Discussing prognosis and end-of-life care in the final year of life: A randomized controlled trial of a nurse-led ommunication support programme for patients and caregivers

Introduction: Timely communication about lifeexpectancy and end-of-life care is crucial forensuring good patient quality-of-life at the end of lifeand a good quality of death. This article describes theprotocol for a multisite randomised controlled trial of anurse-led communication support programme tofacilitate patients' and caregivers' efforts tocommunicate about these issues with theirhealthcare team.Methods and analysis: This NHMRC-sponsored trialis being conducted at medical oncology clinics locatedat/affiliated with major teaching hospitals in Sydney,Australia. Patients with advanced, incurable cancer andlife expectancy of less than 12 months will participatetogether with their primary informal caregiver wherepossible. Guided by the self-determination theory ofhealth-behaviour change, the communication supportprogramme pairs a purpose-designed Question PromptList (QPL-an evidence-based list of questionspatients/caregivers can ask clinicians) with nurse-ledexploration of QPL content, communication challenges,patient values and concerns and the value of earlydiscussion of end-of-life issues. Oncologists are alsocued to endorse patient and caregiver question askingand use of the QPL. Behavioural and self-report datawill be collected from patients/caregivers approximatelyquarterly for up to 2.5 years or until patient death, afterwhich patient medical records will be examined.Analyses will examine the impact of the intervention onpatients' and caregivers' participation in medicalconsultations, their self-efficacy in medical encounters,quality-of-life, end-of-life care receipt and quality-ofdeathindicators.Ethics and dissemination: Approvals have beengranted by the human ethics review committee ofRoyal Prince Alfred Hospital and governance officersat each participating site. Results will be reported inpeer-reviewed publications and conferencepresentations.Trial registration number: Australian New ZealandClinical Trials Registry ACTRN12610000724077

A standardised sampling protocol for robust assessment of reach-scale fish community diversity in wadeable New Zealand streams

The New Zealand fish fauna contains species that are affected not only by river system connectivity, but also by catchment and local-scale changes in landcover, water quality and habitat quality. Consequently, native fish have potential as multi-scale bioindicators of human pressure on stream ecosystems, yet no standardised, repeatable and scientifically defensible methods currently exist for effectively quantifying their abundance or diversity in New Zealand stream reaches. Here we report on the testing of a back-pack electrofishing method, modified from that used by the United States Environmental Protection Agency, on a wide variety of wadeable stream reaches throughout New Zealand. Seventy-three first- to third-order stream reaches were fished with a single pass over 150-345 m length. Time taken to sample a reach using single-pass electrofishing ranged from 1-8 h. Species accumulation curves indicated that, irrespective of location, continuous sampling of 150 stream metres is required to accurately describe reach-scale fish species richness using this approach. Additional species detection beyond 150 m was rare (<10%) with a single additional species detected at only two out of the 17 reaches sampled beyond this distance. A positive relationship was also evident between species detection and area fished, although stream length rather than area appeared to be the better predictor. The method tested provides a standardised and repeatable approach for regional and/or national reporting on the state of New Zealand's freshwater fish communities and trends in richness and abundance over time

Patient perspectives regarding communication about prognosis and end-of-life issues: How can it be optimised?

Objective: To explore patients' perspectives across two cultures (Australia and USA) regarding communication about prognosis and end-of-life care issues and to consider the ways in which these discussions can be optimised. Methods: Fifteen Australian and 11 US patients completed individual semi-structured qualitative interviews. A further 8 US patients participated in a focus group. Interviews and focus group recordings were transcribed verbatim and interpreted using thematic text analysis with an inductive, data-driven approach. Results: Global themes identified included readiness for and outcomes of discussions of prognosis and end-of-life issues. Contributing to readiness were sub themes including patients' adjustment to and acceptance of their condition (together with seven factors promoting this), doctor and patient communication skills, mutual understandings and therapeutic relationship elements. Outcomes included sub themes of achievement of control and ability to move on. A model of the relationships between these factors, emergent cross cultural differences, and how factors may help to optimise these discussions are presented. Conclusion: Identified optimising factors illustrate Australian and US patients' perspectives regarding how prognosis and end-of-life issues can be discussed with minimised negative impact. Practice implications: Recognition of factors promoting adjustment, acceptance and readiness and use of the communication skills and therapeutic relationship elements identified may assist in optimising discussions and help patients plan care, achieve more control of their situation and enjoy an optimal quality-of-life. © 2011 Elsevier Ireland Ltd

Repetitive elements in parasitic protozoa

A recent paper published in BMC Genomics suggests that retrotransposition may be active in the human gut parasite Entamoeba histolytica. This adds to our knowledge of the various types of repetitive elements in parasitic protists and the potential influence of such elements on pathogenicity

Elevated hemostasis markers after pneumonia increases one-year risk of all-cause and cardiovascular deaths

Background: Acceleration of chronic diseases, particularly cardiovascular disease, may increase long-term mortality after community-acquired pneumonia (CAP), but underlying mechanisms are unknown. Persistence of the prothrombotic state that occurs during an acute infection may increase risk of subsequent atherothrombosis in patients with pre-existing cardiovascular disease and increase subsequent risk of death. We hypothesized that circulating hemostasis markers activated during CAP persist at hospital discharge, when patients appear to have recovered clinically, and are associated with higher mortality, particularly due to cardiovascular causes. Methods: In a cohort of survivors of CAP hospitalization from 28 US sites, we measured D-Dimer, thrombin-antithrombin complexes [TAT], Factor IX, antithrombin, and plasminogen activator inhibitor-1 at hospital discharge, and determined 1-year all-cause and cardiovascular mortality. Results: Of 893 subjects, most did not have severe pneumonia (70.6% never developed severe sepsis) and only 13.4% required intensive care unit admission. At discharge, 88.4% of subjects had normal vital signs and appeared to have clinically recovered. D-dimer and TAT levels were elevated at discharge in 78.8% and 30.1% of all subjects, and in 51.3% and 25.3% of those without severe sepsis. Higher D-dimer and TAT levels were associated with higher risk of all-cause mortality (range of hazard ratios were 1.66-1.17, p = 0.0001 and 1.46-1.04, p = 0.001 after adjusting for demographics and comorbid illnesses) and cardiovascular mortality (p = 0.009 and 0.003 in competing risk analyses). Conclusions: Elevations of TAT and D-dimer levels are common at hospital discharge in patients who appeared to have recovered clinically from pneumonia and are associated with higher risk of subsequent deaths, particularly due to cardiovascular disease. © 2011 Yende et al

A rare case of intussusception leading to the diagnosis of acquired immune deficiency syndrome: a case report

<p>Abstract</p> <p>Introduction</p> <p>Although a common cause of intestinal obstruction in children, intussusception is a rare event in the adult population living in temperate regions. It has long been known that various acquired immune deficiency syndrome related conditions of the bowel such as lymphoma, lymphoid hyperplasia, cytomegalovirus colitis and Kaposi's sarcoma can lead to intussusception. The diagnosis is particularly difficult in this population of patients due to the non-specific nature of the symptoms as well as the depressed immune response obscuring inflammation or ischemia. Though the reported acquired immune deficiency syndrome associated cases of intussusception refer to patients with known human immunodeficiency virus infection, in our case we present an intestinal intussusception as the first manifestation of human immunodeficiency virus infection.</p> <p>Case presentation</p> <p>A 58-year-old white heterosexual Greek man with a clean medical record and no history of abdominal operation presented to the emergency department with symptoms and signs of bowel obstruction. Plain abdominal radiographs were highly suspicious for intussusception which was eventually confirmed on a computed tomography scan. Due to the patients clean medical record as well as the radiologic diagnosis of intussusception, we promptly undertook further serologic tests for human immunodeficiency virus and eventually established the diagnosis of acquired immune deficiency syndrome. The patient was operated 3 days later and this confirmed the diagnosis of small-bowel invagination due to a 4 cm polypoid growing intraluminal tumor, the pathologic examination of which revealed a diffuse high-grade B cell lymphoblastic lymphoma.</p> <p>Conclusion</p> <p>Human immunodeficiency virus infection may have a silent course and gastrointestinal manifestations of the disease leading to intussusception might be the first clinical sign. Patients with intestinal intussusception, and the presence of risk factors for human immunodeficiency virus infection should be eligible for serologic tests for human immunodeficiency virus infection.</p

The effect of posterior capsule repair upon post-operative hip dislocation following primary total hip arthroplasty

<p>Abstract</p> <p>Background</p> <p>Herein, we evaluated, retrospectively, the effect of posterior capsular repair upon postoperative hip dislocation subsequent to total hip arthroplasty (THA) incorporating a posterolateral approach.</p> <p>Methods</p> <p>A total of 181 patients undergoing 204 primary non-complicated THA surgical procedures in the period from January 2000 to October 2005 inclusively were included in this study. The patients were separated into two groups by whether the posterior capsular repair had been incorporated in the surgical procedure. For the surgeon did not commence repairing the posterior capsule until July, 2003, all members in the group that did not undergo posterior capsular repair (142 hips from 131 patients) were collected since January, 2000 to July, 2003, while the members in the group that underwent posterior capsular repair (62 hips from 52 patients) were followed since July, 2003, to October, 2005. With a minimum follow-up period of 12 months, we evaluated the early post-operative dislocation rate.</p> <p>Results</p> <p>The early postoperative hip-dislocation rate for the group who did not undergo posterior capsular repair appeared to be substantially greater (6.38% versus 0%) than the corresponding figure for the group the members of which underwent posterior capsular repair. In addition, patient demographics and the orientation of acetabular components for the replaced hip joints, as presented in postoperative radiographs, did not differ between the two groups.</p> <p>Conclusion</p> <p>Thus, surgeons should include posterior capsular repair as an important step in the surgical procedures of posterolateral approach for all THA in order to reduce the likelihood of early hip dislocation subsequent to THA.</p

Effect of Global Cardiac Ischemia on Human Ventricular Fibrillation: Insights from a Multi-scale Mechanistic Model of the Human Heart

Acute regional ischemia in the heart can lead to cardiac arrhythmias such as ventricular fibrillation (VF), which in turn compromise cardiac output and result in secondary global cardiac ischemia. The secondary ischemia may influence the underlying arrhythmia mechanism. A recent clinical study documents the effect of global cardiac ischaemia on the mechanisms of VF. During 150 seconds of global ischemia the dominant frequency of activation decreased, while after reperfusion it increased rapidly. At the same time the complexity of epicardial excitation, measured as the number of epicardical phase singularity points, remained approximately constant during ischemia. Here we perform numerical studies based on these clinical data and propose explanations for the observed dynamics of the period and complexity of activation patterns. In particular, we study the effects on ischemia in pseudo-1D and 2D cardiac tissue models as well as in an anatomically accurate model of human heart ventricles. We demonstrate that the fall of dominant frequency in VF during secondary ischemia can be explained by an increase in extracellular potassium, while the increase during reperfusion is consistent with washout of potassium and continued activation of the ATP-dependent potassium channels. We also suggest that memory effects are responsible for the observed complexity dynamics. In addition, we present unpublished clinical results of individual patient recordings and propose a way of estimating extracellular potassium and activation of ATP-dependent potassium channels from these measurements

Routes for breaching and protecting genetic privacy

We are entering the era of ubiquitous genetic information for research, clinical care, and personal curiosity. Sharing these datasets is vital for rapid progress in understanding the genetic basis of human diseases. However, one growing concern is the ability to protect the genetic privacy of the data originators. Here, we technically map threats to genetic privacy and discuss potential mitigation strategies for privacy-preserving dissemination of genetic data.Comment: Draft for comment

Breast cancer incidence and mortality in Tyrol/Austria after fifteen years of opportunistic mammography screening

<p>Abstract</p> <p>Background</p> <p>The aim of this study was to analyse breast cancer incidence and mortality in Tyrol from 1970 to 2006, namely after performing more than a decade of opportunistic mammography screening and just before piloting an organised screening programme. Our investigation was conducted on a population level.</p> <p>Methods</p> <p>To study time trends in breast cancer incidence and mortality, we applied the age-period-cohort model by Poisson regression to the official mortality data covering more than three decades from 1970 to 2006 and to the incidence data ranging from 1988 to 2006. In addition, for incidence data we analysed data on breast cancer staging and compared these with EU guidelines.</p> <p>Results</p> <p>For the analysis of time trend in breast cancer mortality in age groups 40-79, an age-period-cohort model fits well and shows for years 2002-2006 a statistically significant reduction of 26% (95% CI 13%-36%) in breast cancer mortality as compared to 1992-1996.</p> <p>We see only slight non-significant increases in breast cancer incidence. For the past five years, incidence data show a 10% proportion of in situ cases, and of 50% for cases in stages II+.</p> <p>Conclusions</p> <p>The opportunistic breast cancer screening programme in Tyrol has only in part exploited the mortality reduction known for organised screening programmes. There seems to be potential for further improvement, and we recommend that an organised screening programme and a detailed screening database be introduced to collect all information needed to analyse the quality indicators suggested by the EU guidelines.</p