Keuhkon- ja sydämensiirtopotilaiden infektiot : tutkimus bronkoskopian merkityksestä infektioiden diagnostiikassa sekä virusten osoittamisesta verestä ja bronkoalveolaarisesta huuhtelunäytteestä

Infection is a major cause of mortality and morbidity after thoracic organ transplantation. The aim of the present study was to evaluate the infectious complications after lung and heart transplantation, with a special emphasis on the usefulness of bronchoscopy and the demonstration of cytomegalovirus (CMV), human herpes virus (HHV)-6, and HHV-7. We reviewed all the consecutive bronchoscopies performed on heart transplant recipients (HTRs) from May 1988 to December 2001 (n = 44) and lung transplant recipients (LTRs) from February 1994 to November 2002 (n = 472). To compare different assays in the detection of CMV, a total of 21 thoracic organ transplant recipients were prospectively monitored by CMV pp65-antigenemia, DNAemia (PCR), and mRNAemia (NASBA) tests. The antigenemia test was the reference assay for therapeutic intervention. In addition to CMV antigenemia, 22 LTRs were monitored for HHV-6 and HHV-7 antigenemia. The diagnostic yield of the clinically indicated bronchoscopies was 41 % in the HTRs and 61 % in the LTRs. The utility of the bronchoscopy was highest from one to six months after transplantation. In contrast, the findings from the surveillance bronchoscopies performed on LTRs led to a change in the previous treatment in only 6 % of the cases. Pneumocystis carinii and CMV were the most commonly detected pathogens. Furthermore, 15 (65 %) of the P. carinii infections in the LTRs were detected during chemoprophylaxis. None of the complications of the bronchoscopies were fatal. Antigenemia, DNAemia, and mRNAemia were present in 98 %, 72 %, and 43 % of the CMV infections, respectively. The optimal DNAemia cut-off levels (sensitivity/specificity) were 400 (75.9/92.7 %), 850 (91.3/91.3 %), and 1250 (100/91.5 %) copies/ml for the antigenemia of 2, 5, and 10 pp65-positive leukocytes/50 000 leukocytes, respectively. The sensitivities of the NASBA were 25.9, 43.5, and 56.3 % in detecting the same cut-off levels. CMV DNAemia was detected in 93 % and mRNAemia in 61 % of the CMV antigenemias requiring antiviral therapy. HHV-6, HHV-7, and CMV antigenemia was detected in 20 (91 %), 11 (50 %), and 12 (55 %) of the 22 LTRs (median 16, 31, and 165 days), respectively. HHV-6 appeared in 15 (79 %), HHV-7 in seven (37 %), and CMV in one (7 %) of these patients during ganciclovir or valganciclovir prophylaxis. One case of pneumonitis and another of encephalitis were associated with HHV-6. In conclusion, bronchoscopy is a safe and useful diagnostic tool in LTRs and HTRs with a suspected respiratory infection, but the role of surveillance bronchoscopy in LTRs remains controversial. The PCR assay acts comparably with the antigenemia test in guiding the pre-emptive therapy against CMV when threshold levels of over 5 pp65-antigen positive leukocytes are used. In contrast, the low sensitivity of NASBA limits its usefulness. HHV-6 and HHV-7 activation is common after lung transplantation despite ganciclovir or valganciclovir prophylaxis, but clinical manifestations are infrequently linked to them.Keuhkon- ja sydämensiirtopotilailla infektiot ovat yleisiä ja ne aiheuttavat merkittävää kuolleisuutta. Infektioiden aiheuttajakirjo on laaja, joten hyvät menetelmät infektioiden diagnostiikassa ovat välttämättömiä. Tässä väitöskirjatutkimuksessa selvitettiin bronkoskopian käyttökelpoisuutta keuhkon- ja sydämensiirtopotilaiden infektiodiagnostiikassa, verrattiin sytomegalovirus(CMV)-infektioiden osoittamiseen käytettäviä menetelmiä näissä potilasryhmissä sekä tutkittiin ihmisen herpesvirusten 6 ja 7 (HHV-6 ja HHV-7) esiintymistä ja merkitystä keuhkonsiirtopotilailla. Tutkimme sydämensiirtopotilaille tehtyjen 44:n ja keuhkonsiirtopotilaille tehtyjen 472:n bronkoskopian tulokset. Seurasimme 21:tä keuhkon- tai sydämensiirron saanutta potilasta veren CMV-antigenemia-, DNAemia- (PCR) ja mRNAemia(NASBA)testein. CMV-infektioiden hoito perustui antigenemiatestiin, johon kahden muun testin tuloksia verrattiin. CMV antigenemiatestin lisäksi 22:ta keuhkonsiirtopotilasta seurattiin HHV-6:n ja HHV-7:n suhteen valkosolujen antigeenitestien avulla. Infektioepäilyn yhteydessä tehtyjen bronkoskopioiden näytteistä saatiin diagnoosi sydämensiirtopotilailla 41 %:ssa ja keuhkonsiirtopotilailla 61 %:ssa tapauksista. Bronkoskopia osoittautui hyödyllisimmäksi ajanjaksona yhdestä kuuteen kuukautta elinsiirrosta. Sen sijaan oireettomille keuhkonsiirtopotilaille tehtyjen ns. seuranta-bronkoskopioiden löydökset vaikuttivat potilaan hoitoon vain 6 %:ssa tapauksista. Yleisimmät bronkoskopianäytteissä todetut mikrobit olivat CMV ja Pneumocystis carinii, joka aiheutti infektioita keuhkonsiirtopotilailla yllättäen myös estolääkityksen aikana. Bronkoskopiaan liittyi vain harvoin merkittäviä komplikaatioita. Lääkehoitoa vaatineista CMV antigenemioista DNAemia-testi oli positiivinen 93 %:ssa ja mRNAemia-testi 61 %:ssa tapauksista. Antigenemia- ja DNAemia-testien tulokset korreloivat aineistossamme hyvin. Antigenemiatasoja 2, 5 ja 10 pp65-positiivista leukosyyttiä/50 000 leukosyyttiä vastaavat parhaan herkkyyden ja tarkkuuden summan tuottavat DNAemia (herkkyys/tarkkuus)-tasot olivat 400 (75.9 % / 92.7 %), 850 (91.3 % / 91.3 %) ja 1250 (100 % / 91.5 %) kopiota/ml. Näitä antigenemiatasoja vastaavat mRNAemia-testin herkkyydet olivat 25.9 %, 43.5 % ja 56.3 %. Keuhkonsiirtopotilaista 91 %:lla todettiin HHV-6 antigenemia ja 50 %:lla HHV-7 antigenemia. Molemmat virukset aktivoituivat yleensä n. kuukauden kuluessa keuhkonsiirron jälkeen. Yhdellä potilaalla HHV-6 viruksen aktivaatio assosioitui radiologisiin keuhkomuutoksiin ja toisella neurologisiin löydöksiin, mutta muutoin HHV-6 ja HHV-7 antigenemiaan ei voitu liittää selkeitä oireita. Gansikloviiri tai valgansikloviiri estolääkityksen aikana 15 potilaalla (79 %) todettiin HHV-6, seitsemällä (37 %) HHV-7 ja yhdellä (7 %) CMV antigenemia. Tämän tutkimuksen perusteella bronkoskopia on turvallinen ja käyttökelpoinen menetelmä keuhkon- ja sydämensiirtopotilaiden infektioiden diagnostiikassa. Sen sijaan oireettomille keuhkonsiirtopotilaille tehtävien seuranta-bronkoskopioiden hyödyllisyys on kyseenalainen. CMV DNAemia-testi (PCR) vaikuttaa toimivan yhtä hyvin verrattuna CMV antigenemiatestiin, kun hoidon aloittamisen kynnysarvoina on käytetty yli 5 pp65-antigeenipositiiivista leukosyyttiä. Sitä vastoin NASBA-testin matala sensitiivisyys rajoittaa sen käyttöä. HHV-6 ja HHV-7 antigenemia on yleistä keuhkonsiirron jälkeen huolimatta CMV infektioita vastaan suunnatusta estolääkityksestä. Näiden virusten aktivaatioon liittyy kuitenkin harvoin selkeitä oireita tai löydöksiä

The required competencies of physicians within palliative care from the perspectives of multi-professional expert groups : a qualitative study

Background Although statements on the competencies required from physicians working within palliative care exist, these requirements have not been described within different levels of palliative care provision by multi-professional workshops, comprising representatives from working life. Therefore, the aim of this study was to describe the competencies required from physicians working within palliative care from the perspectives of multi-professional groups of representatives from working life. Methods A qualitative approach, using a workshop method, was conducted, wherein the participating professionals and representatives of patient organizations discussed the competencies that are required in palliative care, before reaching and documenting a consensus. The data (n = 222) was collected at workshops held in different parts of Finland and it was analyzed using a qualitative content analysis method. Results The description of the competencies required of every physician working within palliative care at the general level included 13 main categories and 50 subcategories in total. 'Competence in advanced care planning and decision-making' was the main category which was obtained from the highest number of reduced expressions from the original data (f = 125). Competence in social interactions was another strong main category (f = 107). In specialist level data, six main categories with 22 subcategories in total were found. 'Competence in complex symptom management' was the main category which was obtained from the biggest number of reduced expressions (f = 46). A notable association between general level and specialist level data was related to networking, since one of the general level categories was 'Competence in consultations and networking' (f = 34) and one of the specialist level categories was 'Competence to offer consultative and educational support to other professionals' (f = 30). Moreover, part of the specialist level results were subcategories which belonged to the main categories produced from the general level data. Conclusions The competencies described in this study emphasize decision-making, social interactions and networking. It is important to listen to the voices of the working-life representatives when planning curricula. Moreover, the views of the working-life representatives inform how the competencies gained during their education meet the challenges of the ordinary work.Peer reviewe

The Trail, 1961-05-02

https://soundideas.pugetsound.edu/thetrail_all/1827/thumbnail.jp

Undergraduate curriculum in palliative medicine at Tampere University increases students' knowledge

Background: Education in palliative medicine (PM) at medical schools reveals wide variation despite the increasing importance of palliative care. Many universities present poor description of the benefits and detailed content of the total curriculum in PM. Using the recommendations of European Association for Palliative Care (EAPC) as a reference, we evaluated the content and outcomes of the curriculum in PM at the University of Tampere, Finland. Methods: We searched for a PM curriculum by examining the teaching offered by every specialty and compared it to EAPC recommendations. Students' knowledge was evaluated using a progress test over three consecutive years. Results: We found 53.5 teaching hours addressing PM issues, which exceeds the recommendation of the EAPC. Basics, symptom management, ethics, and communication skills were well established, while education in psychosocial/spiritual aspects, teamwork and self-reflection failed to reach the recommendations. Out of the maximum of 4.0, the progress test mean scores in PM among the third, fourth, fifth and sixth year students were 0.1 (SD 0.71), 0.69 (SD 1.28), 1.38 (SD 1.46) and 2.53 (SD 1.26), respectively (p <0.001). This growing knowledge was associated with the timely increase in teaching provided through the PM discipline. In addition, the students who completed the optional PM course achieved better mean scores (2.66; SD 1.27) than the others (1.33; SD 1.43) (p <0.001). Conclusions: The curriculum in PM at the University of Tampere is integrated into the teaching of many disciplines and complied well with the EAPC recommendations. This education led to increasing knowledge in PM among medical students.Peer reviewe

Elämän loppuvaiheen ennakoiva hoitosuunnitelma

English summaryPeer reviewe

mMRC dyspnoea scale indicates impaired quality of life and increased pain in patients with idiopathic pulmonary fibrosis

Peer reviewe

Cancer Patients' Symptom Burden and Health-related Quality of Life (HRQoL) at Tertiary Cancer Center from 2006 to 2013 : A Cross-sectional Study

Background/Aim: To observe changes in symptoms and health-related quality of life (HRQoL) over 7 years among cancer patients at different stages of the disease. Patients and Methods: This prospective cross-sectional study at the Helsinki University Hospital Cancer Center, was carried out in 2006 and repeated in 2013. All participants filled in the EORTC-QLQ-C30 questionnaire. Results: Altogether, 581 patients responded (49% in 2006 and 54% in 2013). The disease was local in 51% and advanced in 49% of patients. The HRQoL was significantly lower, except for emotional and cognitive functions, and the symptom burden more severe in advanced cancer. The most prevalent symptoms were fatigue (93% and 85%; moderate/severe 22% and 9%), pain (65% and 47%; moderate/severe 16% and 5%), and insomnia (64% and 60%; moderate/severe 20 and 21%), respectively. No changes in HRQoL or symptoms were found at 7 years. Conclusion: There is a need for early integrated palliative care to improve HRQoL during cancer treatments.Peer reviewe

Asiantuntijoiden näkemyksiä palliatiivisen hoidon ja saattohoidon kehittämis- ja tutkimustarpeista

Vertaisarvioitu. English summary.Peer reviewe

The indirect costs of palliative care in end-stage cancer : A real-life longitudinal register- and questionnaire-based study

Background: Palliative care needs are increasing as more people are dying from incurable diseases. Healthcare costs have been reported to be highest during the last year of life, but studies on the actual costs of palliative care are scarce. Aim: To explore the resource use and costs of palliative care among end-stage breast, colorectal and prostate cancer patients after termination of life-prolonging oncological treatments, that is, during the palliative care period. Design: A real-life longitudinal register- and questionnaire-based study of cancer patients' resource use and costs. Participants: In total, 70 patients in palliative care with no ongoing oncological treatments were recruited from the Helsinki University Hospital or from the local hospice. Healthcare costs, productivity costs and informal care costs were included. Results: The mean duration of the palliative care period was 179days. The healthcare cost accounted for 55%, informal care for 27% and productivity costs for 18% of the total costs. The last 2weeks of life contributed to 37% of the healthcare cost. The costs of the palliative care period were higher in patients living alone, which was mostly caused by inpatient care (p=0.018). Conclusion: The 45% share of indirect costs is substantial in end-of-life care. The healthcare costs increase towards death, which is especially true of patients living alone. This highlights the significant role of caregivers. More attention should be paid to home care and caregiver support to reduce inpatient care needs and control the costs of end-of-life care.Peer reviewe