-Saharan Africa for 2000–18 and sought data on the number of individuals on antiretroviral therapy (ART) by second-level administrative unit. We then modified the Estimation and Projection Package (EPP) to use these HIV prevalence and treatment estimates to estimate HIV incidence and mortality by second-level administrative unit. Findings: The estimates suggest substantial variation in HIV incidence and mortality rates both between and within countries in sub-Saharan Africa, with 15 countries having a ten-times or greater difference in estimated HIV incidence between the second-level administrative units with the lowest and highest estimated incidence levels. Across all 44 countries in 2018, HIV incidence ranged from 2 ·8 (95% uncertainty interval 2·1–3·8) in Mauritania to 1585·9 (1369·4–1824·8) cases per 100 000 people in Lesotho and HIV mortality ranged from 0·8 (0·7–0·9) in Mauritania to 676· 5 (513· 6–888·0) deaths per 100 000 people in Lesotho. Variation in both incidence and mortality was substantially greater at the subnational level than at the national level and the highest estimated rates were accordingly higher. Among second-level administrative units, Guijá District, Gaza Province, Mozambique, had the highest estimated HIV incidence (4661·7 [2544·8–8120·3]) cases per 100000 people in 2018 and Inhassunge District, Zambezia Province, Mozambique, had the highest estimated HIV mortality rate (1163·0 [679·0–1866·8]) deaths per 100 000 people. Further, the rate of reduction in HIV incidence and mortality from 2000 to 2018, as well as the ratio of new infections to the number of people living with HIV was highly variable. Although most second-level administrative units had declines in the number of new cases (3316 [81· 1%] of 4087 units) and number of deaths (3325 [81·4%]), nearly all appeared well short of the targeted 75% reduction in new cases and deaths between 2010 and 2020. Interpretation: Our estimates suggest that most second-level administrative units in sub-Saharan Africa are falling short of the targeted 75% reduction in new cases and deaths by 2020, which is further compounded by substantial within-country variability. These estimates will help decision makers and programme implementers expand access to ART and better target health resources to higher burden subnational areas