Predictors of caregiver burden across the home-based palliative care trajectory in Ontario, Canada

Family caregivers of patients enrolled in home-based palliative care programmes provide unpaid care and assistance with daily activities to terminally ill family members. Caregivers often experience caregiver burden, which is an important predictor of anxiety and depression that can extend into bereavement. We conducted a longitudinal, prospective cohort study to comprehensively assess modifiable and non-modifiable patient and caregiver factors that account for caregiver burden over the palliative care trajectory. Caregivers (n = 327) of patients with malignant neoplasm were recruited from two dedicated home-based palliative care programmes in Southern Ontario, Canada from 1 July 2010 to 31 August 2012. Data were obtained from bi-weekly telephone interviews with caregivers from study admission until death, and from palliative care programme and home-care agency databases. Information collected comprised patient and caregiver demographics, utilisation of privately and publicly financed resources, patient clinical status and caregiver burden. The average age of the caregivers was 59.0 years (SD: 13.2), and almost 70% were female. Caregiver burden increased over time in a non-linear fashion from study admission to patient death. Increased monthly unpaid care-giving time costs, monthly public personal support worker costs, emergency department visits and low patient functional status were associated with higher caregiver burden. Greater use of hospice care was associated with lower burden. Female caregivers tended to report more burden compared to men as death approached, and burden was higher when patients were male. Low patient functional status was the strongest predictor of burden. Understanding the influence of modifiable and non-modifiable factors on the experience of burden over the palliative trajectory is essential for the development and targeting of programmes and policies to support family caregivers and reduce burden. Supporting caregivers can have benefits such as improved caregiver health outcomes, and enhancing their ability to meet care-giving demands, thereby potentially allowing for longer patient care in the home setting.

Providing a ‘whole-of-family’ approach to care: family-focused practices in mental health services

Introduction: Family members including children are all impacted by a family member’s mental illness. Although mental health services are increasingly encouraged to engage in family-focused practice, this is not a well-understood concept or practice in mental health care. Methods: An integrative review using systematic methods was conducted with international literature, with the aim of identifying concepts and practices of family-focused practice in child and youth and adult mental health services. Results: Findings from 40 peer-reviewed literature identified a range of understandings and applications of family-focused practice, including who comprises the ‘family’, whether the focus is family of origin or family of procreation or choice, and whether the context of practice is child and youth or adult. ‘Family’ as defined by its members forms the foundation for practice that aims to provide a whole-of-family approach to care. Six core practices comprise a family focus to care: assessment; psychoeducation; family care planning and goal-setting; liaison between families and services; instrumental, emotional and social support; and a coordinated system of care between families and services. Conclusion: By incorporating key principles and the core family-focused practices into their care delivery, clinicians can facilitate a whole-of-family approach to care and strengthen family members’ wellbeing and resilience, and their individual and collective health outcomes.

Ultrasound in undergraduate medical education: A systematic and critical review

Introduction: Point-of-care ultrasound (POCUS) use in clinical care is growing rapidly, and advocates have recently proposed the integration of ultrasound into undergraduate medical education (UME). The evidentiary basis for this integration has not been evaluated critically or systematically. In this study, we conducted a critical and systematic review framed by the rationales enumerated by advocates of ultrasound in UME in academic publications.

Methods: This research was conducted in two phases. First, the dominant discursive rationales for the integration of ultrasound in UME were identified using techniques from Foucauldian critical discourse analysis (CDA) from an archive of 403 academic publications. We then sought empirical evidence in support of theses rationales, using a critical synthesis methodology also adapted from CDA.

Results: We identified four dominant discursive rationales, with different levels of evidentiary support. Ultrasound was not demonstrated to improve students’ understanding of anatomy. The benefit of ultrasound in teaching physical examination was inconsistent,and rests on minimal evidence. With POCUS, students’ diagnostic accuracy was improved for certain pathologies, but findings were inconsistent for others. Finally, the rationale that ultrasound training in UME will improve quality of patient care was difficult to evaluate.

Discussion: Our analysis has shown that the frequently repeated rationales for the integration of ultrasound in UME are not supported by a sufficient base of empirical research. The repetition of these dominant discursive rationales in academic publications legitimizes them and may preclude further primary research. Since the value of clinical ultrasound use by medical students remains unproven, educators must consider whether the associated financial and temporal costs are justified or whether more research is required.

Faktorer som påverkar omvårdnaden av patienter från olika kulturer inom palliativ vård – en litteraturöversikt

När befolkningen i Sverige blir allt äldre kommer det bland annat leda till ett ökat sjukvårdsbehov. I genomsnitt har människor födda i länder långt från Norden sämre hälsa än personer födda inom Norden, de kan ha en annan kultur och tolka kommunikationen inom vården annorlunda. Syfte: Att beskriva faktorer som påverkar omvårdnaden av patienter och anhöriga från andra kulturer inom palliativ vård. Metod: En litteraturöversikt. Resultat: Är baserat på nio vetenskapliga artiklar. Det fanns kulturella skillnader i synen på allvarlig sjukdom och död. Inom flera kulturer är det tabubelagt att tala om döden och detta var sjuksköterskorna inom västerländsk kultur oerfarna vid, de var mer vana vid en rak och ärlig kommunikation med patienterna. Sjuksköterskorna hade kommunikationssvårigheter med patienter och närstående då de inte hade samma språk. Det var även svårt och tidskrävande att finna lämpliga tolkar som kunde hantera känsliga ämnen relaterat till palliativ vård. Konklusion: Sjuksköterskor upplevde att möten med patienter och anhöriga från andra kulturer ofta var svåra om de inte pratade samma språk. Trots detta upplevde sjuksköterskorna arbetet som tillfredsställande. Det framkom att för lite tid och stress var ett av problemen samt att behovet av tolkar var stort.

Visual functioning and health-related quality of life in diabetic patients about to undergo anti-vascular endothelial growth factor treatment for sight-threatening macular edema

Purpose To examine patient-reported outcome (PRO) in a selected group of Swedish patients about to receive anti-vascular endothelial growth factor (VEGF) treatment for diabetic macular edema (DME). Material and methods In this cross-sectional study, 59 patients with diabetes mellitus, who regularly visited the outpatient eye-clinics, were included. Sociodemographic and clinical data were collected and the patients completed PRO measures before starting anti-VEGF treatment. PRO measures assessed eye-specific outcomes (NEI-VFQ-25) and generic health-related quality of life (SF-36). Results The participants consisted of 30 men and 29 women (mean age, 68.5 years); 54 (92 %) patients had type 2 diabetes; Five (9%) patients had moderate or severe visual impairment; 28 (47 %) were classified as having mild visual impairment. Some of the patients reported overall problems in their daily lives, such as with social relationships, as well as problems with impaired sight as a result of reduced distance vision. Conclusions Further studies are needed to investigate PRO factors related to low perceived general health in this patient population. It is important to increase our understanding of such underlying mechanisms to promote improvements in the quality of patient care.

Understanding the Patient Experience Through the Power of Film: a Mixed Method Qualitative Research Study

Background For decades film has proved to be a powerful form of communication. Whether produced as entertainment, art or documentary, films have the capacity to inform and move us. Films are a highly attractive teaching instrument and an appropriate teaching method in health education. It is a valuable tool for studying situations most transcendental to human beings such as pain, disease and death. Objectives The objectives were to determine how this helps students engage with their role as health care professionals; to determine how they view the personal experience of illness, disease, disability or death; and to determine how this may impact upon their provision of patient care. Design, Setting and Participants The project was underpinned by the film selection determined by considerate review, intensive scrutiny, contemplation and discourse by the research team. 7 films were selected, ranging from animation; foreign, documentary, biopic and Hollywood drama. Each film was shown discretely, in an acoustic lecture theatre projected onto a large screen to pre-registration student nurses (adult, child and mental health) across each year of study from different cohorts (n = 49). Method A mixed qualitative method approach consisted of audio-recorded 5-minute reactions post film screening; coded questionnaires; and focus group. Findings were drawn from the impact of the films through thematic analysis of data sets and subjective text condensation categorised as: new insights looking through patient eyes; evoking emotion in student nurses; spiritual care; going to the moves to learn about the patient experience; self discovery through films; using films to link theory to practice. Results Deeper learning through film as a powerful medium was identified in meeting the objectives of the study. Integration of film into pre registration curriculum, pedagogy, teaching and learning is recommended. Conclusion The teaching potential of film stems from the visual process linked to human emotion and experience. Its impact has the power to not only help in learning the values that underpin nursing, but also for respecting the patient experience of disease, disability, death and its reality.

Découverte de nouveaux marqueurs pharmacogénomiques de la maladie du greffon contre l'hôte en transplantation de cellules souches hématopoïétiques

La transplantation de cellules souches hématopoïétiques (CSH) constitue une avenue thérapeutique potentiellement curative pour plusieurs cancers hématologiques comme la leucémie. L’utilisation d’une thérapie immunosuppressive pour prévenir la maladie du greffon contre l’hôte (GvHD) est un déterminant majeur du succès de la greffe. Malgré tout, cette complication survient chez 25 à 50% des transplantés et est une cause majeure de mortalité. L’optimisation du régime d’immunosuppression est un facteur facilement modifiable qui pourrait améliorer le pronostic des patients. Particulièrement, les polymorphismes du génome du donneur ou du receveur dans les voies pharmacogénomiques des immunosuppresseurs pourraient influencer l’exposition et l’action de ces médicaments, de même que le pronostic du patient. Le profilage de 20 pharmacogènes prioritaires chez des paires de donneurs-receveurs en greffe de CSH a permis d’identifier des variations génétiques liées au risque de la GvHD aiguë. Principalement, le statut génétique du receveur pour les protéines ABCC1 et ABCC2, impliquées dans le transport du méthotrexate (MTX), ainsi que des cibles moléculaires de ce médicament (ATIC et MTHFR) ont été associées au risque de GvHD aiguë. Similairement, le NFATc1, codant pour une cible moléculaire de la cyclosporine, augmentait lui aussi le risque de la maladie. Les porteurs de deux génotypes à risque et plus étaient particulièrement prédisposés à développer cette complication. Par surcroît, le statut génétique du donneur influençait également le pronostic du receveur après la greffe. Entre autres, des allèles protecteurs ont été identifiés dans les voies liées au transport (SLC19A1) et à l’action du MTX (DHFR). Inversement, NFATc2 a été associé à une augmentation du risque de GvHD aiguë. Afin de mieux comprendre les associations observées entre ces marqueurs génétiques et le risque de GvHD aiguë, une étude prospective innovante est en cours chez des greffés de CSH. Cette étude permettra d’étudier comment la génétique du patient ou du donneur peut influencer la pharmacocinétique et la pharmacodynamie des immunosuppresseurs, de même que leurs liens avec la GvHD aiguë. Ces paramètres sont quantifiés grâce à des approches analytiques que nous avons mises au point afin de répondre aux besoins spécifiques et uniques de cette étude. Les approches proposées dans cette thèse sont complémentaires aux méthodes classiques de suivi des immunosuppresseurs et pourraient aider à optimiser la pharmacothérapie du patient. Une meilleure identification des patients à haut risque de GvHD aiguë avant la greffe, basée sur des marqueurs pharmacogénomiques identitaires, pourrait guider le choix de la prophylaxie immunosuppressive, et ainsi améliorer l’issue clinique de la greffe.

Economia na consulta de Endodontia

Introdução: Em Portugal a realidade actual, clínica e financeira do exercício da Medicina Dentária é bem distinta da do final do séc. XX devido à pletora de Médicos Dentistas e à baixa de honorários por acto Médico registada nos últimos anos. Objectivos: Este trabalho teve como objectivo perceber um pouco sobre os detalhes a ter em consideração aquando da abertura de uma clínica centrada na realização de tratamentos na área da Endodontia, e como publicitá-la de forma legal e apelativa. Pretende-se depois também estimar o custo mínimo para a realização de tratamentos Endodonticos com diferentes equipamentos e comparar a eficácia entre tratamentos usando ferramentas diferentes. Materiais e Métodos: Foram usadas como fontes de pesquisa para o presente trabalho bases de dados como a PubMed, B-On e Cochrane Library. Foi também usado o Google. Para pesquisa no PubMed foram usados vários descritores MeSH, como “Commerce”, “Dentistry”, “Endodontics”, “Management” e “Marketing”. Foram também usadas diversas palavras-chave no PubMed e nos outros motores de pesquisa, como “Anesthesia”, “Dental Office”, “Files”, “Irrigation”, “Magnification”, “Microscope”, “Obturation Systems” e “Rotatory Systems”. As pesquisas foram filtradas para serem apresentados apenas resultados entre 2011 e 2016, sendo este filtro retirado só quando não eram encontrados resultados satisfatórios ou relevantes para os temas discutidos no trabalho. Foram obtidos 3927 artigos e seleccionados 24. A inclusão destes artigos foi feita tendo em conta as suas fontes bibliográficas e a qualidade dos estudos a que se reportavam. Foram excluídos artigos que se reportavam a estudos muito antigos ou a tecnologias ultrapassadas, como sistemas de limas antigos. Conclusões: As novas tecnologias usadas para tratamento Endodontico, apesar de dispendiosas, melhoram muito o atendimento ao paciente.

A longitudinal qualitative exploration of healthcare and informal support needs among survivors of critical illness: the RELINQUISH protocol.

Introduction and background: Survival following critical illness is associated with a significant burden of physical, emotional and psychosocial morbidity. Recovery can be protracted and incomplete, with important and sustained effects upon everyday life, including family life, social participation and return to work. In stark contrast with other critically ill patient groups (eg, those following cardiothoracic surgery), there are comparatively few interventional studies of rehabilitation among the general intensive care unit patient population. This paper outlines the protocol for a sub study of the RECOVER study: a randomised controlled trial evaluating a complex intervention of enhanced ward-based rehabilitation for patients following discharge from intensive care. Methods and analysis: The RELINQUISH study is a nested longitudinal, qualitative study of family support and perceived healthcare needs among RECOVER participants at key stages of the recovery process and at up to 1 year following hospital discharge. Its central premise is that recovery is a dynamic process wherein patients’ needs evolve over time. RELINQUISH is novel in that we will incorporate two parallel strategies into our data analysis: (1) a pragmatic health services-oriented approach, using an a priori analytical construct, the ‘Timing it Right’ framework and (2) a constructivist grounded theory approach which allows the emergence of new themes and theoretical understandings from the data. We will subsequently use Qualitative Health Needs Assessment methodology to inform the development of timely and responsive healthcare interventions throughout the recovery process. Ethics and dissemination: The protocol has been approved by the Lothian Research Ethics Committee (protocol number HSRU011). The study has been added to the UK Clinical Research Network Database (study ID. 9986). The authors will disseminate the findings in peer reviewed publications and to relevant critical care stakeholder groups.

Brucella Non-Neutrocytic Bacterascites in a Patient with Chronic Liver Disease

Objectives: To report a case of Brucella peritonitis. Patient and methods: We describe the case of a patient and present a brief review of the few published reports. Results: The patient had alcoholic cirrhosis of the liver and was diagnosed with Brucella non-neutrocytic bacterascites. Conclusion: Brucellosis is a common zoonosis with worldwide distribution. It is a systemic disease with the potential to predominantly affect one organ or a specific system (focal brucellosis). However, peritoneal focalization of this disease is a very rare presentation.

Adaptive regulation or governmentality: patient safety and the changing regulation of medicine

Studies from across the world have shown that clinical mistakes are a major threat to the safety of patient care (World Health Organisation 2004). For the National Health Service (NHS) of England and Wales it is estimated that one in ten hospital patients experience some form of error, and each year these cost the service over £2billion in remedial care (Department of Health 2000). Unsurprisingly, ‘patient safety’ is now a major international health policy priority, questioning the efficacy of existing regulatory practices and proposing a new ethos of learning. Within England and Wales, the National Patient Safety Agency (NPSA) has been created to lead policy development and champion service-wide learning, whilst throughout the NHS the National Reporting and Learning System (NRLS) has been introduced to enable this learning (NPSA 2003). This paper investigates the extent to which, in seeking to better manage the threats to patient safety, this policy agenda represents a transition in medical regulation.

A systematic review of the cost-effectiveness of targeted therapies for metastatic non-small cell lung cancer (NSCLC)

Background: Non-small cell lung cancer (NSCLC) imposes a substantial burden on patients, health care systems and society due to increasing incidence and poor survival rates. In recent years, advances in the treatment of metastatic NSCLC have resulted from the introduction of targeted therapies. However, the application of these new agents increases treatment costs considerably. The objective of this article is to review the economic evidence of targeted therapies in metastatic NSCLC. Methods: A systematic literature review was conducted to identify cost-effectiveness (CE) as well as cost-utility studies. Medline, Embase, SciSearch, Cochrane, and 9 other databases were searched from 2000 through April 2013 (including update) for full-text publications. The quality of the studies was assessed via the validated Quality of Health Economic Studies (QHES) instrument. Results: Nineteen studies (including update) involving the MoAb bevacizumab and the Tyrosine-kinase inhibitors erlotinib and gefitinib met all inclusion criteria. The majority of studies analyzed the CE of first-line maintenance and second-line treatment with erlotinib. Five studies dealt with bevacizumab in first-line regimes. Gefitinib and pharmacogenomic profiling were each covered by only two studies. Furthermore, the available evidence was of only fair quality. Conclusion: First-line maintenance treatment with erlotinib compared to Best Supportive Care (BSC) can be considered cost-effective. In comparison to docetaxel, erlotinib is likely to be cost-effective in subsequent treatment regimens as well. The insights for bevacizumab are miscellaneous. There are findings that gefitinib is cost-effective in first- and second-line treatment, however, based on only two studies. The role of pharmacogenomic testing needs to be evaluated. Therefore, future research should improve the available evidence and consider pharmacogenomic profiling as specified by the European Medicines Agency. Upcoming agents like crizotinib and afatinib need to be analyzed as well. © Lange et al.

Non-communicable diseases among children in Ghana: health and social concerns of parent/caregivers.

Background: Globally, there is a progressive rise in the burden of non-communicable diseases (NCDs). This paper examined the health and social concerns of parents/caregivers on in-patient care for children with NCDs in Ghana. Methods: This was a cross-sectional study in three large health facilities in Ghana (the largest in the South, the largest in the North and the largest in the Eastern part of Ghana. Data was collected with a structured questionnaire among 225 caregivers (≥18 years) of 149 children with NCDs in health facilities in the three regions. Data was analyzed with simple descriptive statistics. Results: Most caregivers 169(75.0%) were women, relatively young (median age 35years), mostly married and resided in urban areas. Sickle cell disease was the commonest NCD among the children. All 169(75.0%) caregivers believed children suffer NCDs because of sins of parents/ancestors, 29(12.9%) believed herbalists/spiritualists have insights into treating NCDs and 73(32.6%) have previously used herbs/traditional medicine for child's illness. NCD in children was a burden and caused financial difficulties for families. Most caregivers (>96.0%) indicated NCDs in children should be included in national health insurance benefits package and a comprehensive national NCD policy is needed. Conclusion: Absence of national NCD policy for children is a major challenge. The burden of care rests mainly on the parents/ caregivers. A national strategic intervention on the importance of awareness generation on the causes, risk factors, prevention and treatment of NCDs for families and communities is essential. Government support through national health and social policy initiatives are essential.

Application of Lidocaine Spray for Tracheal Intubation in Neonates - A Clinical Trial Study

Background: Tracheal intubation is extremely distressing, painful, and may influence heart rate and blood pressure. Sedatives, analgesics, and muscle relaxants are not commonly used for intubation in neonates. Objectives: This study aimed to evaluate the effects of lidocaine spray as a non-intravenous drug before neonatal intubation on blood pressure, heart rate, oxygen saturation and time of intubation. Patients and Methods: In a randomized, controlled study each neonate was randomly assigned to one of the two study groups by staffs who were not involved in the infant's care. The allocation concealment was kept in an opaque sealed envelope, and the investigators, the patient care team, and the assessors were blinded to the treatment allocation. The selected setting was NICU unit of a teaching hospital in Ilam city, Iran and participants were 60 neonates with indication of tracheal intubation with gestational age >30 weeks. Patients in the treatment group received lidocaine spray and the placebo group received spray of normal saline prior to intubation. Main outcome measurements were the mean rates of blood pressure, heart rate, oxygen saturation, intubation time and lidocaine side effects were measured before and after intubation. Results: Totally 60 newborns including 31 boys and 29 girls were entered into the study (drug group n = 30; placebo group n = 30). Boy/girl ratio in treatment and placebo groups were 1.3 and 0.88, respectively. Mean age ± SD of participants was 34.1 ± 24.8 hours (treatment: 35.3 ± 25.7; placebo: 32.9 ± 24.3; P < 0.0001). Mean weight ± SD of neonates was 2012.5 ± 969 g. Application of lidocaine spray caused a significant reduction of mean intubation time among treatment group compared with placebo group (treatment: 15.03 ± 2.2 seconds; placebo: 18.3 ± 2.3 seconds; P < 0.0001). Mean blood pressure, heart rate and oxygen saturation rate, among neonates in treatment group was reduced after intubation compared with their relevant figures before intubation; however, their differences were not statistically significant except for mean oxygen saturation rate that was reduced significantly in placebo group. No side effects were observed during study. Conclusions: Though the current study revealed some promising results in the application of lidocaine spray during neonatal intubation without any considerable side effects; however, the current investigation could only be considered as a pilot study for further attempts in different locations with higher sample sizes and in different situations.