Medical treatment for inoperable malignant bowel obstruction: a qualitative systematic review

The use of symptomatic agents has greatly improved the medical treatment of advanced cancer patients with inoperable bowel obstruction. A systematic review of studies of the most popular drugs used in the medical management of inoperable malignant bowel obstruction was performed to assess the effectiveness of these treatments and provide some lines of evidence. Randomized trials that involved patients with a clinical diagnosis of intestinal obstruction due to advanced cancer treated with these drugs were reviewed. Five reports fulfilled inclusion criteria. Three studies compared octreotide (OC) and hyoscine butylbromide (HB), and two studies compared corticosteroids (CSs) and placebo. Globally, 52 patients received OC, 51 patients received HB, 37 patients received CSs, 15 patients received placebo, and 37 patients received both placebo and CSs. On the basis of these few data, the superiority of OC over HB in relieving gastrointestinal symptoms was evidenced in a total of 103 patients. The latter studies had samples more defined in terms of stage and inoperability, and had a shorter survival in comparison with studies of CSs (less than 61 days, most of them less than 20 days). Data on CSs are less convincing, due to the methodological weakness of existing studies. This review confirms the difficulties in conducting randomized controlled trials in this population

The use of opioids for breakthrough pain in acute palliative care unit by using doses proportional to opioid basal regimen.

OBJECTIVES: To determine the efficacy and safety of different opioids used in doses proportional to the basal opioid regimen for the management of breakthrough pain (BP). METHODS: In 66 patients consecutive patients admitted to a pain relief and palliative care unit, the efficacy and safety of different opioids used in doses proportional to the basal opioid regimen for the management of breakthrough pain (BP) were assessed. The choice of the opioid to be administered as rescue medication was based on the characteristics of patients, clinical stability, compliance, preference, and so on. For each episode, nurses were instructed to routinely collect changes in pain intensity and emerging problems when pain became severe (T0), and to re-assess the patient 15 minutes after the opioid given as a rescue medication (T15). RESULTS: Six hundred twenty four episodes of BP were recorded during admission. Intravenous morphine (IV-MO) and oral transmucosal fentanyl (OTFC) were most frequently administered. Of 503 events available, 427 episodes were defined as successfully treated, while 76 episodes required a further administration of opioids. Pain intensity significantly decreased at T15 in all the groups (P<0.001). In 97.2% and 90.7% of cases treated with IV-MO, BP events had a reduction in pain intensity of more than 33% and 50%, respectively. In 99.2% and 97.6% patients receiving OTFC, BP events had a reduction in pain intensity of more than 33% and 50%, respectively. DISCUSSION: This survey suggests that doses of opioids for BP proportional to the basal opioid regimen, are very effective and safe in clinical practice, regardless the opioid and modality used

Cardiac auscultation training of medical students: a comparison of electronic sensor-based and acoustic stethoscopes

BACKGROUND: To determine whether the use of an electronic, sensor based stethoscope affects the cardiac auscultation skills of undergraduate medical students. METHODS: Forty eight third year medical students were randomized to use either an electronic stethoscope, or a conventional acoustic stethoscope during clinical auscultation training. After a training period of four months, cardiac auscultation skills were evaluated using four patients with different cardiac murmurs. Two experienced cardiologists determined correct answers. The students completed a questionnaire for each patient. The thirteen questions were weighted according to their relative importance, and a correct answer was credited from one to six points. RESULTS: No difference in mean score was found between the two groups (p = 0.65). Grading and characterisation of murmurs and, if present, report of non existing murmurs were also rated. None of these yielded any significant differences between the groups. CONCLUSION: Whether an electronic or a conventional stethoscope was used during training and testing did not affect the students' performance on a cardiac auscultation test

A channel aware adaptive modem for underwater acoustic communications

Acoustic underwater channels are very challenging, because of limited bandwidth, long propagation delays, extended multipath, severe attenuation, rapid time variation and large Doppler shifts. A plethora of underwater communication techniques have been developed for dealing with such a complexity, mostly tailoring specific applications scenarios which can not be considered as one-size-fits-all solutions. Indeed, the design of environment-specific solutions is especially critical for modulations with high spectral efficiency, which are very sensitive to channel characteristics. In this paper, we design and implement a software-defined modem able to dynamically estimate the acoustic channel conditions, tune the parameters of a OFDM modulator as a function of the environment, or switch to a more robust JANUS/FSK modulator in case of harsh propagation conditions. The temporal variability of the channel behavior is summarized in terms of maximum delay spread and Doppler spread. We present a very efficient solution for deriving these parameters and discuss the limit conditions under which the OFDM modulator can work. In such scenarios, we also calibrate the prefix length and the number of sub-carriers for limiting the inter-symbol interference and signal distortions due to the Doppler effect. We validate our estimation and adaptation techniques by using both a custom-made simulator for time-varying underwater channels and the well-known Watermark simulator, as well as real in field experiments. Our results show that, for many practical cases, a dynamic adjustment of the prefix length and number of sub-carriers may enable the utilization of OFDM modulations in underwater communications, while in harsher environments JANUS can be used as a fall-back modulation

Transmucosal fentanyl vs intravenous morphine in doses proportional to basal opioid regimen for episodic-breakthrough pain

The use of supplemental doses of opioids is commonly suggested to manage breakthrough pain. A comparative study of intravenous morphine (IV-MO) and oral transmucosal fentanyl citrate (OTFC) given in doses proportional to the basal opioid regimen was performed in 25 cancer patients receiving stable opioid doses. For each episode, when it occurred and 15 and 30 min after the treatment, pain intensity and opioid-related symptoms were recorded. Fifty-three couples of breakthrough events, each treated with IV-MO and OTFC, were recorded. In episodes treated with IV-MO, pain intensity decreased from a mean of 6.9 to 3.3 and to 1.7 at T1 and T2, respectively. In episodes treated with OTFC, pain intensity decreased from a mean of 6.9 to 4.1 and to 2.4 at T1 and T2, respectively. Statistical differences between the two treatments were found at T1 (P=0.013), but not at T2 (P=0.059). Adverse effects were comparable and were not significantly related with the IV-MO and OTFC doses. Intravenous morphine and OTFC in doses proportional to the scheduled daily dose of opioids were both safe and effective, IV-MO having a shorter onset than OTFC. Future comparative studies with appropriate design should compare titration methods and proportional methods of OTFC dosing

A Channel-Aware Adaptive Modem for Underwater Acoustic Communications

Acoustic underwater channels are very challenging, because of limited bandwidth, long propagation delays, extended multipath, severe attenuation, rapid time variation and large Doppler shifts. A plethora of underwater communication techniques have been developed for dealing with such a complexity, mostly tailoring specific applications scenarios which can not be considered as one-size-fits-all solutions. Indeed, the design of environment-specific solutions is especially critical for modulations with high spectral efficiency, which are very sensitive to channel characteristics. In this paper, we design and implement a software-defined modem able to dynamically estimate the acoustic channel conditions, tune the parameters of a OFDM modulator as a function of the environment, or switch to a more robust JANUS/FSK modulator in case of harsh propagation conditions. The temporal variability of the channel behavior is summarized in terms of maximum delay spread and Doppler spread. We present a very efficient solution for deriving these parameters and discuss the limit conditions under which the OFDM modulator can work. In such scenarios, we also calibrate the prefix length and the number of sub-carriers for limiting the inter-symbol interference and signal distortions due to the Doppler effect. We validate our estimation and adaptation techniques by using both a custom-made simulator for time-varying underwater channels and the well-known Watermark simulator, as well as real in field experiments. Our results show that, for many practical cases, a dynamic adjustment of the prefix length and number of sub-carriers may enable the utilization of OFDM modulations in underwater communications, while in harsher environments JANUS can be used as a fall-back modulation

Physician empathy: definition, components, measurement, and relationship to gender and specialty

OBJECTIVE: There is a dearth of empirical research on physician empathy despite its mediating role in patient-physician relationships and clinical outcomes. This study was designed to investigate the components of physician empathy, its measurement properties, and group differences in empathy scores. METHOD: A revised version of the Jefferson Scale of Physician Empathy (with 20 Likert-type items) was mailed to 1,007 physicians affiliated with the Jefferson Health System in the greater Philadelphia region; 704 (70%) responded. Construct validity, reliability of the empathy scale, and the differences on mean empathy scores by physicians’ gender and specialty were examined. RESULTS: Three meaningful factors emerged (perspective taking, compassionate care, and standing in the patient’s shoes) to provide support for the construct validity of the empathy scale that was also found to be internally consistent with relatively stable scores over time. Women scored higher than men to a degree that was nearly significant. With control for gender, psychiatrists scored a mean empathy rating that was significantly higher than that of physicians specializing in anesthesiology, orthopedic surgery, neurosurgery, radiology, cardiovascular surgery, obstetrics and gynecology, and general surgery. No significant difference was observed on empathy scores among physicians specializing in psychiatry, internal medicine, pediatrics, emergency medicine, and family medicine. CONCLUSIONS: Empathy is a multidimensional concept that varies among physicians and can be measured with a psychometrically sound tool. Implications for specialty selection and career counseling are discussed