bluuebunny/crossref_metadata_2025 huggingface dataset:
Paediatric perfusion practice in North America: an update
Authors: Groom Robert C , Hill Aaron G , Kurusz Mark , Munoz Ruben , McGowen Kelley J , Resley Justin J , Akl Bechara F , Speir Alan , Lefrak Edward A
Published: November 2007

In August 1994, an updated survey questionnaire was mailed to each paediatric open-heart surgery programme in North America as a follow-up to the 1989 paediatric survey. The survey requested demographic data, equipment selection criteria and specific perfusion techniques for paediatric patients. The earlier survey revealed a wide range of clinical practice. Data from the recent survey were compared with the 1989 survey to identify current programme demographics and trends in equipment use and techniques.

Responses were received from 125 hospitals (110 active programmes and 15 programmes that do not perform paediatric open-heart surgery) for a response rate of 74%. Of the 110 active centres, 77 perform both adult and paediatric cardiac surgery, and 33 perform paediatric surgery exclusively. Forty-three centres reported that they perform paediatric cardiac transplantation, an increase from 35 centres in 1989. Total caseload increased by more than 8% per year from 1988 to 1994. In 1994, 18% of the patients were operated upon during the first month of life (versus 15% in 1989), and 46% were operated on during the first year of life (versus 45% in 1989)

While the 1989 survey was characterized by a high degree of heterogeneity in equipment and techniques, the recent survey reveals a trend toward homogeneity among respondents. The use of membrane oxygenation and arterial line filtration has become universal, and there was an increase in the use of all types of safety devices in the cardiopulmonary bypass circuit.
A comparison of albumin, polygeline and crystalloid priming solutions for cardiopulmonary bypass in patients having coronary artery bypass graft surgery
Authors: Scott DA , Hore P.J. , Cannata J. , Mason K. , Treagus B. , Mullaly J.
Published: November 2007

This study was designed to assess the effect of different prime solution compositions on a patient's fluid balance, transfusion requirements, renal function and haemodynamic stability over the first 24 hours postbypass. Ninety-three patients presenting for first-time coronary artery bypass graft (CABG) surgery were randomly allocated to receive one of three prime solutions for the CPB pump: albumin (4.6%) + Plasmalyte (Group A, n = 32), polygeline (Hemaccel) + Plasmalyte (Group P, n = 29), or crystalloid (Plasmalyte) alone (Group C, n = 32). Patients, anaesthetists, surgeons and intensive care unit (ICU) staff were all blinded as to the solution type.

The groups were demographically and haemodynamically similar. There were no differences between the groups with respect to white cell or platelet counts during the study. There was a significant difference in haemoglobin levels between the groups on weaning from CPB and on arrival in the ICU (Group C > Groups P and A, p < 0.001 for both times). There was no difference in blood transfusion requirements between any of the groups. During CPB, Group C required significantly more crystalloid than the other groups (p < 0.001). Urine output was significantly higher in Group C compared with Groups P and A at all time periods up to and including ICU 12 hours (p < 0.05). The use of frusemide was significantly higher in the ICU in Groups P and A (p < 0.01). There was a net gain of 3132 ± 412 ml in Group C in 24 hour fluid balance, which was significantly higher than Group A (2166 ± 223 ml, p = 0.04). Our results show that, in this patient population, there is no advantage in using a colloid-based prime solution over a purely crystalloid solution from a haemotologic or haemodynamic point of view for the first 24 hours after CPB. There appears to be an increase in extracellular fluid (ECF) retention in Group C, but this caused no related problems in the study period. On the other hand, diuretics (frusemide) needed to be given significantly less often in these patients to offset oliguria.
Normalization of experimental results with respect to inlet conditions in membrane oxygenator testing
Authors: Costantino ML , Fiore GB
Published: November 2007

This study looked at the problem of the excessive variability in oxygenator testing results, induced by variation of inlet parameters, particularly of inlet oxyhaemoglobin saturation.

The investigation was carried out in the laboratory. An in vitro circuit was used to perfuse a small oxygenating cell. Blood flow rate (BFR) and film thickness (BFT) were varied to obtain different oxygenation conditions, while the inspired oxygen fraction (FiO 2) and ventilation ratio were kept at constant values. With each test condition, inlet saturation was varied in the range 60-70% and a number of veno-arterial blood samples (at least 20) were withdrawn and analysed for numerical computing and statistical analysis.

The generic law relating oxygenation increment to inlet saturation was found. This allowed a useful normalization procedure to be applied to oxygenator testing results and render them comparable, even if obtained at different inlet conditions.
Comparison of the performance characteristics of three generations of membrane oxygenators: Univox®, Univox® Gold™ and SpiralGold™
Authors: Beckley Philip D , Morris Susan M , Smith James J , McNamara Jerri L , Novak Julie A
Published: November 2007

With continuous enhancement in oxygenator design, the question is raised as to how these changes actually impact the performance of the oxygenator. The recent addition of two new oxygenators by the Bentley Division of Baxter Healthcare Corporation provided us with a unique opportunity to compare the performance of each device and isolate the impact of each design change on performance. While the basic design and flow patterns have remained the same, application of the Duraflo® II treatment has produced the Univox® Gold™ and a change in the fibre-winding technique has produced the SpiralGold™. This study compared the effects of heparin coating (Univox® to Univox® Gold™) and fibre-winding (Univox® Gold™ to SpiralGold™) on gas and heat transfer and resistance to blood flow (pressure drop). Six oxygenators of each model were evaluated utilizing an in vitro single pass circuit, which first conditioned bovine blood to the Association for the Advancement of Medical Instrumentation (AAMI) venous standards. Blood flows of 4.0, 5.0, 6.0 and 7.0 I/min, FiO2 values of 1.0, 0.8 and 0.6, and gas-to-blood flow ratios of 0.5, 1.0 and 1.5 were chosen as test variables. Data generated included oxygen transfer, carbon dioxide transfer, arterial pO2, resistance to blood flow, and coefficient of heat exchange. The results indicate that the Duraflo II treatment does not have a significant effect on gas and heat transfer or resistance to blood flow. The fibre-winding technique employed with the new SpiralGold™, however, has improved significantly gas exchange and arterial PO2 when compared with the previous Univox® models. Resistance to blood flow and coefficient of heat exchange were not affected significantly by the winding technique.
Cell saver efficacy for routine coronary artery bypass surgery
Authors: Sakert Tamara , Gil William , Rosenberg Ian , Carpellotti Deborah , Boss Kathy , Williams Tim , Ferneding Joseph , Christlieb Ignacio
Published: November 2007

A retrospective study was conducted to determine the effect of intraoperative Haemonetics Cell Saver® (HCS) usage on postoperative homologous blood product requirements in CABG patients. From 1 January to 31 December 1993, 516 patients without renal disease or postoperative surgical or gastrointestinal haemorrhage had elective, first-time CABG surgery. The HCS was utilized in 435 of these patients (Group CS) and in 81 patients the HCS was excluded (Group NCS). Preoperative patient variables were similar in the group. We evaluated the HCS effect on blood product transfusion by comparing x units of red blood cells (RBC), fresh frozen plasma (FFP) and platelets (PLTS) transfused per patient between groups CS and NCS. There were no differences in the x units of RBC (1.9 ± 2.7 CS vs 1.8 ± 1.5 NCS) or in the RBC transfusion rate (48% CS vs 50% NCS). There were also no significant differences between the groups in x units of FFP (0.9 ± 0.8 CS vs 0.4 ± 0.9 NCS) or PLTS (0.7 ± 3.1 CS vs 0.4 ± 2.5 NCS), or in the percentage of patients receiving these products (12% CS vs 8% NCS). These data provide no evidence that the use of the HCS decreases the amount of homologous blood bank products required postoperatively in patients having routine first-time CABG surgery. The current era of aggressive blood conservation may have limited the role of the HCS in routine CABG surgery.
The activated clotting time loading dose response ratio (ACTLORR) as an indicator of heparin demand during cardiopulmonary bypass
Authors: Reece Ian J , Linley Gerrard , Al Tareif Habib , DeVroege Rollie , Tolia Jitesh , Sheth Jayesh
Published: November 2007

Data relating to the activated clotting time response to a 4 mg/kg heparin loading dose were collected prospectively in 358 patients having cardio pulmonary bypass. After excluding patients with factors known to cause relative heparin resistance or sensitivity, the activated clotting time (ACT) loading dose response ratio (ACTLORR) was calculated retrospectively in 263 patients and found to correlate significantly (p = 0.0001) with the need for extra heparin administration during bypass. Where the ACTLORR was above 5.5, 92% of patients required no additional heparin during the first 90 minutes of bypass (n = 98). Where the ACTLORR was between 4.0 and 5.0, it was far less predictive, with approximately 35% of patients requiring additional heparin.

This study indicates that a large ACT response to the initial heparin loading dose (a high ACTLORR) is predictive of stable, adequate anticoagulation during the first 90 minutes of bypass, but that a low initial response is not necessarily associated with declining ACTs and the need for additional heparin administration.
Factors influencing haemostasis and blood transfusion in cardiac surgery
Authors: Bo Liu  , Belboul Ali , Larsson Sture , Roberts Donald
Published: November 2007

To find out the risk factors influencing perioperative bleeding and use of blood products in cardiac surgery so that appropriate intervent.ions can be selected for blood conservation, risk factors were analysed in 343 cardiac surgical patients, retrospectively, by multiple regression technique. The results showed that the factors related to postoperative bleeding were male gender, Higgins score, cardiopulmonary bypass (CPB) time, operation procedures, intraopera tive blood loss and use of internal mammary artery (IMA) graft. Factors related to perioperative homologous blood transfusions were emergency surgery, preoperative haemoglobin level, Higgins score, intraoperative blood loss, operation time and operation procedures. The geometric mean of postoperative bleeding in the entire series was 1085 ml and the mean packed red cell, plasma and platelet transfusions were 3.29 ± 0.4, 1.96 ± 0.39 and 0.21 ± 0.05 units respectively. The incidence of homologous blood transfusion during the hospital stay was 58.9% for the entire series and 54.5% in the nonrevision patients. Emergency patients received significantly more blood transfusion (p = 0.0001). Perioperative blood loss and transfusions are still problems in cardiac surgery and certain patient groups in this study were identified as high risk; available blood conservation techniques, therefore, are recommended in these patients.
Review on the multifactorial aspects of bioincompatibility in CPB
Authors: Daniel Serge
Published: November 2007

'In cardiopulmonary bypass as applied to open heart surgery, we are no longer looking for improving one thing 100% but improving everything by 1 %.'

Adapted from Mr Carlson, CEO, Scandinavian Airlines.

Over the last few years, a great emphasis has been placed on the bioincompatibility of foreign, nonphysiological materials used during CPB. It is only recently that bioincompatibility has objectively been recognized to be multifactorial, with the dominant implicated sources being cardiotomy blood suction, shear stresses or flow dynamics and, to a lesser degree, the blood/artificial surface interactions, the heparin/protamine complex and the various forms of emboli or debris.

In summary, in CPB, the reduction of postoperative complications, such as whole body inflammatory reactions, bleeding and organ dysfunctions, can only be impacted if the primary, dominant sources of bioincompatibility are reduced or eliminated.
Efficacy and safety of aprotinin in aortocoronary bypass and valve replacement operations: a placebo-controlled randomized double-blind study
Authors: Rodrigus IE , Vermeyen KM , De Hert SG , Amsel BJ , Walter PJ
Published: November 2007

To assess the efficacy and safety of the use of a high-dose regimen of aprotinin in routine cardiac operations, a placebo-controlled randomized double- blind study was conducted in 93 adult patients undergoing cardiopulmonary bypass. Aprotinin-treated patients (group A, n = 46) received 2 × 106 Kallikrein Inactivating Units (KIU) of aprotinin before incision, 2 × 106 KIU in the priming solution and 5 x 105 KIU/h during CPB. Control patients (group B, n = 47) received the same volume of normal saline.

Mean postoperative blood loss in ml after six hours and in total until removal of thoracic drains decreased significantly from 752 and 1933 in controls, to 358 and 1051 in treated patients ( p < 0.001). Mean total transfusion needs were 2.6 (A) and 4.8 (B) units per patient. Adverse events were evenly distributed between both groups and could not be attributed to aprotinin use. We, therefore, recommend the use of a high-dose regimen of aprotinin for routine cardiac operations despite its cost.
Troponin T release with warm and cold cardioplegia
Authors: Brackenbury ET , Sherwood R. , Meehan N. , Whitehorne MA , Forsyth AT , Marrinan MT , Desai JB
Published: November 2007

Cardiac troponin T (cTnT) levels were measured in 41 patients undergoing elective coronary artery surgery. Twenty-one patients received continuous warm antegrade blood cardioplegia to maintain asystole whilst 20 patients received antegrade cold blood cardioplegia intermittently. Serum levels of cTnT were determined preoperatively and at 0, 6, 12 and 18 h postbypass. Peak cTnT levels and total cTnT release (calculated from the area under the curve postoperatively) were found to be significantly higher (p < 0.05: Mann-Whitney) when cold cardioplegic solutions were used.

Continuous warm cardioplegia results in lower cTnT release than intermittent cold blood cardioplegia suggesting that the former may provide better myocardial preservation.
Anaesthetic experience with isolated limb perfusion with melphalan for melanoma
Authors: Kam Pca , Thompson JF
Published: November 2007

Hyperthermic isolated limb perfusion (ILP) with melphalan is an accepted method of treatment for advanced or recurrent melanoma on a limb. In a review of 124 patients who underwent 130 ILPs at the Sydney Melanoma Unit, the anaesthetic considerations are summarized. All patients received general anaesthesia. The level of monitoring is discussed and monitoring of the limb venous pressure is important to minimize major fluid shifts between the systemic vasculature and the vascular compartment of the isolated limb and extracorporeal circuit.
The effect of fast-tracking on neurological complications post-cardiopulmonary bypass
Authors: Palanzo David A , Zarro Debra L
Published: November 2007

With the push to get patients through the system in five days, most patients undergoing nonemergency coronary artery bypass grafting (CABG) are being 'fast-tracked'. Using this anaesthetic regimen appears to keep patients less anaesthetized (light) during cardiopulmonary bypass (CPB) than when using our previous regimen. This is manifested by higher mean arterial pressures (maintained above 65 mmHg) during CPB. If patients are receiving less anaesthesia during CPB, they may have an increased cerebral metabolism. This could lead to decreased cerebral oxygenation with a resultant neurological deficit postoperatively.

A retrospective analysis of 200 patients who underwent nonemergency CABG was conducted to evaluate postoperative neurological complications The patients were matched by surgeon, procedure and CPB time. They were separated into two groups: group 1 had maintained mean arterial pressures greater than 65 mmHg on CPB (n = 100) and group 2 had pressures less than 65 mmHg (n = 100). Group 1 had two patients (2%) who exhibited neurological complications after CPB (delirium, continuous coma for at least 24 h) with both of these patients previously having noted cerebrovascular disease. Group 2 also had two patients (2%) with postoperative neurological complications (delirium, transient stroke) with one patient having cerebrovascular disease.

From our study, we cannot say that fast-tracking increases the risk for postoperative neurological complications This could be due to the fact that we maintained the mean venous oxygen saturation during CPB above 70%. More specific testing needs to be done to truly rule out any negative postoperative effect.
Anticoagulation practices during neonatal extracorporeal membrane oxygenation: survey results
Authors: Graves Donna F , Chernin Jill M , Kurusz Mark , Zwischenberger Joseph B
Published: November 2007

To ascertain current anticoagulation management during neonatal extracorporeal membrane oxygenation (ECMO), a telephone survey was undertaken of all active ECMO (n = 81, 100% response rate) centres in the USA. Hospital policies regarding federal regulations governing laboratory tests [Clinical Laboratory Improvement Amendment (CLIA) 1988] were determined along with specific patient anticoagulation strategies and use of specific activated coagulation time (ACT) equipment. More than 90% of the respondents use the Hemochron device (International Technidyne Corp, Edison, NJ, USA) while the remaining centres use the Hemotec device (Medtronic Hemotec, Inc, Englewood, CO, USA). Quality control (QC) testing is performed by most centres, but there is no consensus regarding frequency of testing nor methods for dealing with abnormal results. Nearly one-half of the centres use beef lung-derived heparin and the other half use porcine intestinal-derived heparin. One-half of the programmes had a minimum heparin dose despite the ACT value, but the range varied significantly. Four out of five respondents reported that heparin dosages were dictated strictly by ACT results, and 63% will temporarily stop heparin administration for high ACT results, bleeding and/or surgery. Approximately one-third of the centres perform proficiency testing of the equipment in compliance with CLIA 1988. In conclusion, there appears to be no consensus regarding commitment to a QC programme among active ECMO centres.
An initial assessment of suffering in terminal illness
Authors: MacAdam DB , Smith Marie
Published: November 2007

This paper reports a study which aimed to develop an instrument which records dying patients' perceptions of their own needs. The particular stimulus for this was the recognition that the ability to relieve suffering in the dying depended on first understanding what were major concerns to the patient. These often differed from the problems thought by medical and nursing staff to be of greatest importance. The instrument developed consisted of 43 questions which were tested with 259 patients. The fact, construct and concurrent validity of the questions is reported. The questions were further refined to reduce them to 20 questions suitable for use during the initial assessment by a member of any profession in the hospice/palliative care team. This brief instrument is compared to others used to measure quality of life.
The treatment of terminally ill geriatric patients
Authors: Wilson JA , Lawson PM , Smith RG
Published: November 2007

A retrospective study was carried out on 150 patients who died in assessment and long stay wards in a geriatric unit to assess problems during their terminal illness. Thirty-two per cent of the long stay and 41 % of the assessment patients were considered to have been distressed during the last week of their life. Agitation was the commonest form of distress. Patients with a respiratory diagnosis were particularly distressed as were those with pulmonary oedema, suggesting that breathing problems are more difficult to manage. No concern was recorded as being expressed by relatives about the treatment patients received but eight relatives were distressed within the last week of the patient's life. A raised urea was more often found in distressed patients. Opiates were used in 56% of all patients but in low doses (2.5-5 mgs diamorphine orally 4-hourly) in the majority. More attention to comfort is requtred for those who are dehydrated and distressed in terminal care.
The use of transcutaneous electrical nerve stimulation (TENS) for the relief of pain in palliative care
Authors: Librach SL , Rapson LM
Published: November 2007

The proposed neurophysiologic mechanisms of action of TENS are briefly reviewed. Recent literature on its use in chronic pain is critically reviewed and modern methods are discussed. Recommendations are made about the equipment and use of TENS in the palliative care setting.
Review article : Emesis in the patient with advanced cancer
Authors: Allan Simon G
Published: November 2007

The control of symptoms related to far advanced cancer has improved dramatically in recent years, making the passage of death more tolerable for such patients. The major impact of analgesic control now allows research efforts to focus on other distressing symptoms such as nausea and vomiting. The emetic process is a complex physiological and psychological one of multifactorial aetiology. Rapid improvement in our understanding of these processes is allowing the more rational use of known antiemetics and the development of new antiemetic agents. A rapid expansion of the literature of cytotoxic-induced emesis has pointed to new antiemetic agents and new schedules of administration.

This review emphasises the need to identify the cause of emesis before attempting indirectly to block the emetic process with antiemetic drugs. It also outlines the many areas where research could be applied to unravel some of the questions about which antiemetic to use, in what dose, and perhaps to identify the main site of emetic stimulus. More effective research is required, but the outlook for improved control of nausea and vomiting in the terminally ill patient is good.
'Captive and free?' : pastoral care of patients with chronic renal failure
Authors: Morton Gillian M
Published: November 2007

It is hoped that these reflections on the pastoral care of patients with chronic renal failure will be relevant in a wider context, even though they are set within a north European health care system. Many of the issues raised apply to chronic conditions in general. Matters of ultimate value and meaning, which transcend differences of culture and race, are addressed from a Christian understanding of the world, but pose related questions for those of other living faiths or of none. This paper suggests that renal failure is experienced by patients as a form of captivity from which they long to escape. It explores the nature of that captivity, the perceived means of escape and the tensions arising from the struggle for freedom. Pastoral care is understood as the process whereby patients are helped to draw on personal and faith resources in order to cope.
Medical training - the early postgraduate years
Authors: Calman KC
Published: November 2007

During early postgraduate medical training, all trainees would benefit from understanding the concepts of palliative medicine. But what should the training objectives be and where should training be provided? What should be the content of the experience and the range of methods used in training? What is the value of exposure to a range of medical and nonmedical specialists and how should postgraduates be supervised?
An approach to the management of the patient with deafferentation pain
Authors: Glynn Chris
Published: November 2007

The problems associated with the management of a patient with deafferentation pain are highlighted by the great variety of therapies suggested, which indicates the lack of understanding of the mechanism of this type of pain. The treatment of these patients will remain a lottery until there is a clearer concept as to the underlying mechanisms. This means there is a need for more clinical research, since there is as yet no reliable experimental model.
Continuous intrathecal lignocaine infusion analgesia: a case report of a nine-week'spinal'
Authors: Hardy PAJ , Wells JCD
Published: November 2007

Continuous intrathecal infusion of lignocaine was used for nine weeks in the control of pain from sacral chordoma not responding to opioid administration. In the period of infusion, sacral and calcaneal pressure sores healed as a consequence of improved patient movement by nursing staff and, possibly, continuous sympathetic blockade.
Pain unresponsive to high dose opiate drugs
Authors: Dickson Robert J , Russell Psb
Published: November 2007

Rarely the pain from malignant disease, primary or metastatic, cannot be adequately relieved by conventional analgesics, even with very high dosage opiate drugs. It is now recognized that in many instances this pain, of deafferentation type, is due to actual nerve infiltration or destruction by tumour. Five such cases are reported, in each of whom, a different manipulation of drug therapy was necessary before adequate pain control was achieved. It is concluded that, until a better understanding of the mechanism of deafferentation pain is reached, treatment of such cases will remain unsatisfactory.
Is terminal restlessness sometimes drug induced?
Authors: Dunlop Robert J
Published: November 2007

The case history of a terminally ill patient who developed continuous myoclonic jerking while comatose is presented. The potential for high dose opioids to produce central nervous system excitation, including twitching, myoclonic jerking and seizures, is highlighted. Attention is drawn to the possible contributory effects of phenothiazines and antihistamines by virtue of their ability to lower seizure threshold. The use of phenobarbitone to control such phenomena is suggested, and a brief review of other anticonvulsants which may be considered in palliative care is included.
Evaluation of a new hospice: the relief of symptoms in cancer patients in the first year
Authors: Mclllmurray M.B. , Warren M.R.
Published: November 2007

The relief of three common symptoms, pain, nausea and vomiting is described in cancer patients admitted to St John's Hospice, Lancaster in its first year. Of 256 evaluable admissions, 132 (53%) were in pain whilst 214 (84%) were taking analgesics of whom 112 (52%) were taking opiates. At discharge or death, the values were 19 (7.5%), 182 (71 %) and 169 (91 %) respectively. Nausea, vomiting or both were present in 76 (30%) patients on admission whilst 77 (30%) were taking antiemetics. At discharge or death the values were 23 (9%) and 80 (31 %) respectively. These findings indicate the extent to which the new hospice has contributed to the relief of symptoms in patients with advanced cancer.
What do palliative-care workers think about portable syringe drivers
Authors: Milner P.C. , Harper R. , Williams B.T.
Published: November 2007

We undertook a postal survey of hospices and home-care services in the UK, to describe the use of portable syringe drivers in such units, their perceived clinical indications and disadvantages and the rules governing their use. Considerable agreement was found among hospice, combined and home-care units concerning the importance of portable syringe drivers in the treatment of patients with vomiting, intestinal obstruction and dysphagia. Home-care teams in particular perceived the benefits of an alternative route for analgesia. Combined units actually used more portable syringe drivers despite reporting more disadvantages to patients, staff and carers. Doctors most often made the decision to commence treatment with a portable syringe driver, often at the suggestion of a nurse. Doctors were also responsible in most instances, for the prescription of the rate of delivery, but nurses usually carried out the tasks of drawing up the infusion and inserting the needle. The presence of other rules did not seem to diminish the number of syringe drivers in use.
Pressure sores: prevention, management and future research — a medical perspective
Authors: Ryan Terence J
Published: November 2007

This introduction to pressure sores emphasises the importance of early recognition of risk factors, covers the principles of management and discusses future research.
The use of subcutaneous midazolam in the home care setting
Authors: Amesbury Bdw , Dunphy KP
Published: November 2007

The use of continuous subcutaneous infusions of midazolam in six patients is described. These patients were all suffering from advanced cancer and cared for at home by a hospice-based team. The drug was used to control restlessness in the last stages of life and in all cases produced a beneficial therapeutic effect. In these cases it provided a desirable alternative to other benzodiazepines or phenothiazines, was convenient to administer and no side effects arising from its use were noted.
The use of metronidazole gel to control the smell of malodorous lesions
Authors: Newman Vicky , Allwood M. , Oakes RA
Published: November 2007

Sixty-eight patients with malodorous lesions were treated with a topical 0.8% metronidazole gel for periods varying from a few days to 15 months. The gel completely controlled the foul smell of 34 (50%) lesions; had a reasonable effect on 31 (46%) and no effect on three. One patient with an infected leg ulcer was reported to have a skin irritation after seven days treatment with the gel. No other possible adverse events were reported.
Safety of diamorphine in overdosage
Authors: O'Neill William M
Published: November 2007

Two case histories of patients given accidental therapeutic overdoses of diamorphine are presented. The use of antagonist drugs was not required, nor did either patient suffer any serious unwanted effects. This demonstrates the safety of diamorphine in patients with previous recent exposure to this drug.
Sources of stress in hospice medical directors and matrons
Authors: Finlay Ilora G
Published: November 2007

Palliative care generates considerable stress in hospice medical directors and matrons. In this survey, increased time working in the hospice correlates with suicidal thoughts in medical directors and a fear of burnout in matrons. Major sources of stress include management committees, administrative duties, relatives and the relationship between the medical director and matron.
The use of coeliac plexus blockade in patients with chronic pain
Authors: Hanna M. , Peat SJ , Woodham MJ , Latham J. , Gouliaris A. , Di Vadi P.
Published: November 2007

Over a four-year period from October 1984 to September 1988, a total of 101 coeliac plexus blocks were performed in this unit. Of these, 89 were in patients suffering intractable abdominal pain due to cancer, and 12 were in patients with pain secondary to benign disease processes. All were performed using X-ray screening and with intravenous sedation rather than general anaesthesia. Excellent or good pain relief was obtained in 80% of the patients with malignant disease, whilst 50% of patients with benign disease had good or complete relief of pain. The only serious complication encountered was a case of paraplegia - probably due to spinal cord ischaemia secondary to damage of the artery of Adamkiewicz.
Inadequacies of care in far advanced cancer patients: a comparison between home and hospital in Italy
Authors: Toscani Franco , Mancini Claudio
Published: November 2007

A previous survey of patients treated by our palliative care service showed that most patients with advanced cancer wished to be cared for at home. This is in contrast with the fact that these patients were increasingly frequently hospitalized because of their belief that a hospital, in spite of its shortcomings, is the place where medical and nursing care are more advanced.

A prospective survey was carried out on 120 advanced cancer patients under the palliative care service of the Cremona Hospital, Italy. The survey recorded all the inadequacies of their care from the time patients were seen until death occurred. Five times as many inadequacies occurred in hospital than at home (an average of 4.4 ± 5.0 every 100 days against 0.8 ± 2.0 every 100 days; p < 10 E -6). The most frequent inadequacies of care at home were caused by both narcotic and drug misuse, and unjustified alterations in the therapy; in the hospital they were related to therapeutic regimes and failure to report new symptoms. These data support the view that general hospital care in Italy today does not necessarily provide the best solutions to the problems of the terminally ill patient. A palliative care programme should include the option of organized home care.
A death in the family
Authors: Baker Merrill , Tonkes Margaret
Published: November 2007

The ability to work through the grieving process by the open expression of grief makes for a healthy bereavement. For the spouse it reduces morbidity and mortality in this period; for the children it diminishes the risk of emotional disorder that may occur later in life when grieving over the death of a parent has not been satisfactorily completed. We describe a death which exemplifies an acceptance of dying and an open expression of grief which we believe was facilitated by the hospice philosophy and team approach to care.
Managing dysphagia in advanced cancer-a flow diagram
Authors: Regnard Claud
Published: November 2007

Dysphagia is here defined as difficulty in transferring solids, pastes or liquids from the oral cavity to the stomach in patients with advanced cancer. The clinical steps required to manage dysphagia are outlined and the importance of including a swallowing therapist in these decisions is emphasized.
Hindu attitude toward suffering, dying and death
Authors: Sharma DL
Published: November 2007

An important element of Hinduism is the attitude of detachment from suffering and attachment to God. Death is seen as a rebirth, in that the present life of an individual influences the course of the life to come. Although suffering may be seen as the result of past misdeeds, this suffering is also regarded as an unavoidable part of life which can be endured bravely. Certain practices with regard to food, drink and cleanliness are important, and their observation contributes to a Hindu's peace of mind.
Review article : Depression and the use of antidepressants in patients with cancer
Authors: Cody Mary
Published: November 2007

Depressive disorders are common sequelae of cancer and its treatment. Fortunately, most of them are transient and respond to information, adequate explanation and emotional support from those involved in patient care. This article concentrates on the less common but more severe depressive disorders which require pharmacological strategies in addition to psychosocial interventions. Guidelines are suggested for identifying depressive disorders and the importance of ruling out potentially reversible organic pathology which may be responsible for the mood disturbance is also emphasized. Estimates of the prevalence of depressive disorders among cancer patients are provided and practical advice is offered on the choice of antidepressant, dosage and side-effects.
Terror or depression? A case report
Authors: Brittlebank Andrew , Regnard Claud
Published: November 2007

A patient is described who initially presented with clinical depression and responded to antidepressants. On her last admission her depression appeared to have worsened. On closer examination, however, it became clear that her major problem was frozen terror, not depression.
Teaching palliative care to United Kingdom medical students
Authors: Thorpe Graham
Published: November 2007

A survey shows that at 29 of the 103 hospices which responded to the questionnaire staff are involved in teaching palliative care on a regular basis to medical students. Most of the teaching is done by doctors. Most medical schools have established links with hospices.
Dyspnoea in advanced nonmalignant disease - a flow diagram
Authors: Regnard Claud , Ahmedzai Sam
Published: November 2007

Dyspnoea is here defined as the subjective sensation in patients with advanced disease where the demand for oxygen is greater than the body's ability to supply oxygen. This flow diagram describes the decision processes required to manage such patients. It excludes malignant causes, which have been covered in a previous flow diagram.1
Does pharmacological treatment affect the sensation of breathlessness in terminal cancer patients?
Authors: de Conno F. , Spoldi E. , Caraceni A. , Ventafridda V.
Published: November 2007

The authors review the pathophysiology, assessment and drug treatment of dyspnoea. Specific drug treatments discussed are theophylline, antiprostaglandins, benzodiazepines, phenothiazines, opioids and local anaesthetics.
Review article : Opioid analgesics in the management of pain in patients with cancer: an update
Authors: Gorman DJ
Published: November 2007

The principles of pain control in cancer have not changed over the past four years, but our understanding of opioids has increased in many areas. This update reviews recent developments and new knowledge in morphine pharmacokinetics, new and established opioids, opioid actions and routes of opioid administration, including spinal routes.
Urinary problems in advanced cancer-a flow diagram
Authors: Regnard Claud , Mannix Kathryn
Published: November 2007

Problems related to the urinary system may accompany many diseases or be their cause. This flow diagram deals with the management of common urinary symptoms and with some special urinary problems associated with advanced cancer.
Review paper: The Lambert-Eaton myasthenic syndrome
Authors: Erlington Giles
Published: November 2007

LEMS in SCLC patients is caused by an immune response against SCLC antigens, which crossreacts with similar antigens on the motor nerve terminal, impeding neuromuscular transmission and presenting with truncal and leg weakness. The diagnosis may be suggested by the presence of dry mouth; and strongly supported by the finding of diminished tendon reflexes which reappear following a sustained muscular contraction. Appropriate neurophysiological tests can confirm the diagnosis more reliably than immunological studies, although there is rapid development in this field. A new diagnosis of LEMS should prompt a careful and ongoing search for underlying SCLC, with serial thoracic CT scans. In patients with established SCLC/LEMS, neuromuscular symptoms usually improve following successful anticancer treatment, or immunosuppression. While awaiting the benefits of these strategies, and for patients in whom they are inappropriate, DAP provides useful palliation of weakness and sometimes of autonomic dysfunction. It is available at a small cost, from specialist centres, on a named patient basis. LEMS is not widely recognized, and is commonly mistaken for myopathy or neuropathy. It appears that many physicians are not surprised to find that SCLC patients are weak, and therefore do not pursue a neurological diagnosis. Those providing palliative care may be the first to consider LEMS in SCLC patients complaining of weakness, and can offer useful therapy once the diagnosis has been established.
Review articles : Transdermal and inhalatory routes of opioid administration: the potential application in cancer pain
Authors: Ripamonti Carla , Bruera Eduardo
Published: November 2007

The aim of this paper is a review of the data in the literature on the transdermal and inhalatory routes of opioid administration. The majority of the published experience is based on the use of transdermal and inhalatory opioids for the management of postoperative pain. Pharmacokinetic data suggest that transdermal fentanyl is well absorbed although there is a considerable delay in reaching steady state plasma level and also a slowly declining plasma concentration after removal of the transdermal patch. Clinical experience suggests that it is well-tolerated. There is very limited knowledge about the absorption and pharmacokinetics of morphine when given by the inhalatory route. A better understanding of the absorption and pharmacokinetics of different nebulized opioids is needed before reliable clinical trials can be designed on these drugs.
Stress among palliative care matrons: a major problem for a minority group
Authors: Alexander David A , MacLeod Morag
Published: November 2007

The occupational welfare of senior nurses in palliative care has been ignored for too long, despite the importance of their role. Findings from nearly 100 nurses in charge of palliative care units in the UK indicate there is considerable scope for managerial action. Matrons reported a lack of managerial support, uncertainties about responsibility, staff and resource shortages, bringing about change, conflict between competing demands and a sense of isolation as common and potent sources of stress. These staff also commonly encounter overwork, frustration and lack of recognition. It would be a strategic error to assign the levels of anxiety and pressure reported by these matrons to the 'weakness' of the individual, to their own lack of managerial experience or to certain personality traits. Whilst the level of job satisfaction is high, complacency about the well-being of these nurses cannot be justified.
Drugs used in combination in the syringe driver-a survey of hospice practice
Authors: Johnson Ian , Patterson Susan
Published: November 2007

A survey of hospices in the UK revealed a wide range of drugs being given in combination by subcutaneous infusion. The reported maximum doses were, in general, higher than those used in previous in vitro studies of drug compatibility. Very wide interhospice variation in the maximum doses of many of the drugs was found. Potential problems relating to the choice of diluent, protection of drugs from light and the method of setting up different models of syringe driver are discussed. The great majority of syringe driver infusions are given over a period of less than 48 hours, but it is possible to set machines to run for much longer periods without refilling. As the number and variety of drugs used in combination in the syringe driver increase, so the need for more studies of the compatibility of these drugs becomes more pressing to avoid the potential for adverse interaction. Whilst these results report current hospice practice they must not be regarded as an endorsement of such practice, but rather as a source of information for those concerned with finding out more about the compatibility of drugs in combination in the syringe driver.
A pilot study, review of the literature, and dosing guidelines for patient-controlled analgesia using subcutaneous morphine sulphate for chronic cancer pain
Authors: Walsh T Declan , Smyth Eileen M , Currie Kathleen , Glare Paul A , Schneider Joanne
Published: November 2007

Providing effective pain control without side effects is a major challenge in patients with advanced cancer. Oral analgesics may not be practical for a variety of reasons, and several alternatives for parenteral administration are available, including patient-controlled analgesia (PCA). This is a report of a pilot study of the effectiveness, dose requirements, side effects and practicality of continuous subcutaneous morphine infusion delivered by PCA in nine patients. A review of the literature of subcutaneous morphine infusions and guidelines for use are described. Continuous subcutaneous infusion of morphine via a PCA device appears to be a safe and effective method of pain control in patients with advanced cancer.
Care and information received by lay carers of terminally ill patients at the Leicestershire Hospice
Authors: Field David , Dand Pauline , Ahmedzai Sam , Biswas Bronwen
Published: November 2007

This paper is based on interviews with 59 lay carers of patients admitted to the Leicestershire Hospice. Carers were interviewed approximately a week after patient admission, and 37 carers were re-interviewed approximately three months after the death of the patient. Most lay carers were satisfied with the care and attention they received, although they were somewhat less satisfied with care and attention received from community nurses and GPs than from hospice nurses and doctors. Carers expressed satisfaction with the care received by hospice inpatients and indicated that the good care their relative or close friend received was an important factor in relieving their anxieties. They were also positive about the reassurance and care which they themselves received from hospice doctors and nurses. There was a generally high level of satisfaction about the information which they received from hospice staff, although a minority of carers had only limited contact with hospice staff, and it was these who were unhappy about the information which they had received.
Palliative care services in Britain and Ireland 1990 - an overview
Authors: Smith Anthony M , Eve Ann , Sykes Nigel P
Published: November 2007

Objective: To describe and quantify the Hospice and Palliative Care services throughout Great Britain and Ireland, and staffing of those services, for the year 1990.

Method: Questionnaires were sent to 428 units or teams in Great Britain and Ireland. A supplementary questionnaire was sent to inpatient units not replying to the first questionnaire. Replies were reviewed and analysed by the Hospice Information Service.

Results: A total of 224 of the 428 (52%) palliative care services replied, including 116 of 156 (74%) inpatient units. The report details bed usage, staffing, services offered and volunteer involvement in the 116 inpatient units. It also describes staffing, caseload and the service offered by home care teams. We attempt to relate bed usage to populations served, size of hospice and staffing ratios. We also report on categories of patients served.
Palliative care in Catalonia 1990-95
Authors: Gomez-Batiste X. , Borras JM , Fontanals MD , Stjernswärd J. , Trias X.
Published: November 2007

We present our basic and preliminary results of a global project to develop palliative care in Catalonia in five years, as part of a World Health Organization demonstration project on cancer.

The project, which has already started, includes measures to implement specific resources at all levels of care simultaneously, measures to train target professionals through initiatives at both the pre-and the postgraduate level, measures to promote the use of oral morphine in primary care, and some proposed indicators for monitoring the services.

At present in Catalonia there are six support teams in hospitals, four units in sociohealth centres, and almost 30 home care teams.
Frequent and difficult problems perceived by nurses caring for the dying in community, hospice and acute care settings
Authors: Copp Gina , Dunn Virginia
Published: November 2007

A total of 167 practising nurses from three practice settings-community, hospice and acute care - were asked to identify the five most common problems encountered when caring for the dying and the five most difficult problems to manage. Nine main categories of problems were elicited, including physical, work-related, nurse-related, death-related and spiritual problems. Key categories have been selected for discussion in this paper. Specific differences in the responses obtained from the three practice settings may be related to differences in the ethos of care of the dying patient in each area, particularly between hospice/community care and acute care. The findings of the survey will serve as a basis for planning initiatives in education and research in palliative care nursing.