bluuebunny/crossref_metadata_2025 huggingface dataset:
Infrastructure Development and the Repositioning of Power in Three Mekong Region Capital Cities
Authors: Walsh John , Amponstira Fuengfa
Published: April 2013

Infrastructure — broadly defined to include road and rail networks, telecommunications, electricity and other utilities — offers both direct and indirect benefits to economic growth. The direct effects include employment and contracts for local firms, while its role as an enabling technology means that a multiplier effect is provided for the economy as a whole. Infrastructure also has a role to play in promoting the efficiency of governance and social cohesion. The relative importance of these factors varies according to the specific conditions applying within a geographical location. The Burmese capital, Naypyidaw, for example, has a symbolic status as the seat of postcolonial Burmese power, while also offering a strategic location from which to govern the country. The role of infrastructure in this case is to promote efficiency of rule and create a network in which the city can form a node connected with economically important locations. In Phnom Penh and Vientiane, by contrast, infrastructure is being used to both promote economic activities and link up with cross‐border markets. In all cases, albeit in different ways, capital cities are being repositioned within actual and emerging power networks in order to control and take advantage of processes of international capital accumulation.
Activities of modified Cry3A‐type toxins on the red flour beetle, Tribolium castaneum (Herbst)
Authors: Mostafa M. A. M. , Vlasák J. , Sehnal F.
Published: April 2013

Bacillus thuringiensis (Bt) is a commonly used bioagent in insect pest control. Its toxicity is largely due to the crystalline (Cry) proteins that act selectively on insects and/or nematodes. Some insects, such as the stored product pest Tribolium castaneum, are relatively resistant to any natural Cry toxin. In attempt to find a Cry protein sufficiently toxic to this beetle, we prepared 18 recombinant modifications of Cry3A protoxins and tested them on the penultimate instar larvae of T. castaneum. Larvae were transferred to diet containing 0, 14, 28, 56 or 112 ppm of a Cry protein and their body growth and mortality were evaluated after 10 days. Cumulative mortality reached 25%, and the growth was nearly halted with 112 ppm of the natural Cry3Aa. The mortality was lower and the body weight increased by 15% of the control value in larvae receiving the recombinant Cry3Aa. Several structural derivatives of Cry3A also caused significant growth reduction and enhanced mortality. As both the natural and the recombinant Cry3Aa were more active than any of the tested Cry3A derivatives, we conclude that structural modifications of Cry3Aa are unlikely to increase toxicity to T. castaneum.
Developmental changes in the connective tissues of the porcine recurrent laryngeal nerve
Authors: Campbell Ellen O. , Samlan Robin A. , McMullen Nathaniel T. , Cook Sarah , Smiley‐Jewell Suzette , Barkmeier‐Kraemer Julie
Published: April 2013

The recurrent laryngeal nerve (RLN) branches from the vagus cranial nerve to innervate structures important for voicing and swallowing. Damage to this nerve, commonly associated with surgery or idiopathic etiologies that largely occur with aging, results in impaired voicing and swallowing (Myssiorek, 2004). Sunderland proposed a model of peripheral nerve damage whereby a nerve's ability to resist damage from stretch and compression is determined by the quantity and composition of its epineurial connective tissues (Sunderland, 1951). Thus, it would be expected that epineurium differs depending upon the forces imposed on a nerve within its anatomical setting. The purpose of this study was to investigate RLN epineurium quantity and composition with development. A porcine model (piglet vs. juvenile) was used because of the similarity between porcine and human laryngeal innervation, anatomy and function. The entire RLN was excised bilaterally, and stereological methods were used to quantify the composition of epineurial connective tissues. Compared with the piglet, the juvenile pig RLN was double the diameter. While the piglet had no differences in the percentage of epineurial collagen and adipose between proximal and distal segments of both sides of the RLN, the juvenile pig had a greater percentage of collagen in the proximal segment of both sides of the RLN and a greater percentage of adipose in the distal segment of the left RLN compared with the proximal segment. In addition, unlike the piglet, the juvenile pig had a greater number of fascicles in the proximal than distal segment of the RLN, regardless of nerve side. These findings are consistent with predicted patterns associated with the different anatomical settings of the left and right RLN, show that the RLN changes with age, and support Sunderland's model.
An investigation of duration of untreated psychosis and the affecting factors
Authors: Sadeghieh Ahari S. , Nikpou H. , Molavi P. , Abdi R. , Amani F. , Shirinzadeh B.
Published: April 2013

Accessible summary

The mean duration of untreated psychosis (DUP) were 261.3 ± 110.8 and 212.5 ± 143.5 days for patients referring to Razi and Fatemi hospital.

The DUP mean here was found to be higher as compared with that of the developed countries.

Lower education, implausible beliefs and culturally rooted social stigma status of visiting a psychiatrist were found to be playing a role in making DUP longer.

One of the main goals in treatment planning of psychiatric disorders is early diagnosis of patients in the early psychosis period so that duration of untreated psychosis (DUP) is decreased and the treatment response and outcome is improved. The aim of this study was to investigate the DUP of psychosis and factors affecting it. In this cross‐sectional study, 80 patients from the psychiatric clinic of Fatemi hospital in Ardabil and Razi hospital in Tabriz who were in the first episode of psychosis completed a questionnaire. The data were analysed by SPSS statistical software. In this study, the mean DUP measured from the appearance of the first symptoms of psychosis were 261.3 ± 110.8 and 212.5 ± 143.5 days for patients referring to Razi and Fatemi hospital, respectively. About 65% of the patients in Fatemi hospital and 32.5% of them in Razi hospital considered visiting a psychiatrist as hard and very hard. The DUP mean here was found to be higher as compared with that of the developed countries. The following factors were found to be playing a role in making DUP longer: lower education, implausible beliefs and culturally rooted social stigma status of visiting a psychiatrist.
Psychological factors associated with successful outcomes in home haemodialysis
Authors: Nearhos Jane , Van Eps Carolyn , Connor Jason
Published: April 2013

Aim

Performing haemodialysis therapy at home has been associated with improved survival for end‐stage kidney disease patients and can generally be delivered at a lower cost to the healthcare system when compared with centre and satellite unit dialysis. However, only a minority of dialysis dependent end‐stage kidney disease patients successfully sustain haemodialysis at home. Current practice for determining dialysis treatment modality and location takes into account medical suitability and social situation, but infrequently formally examines the contribution of psychological factors. This study explores demographic, health, and psychological factors that may predict patients' ability to sustain home haemodialysis.

Methods

One hundred and thirteen successful and unsuccessful home haemodialysis users were recruited to the study, and 55 responded to self‐report measures. Demographic (age, gender, education level, carer support), health (comorbidities, diabetes, psychiatric condition) and psychological (locus of control beliefs, coping styles) information was used as predictor variables for the participants' time maintaining home therapy (Home Time).

Results

In a three‐step regression, the model explained 32% of variance in Home Time. Coping styles significantly contributed 16% of the variance in Home Time after accounting for other variables. Adaptive Coping was significantly correlated with the length of time sustaining home therapy.

Conclusion

Adaptive coping strategies are associated with improved ability to sustain home haemodialysis therapy. Evidence‐based psychological approaches can help patients develop more adaptive coping strategies. More research is needed to assess whether instituting these psychological interventions will assist patients to adopt and sustain dialysis therapies which require increased patient self‐management.
Clinical outcome of elderly peritoneal dialysis patients with assisted care in a single medical centre: A 25 year experience
Authors: Cheng Chi‐Hung , Shu Kuo‐Hsiung , Chuang Ya‐Wen , Huang Shih‐Ting , Chou Ming‐Chih , Chang Horng‐Rong
Published: April 2013

Aim

Peritoneal dialysis (PD) is an alternative treatment for elderly patients with end‐stage renal disease (ESRD). In Taiwan, non‐professional personnel are employed to provide assisted care for elderly patients. Whether assisted care is appropriate for elderly patients is unknown. The aim of this paper is to evaluate the outcomes of assisted care in a single centre.

Methods

This is a retrospective cohort study in a single medical centre. The outcomes were derived from the assessment of patient survival, technique survival and peritonitis incidence between self‐care patients and assisted‐care patients.

Results

From 1984 to 2010, there were 138 elderly PD patients at Taichung Veterans General Hospital, of which 70% were assisted‐care patients and 30% self‐care patients. The mean duration of PD survival was 49.2 months in self‐care patients, which was significantly longer than the 17.0 months of assisted‐care patients (P < 0.05). Using the multivariate Cox proportion regression model to adjust for risk factors, it was found that self‐care patients had a lower risk in both patient survival (Hazard Ratio 0.15; 95% confidence interval (CI) 0.2–0.94, P < 0.05) and technique survival (Hazard ratio; 0.11, 95% CI 0.1–0.9, P < 0.05). Fluid overloading was the major cause of technique failure in assisted‐care patients. Type of assistance was not a risk factor for PD‐related peritonitis.

Conclusion

Our elderly assisted care had patients had a poorer survival and technique survival rates than those of the self‐care patients. We argue that this is because early recognition of medical deterioration and early medical intervention are necessary for a better outcome for elderly PD patients.
Revisit of Typical Counterclockwise Atrial Flutter Wave in the ECG: Electroanatomic Studies on the Determinants of the Morphology
Authors: SASAKI KENICHI , SASAKI SHINGO , KIMURA MASAOMI , OWADA SHINGEN , HORIUCHI DAISUKE , ITOH TAIHEI , ISHIDA YUJI , OKUMURA KEN
Published: April 2013

Background

Cavotricuspid isthmus‐dependent counterclockwise atrial flutter (typical AFL) is characterized by negative saw‐tooth morphology flutter wave (F‐wave) in the inferior leads, which is classified as type 1 with purely negative F‐wave without positive terminal deflection (PTD), type 2 with small PTD, and type 3 with broad PTD. The determinants of these morphological differences remain to be elucidated.

Methods and Results

Of 72 patients (58 males, 65 ± 13 years) with typical AFL, 19 were classified as type 1 and 53 as types 2 and 3. We created an electroanatomic map of the right atrium (RA) during AFL and determined which RA site activation corresponded to which F‐wave component by analyzing the activation map. It was revealed that F‐wave component from the nadir to terminal deflection point coincided with the cranio‐caudal activation of the RA free wall (RAFW) in all types. The bipolar voltage map showed that type 1 had the greater extent of low voltage (<0.5 mV) area (LVA) in RAFW (39 ± 24%) than types 2 and 3 (4 ± 3%) (P < 0.0001), explaining the absence of PTD in type 1. In types 2 and 3, F‐wave amplitude determining the PTD magnitude was highly correlated with the longitudinal distance between two points on RAFW corresponding to the nadir and peak of F‐wave (r = 0.73, P < 0.0001).

Conclusions

Terminal positivity and amplitude of F‐wave in typical AFL are primarily related to the RAFW activity: negatively by the extent of LVA and positively by the longitudinal vector of activation.
Spontaneous Dissociated Firing from the Pulmonary Veins during Ablation of Paroxysmal Atrial Fibrillation: Implications and Impact on Arrhythmia‐Free Survival
Authors: HUSSEIN AYMAN A. , OZAKI ASUKA , MARTIN DAVID O. , BHARGAVA MANDEEP , BARANOWSKI BRYAN , DRESING THOMAS , CALLAHAN THOMAS , KANJ MOHAMED , TCHOU PATRICK , NATALE ANDREA , LINDSAY BRUCE D. , SALIBA WALID I. , WAZNI OUSSAMA M.
Published: April 2013

Background

Following pulmonary vein isolation (PVI) for the treatment of paroxysmal atrial fibrillation (AF), spontaneous dissociated firing (DiFi) from the isolated veins may be observed. Little is known about the significance and prognostic implications of this phenomenon. We sought to determine the relationship between DiFi and ablation outcomes.

Methods

The study population consisted of 156 paroxysmal AF patients who underwent first time PVI and were found to have spontaneous DiFi from the pulmonary veins (PVs). Their outcomes were compared to a population of 156 propensity‐matched controls from our prospectively maintained AF ablation data registry.

Results

DiFi was most frequently observed from the right superior PV and occurred in 89 patients (57.1%). After 24 months of follow‐up, patients with DiFi had better success rates compared to those with silent veins after isolation (88.5% vs 75%, P = 0.002). The overall distribution of types of recurrent arrhythmia was similar between DiFi patients and their matched controls (P = NS). During repeat ablations, DiFi patients were less likely to have PV conduction recovery (60% vs 93.3%, P = 0.02). Importantly, none of the veins with DiFi during index procedures was found to have conduction recovery.

Conclusion

In patients with paroxysmal AF undergoing ablation, DiFi from the PVs after their isolation was associated with improved ablation outcomes. It is possible that DiFi is an indicator of successful durable isolation of the PVs. The findings suggest that confirmation of exit block may be warranted to improve AF ablation outcomes.
Fitness in Naturally Occurring and Restored Populations of a Grassland Plant Lychnis flos‐cuculi in a Swiss Agricultural Landscape
Authors: Aavik Tsipe , Bosshard Daniel , Edwards Peter J. , Holderegger Rolf , Billeter Regula
Published: April 2013

Wildflower seed mixtures are widely used for restoration of grasslands. However, the genetic and fitness consequences of using seed mixes have not been fully evaluated. Here, we studied the role of genetic diversity, origin (commercial regional seed mixtures, natural populations), and environmental conditions for the fitness of a grassland species Lychnis flos‐cuculi. First, we examined the relationship between genetic diversity, environmental parameters, and fitness in sown and natural populations of this species in a Swiss agricultural landscape. Second, we established an experiment in the study area and in an experimental garden to study the implications of local adaptation for plant fitness. Third, to examine the response of plants to different soil properties, we conducted an experiment in climate chambers, where we grew plants from sown and natural populations of L. flos‐cuculi as well as from seed suppliers on soils with different nutrient and moisture content. We detected no significant effect of genetic diversity on the fitness of sown and natural populations. There was no clear indication that plants from natural populations were better adapted to local environment than plants from sown populations or seed suppliers. However, plants of natural origin invested more into generative reproduction than plants from sown populations or seed suppliers. Furthermore, in the climate chamber, plants originating from natural populations tended to flower earlier. Our results indicate that using nonlocal seeds for habitat recreation may influence restoration success even if the seeds originate from the same seed zone as the restored site.
Initiation of antiretroviral therapy in HIV‐infected tuberculosis patients in rural Kenya: an observational study
Authors: Stockdale Alexander J. , Nkuranga Joseph , Török M. Estée , Faragher Brian , Lalloo David G.
Published: April 2013

Objective

To provide information on the effect of timing of antiretroviral therapy (ART) initiation on outcomes of TB infection in real‐life, non‐clinical trial, rural settings in sub‐Saharan Africa.

Methods

We conducted an observational cohort study of all HIV‐infected TB patients presenting to a rural hospital in Kenya between 2005 and 2009. We analysed the association between timing of initiation of ART and mortality, using a Cox regression survival analysis, adjusted for measured confounders.

Results

A total of 404 antiretroviral‐naïve HIV/TB coinfected patients were included in the study. Initiation of ART during the first 8 weeks of TB treatment (early group) was not associated with changes in mortality at 1 year compared with initiation of ART after 8 weeks (late group) [Hazard Ratio (HR) = 0.74 (Confidence Interval (CI), 0.33–1.64, P = 0.46]. In patients with baseline CD4 counts ≤50 cells/μl, there was a significant reduction in mortality in the early group compared with the late group (HR = 0.20; 95% CI, 0.042–0.99; P = 0.049). In patients with a CD4 count >50 cells/μl, there was no significant difference between early and late groups (HR 1.79; 95% CI, 0.64–5.03; P = 0.27).

Conclusions

We found that in HIV/TB coinfected patients in rural Kenya, early ART initiation (within 8 weeks) was associated with reduced mortality in those with CD4 counts ≤50 cells/μl. In patients with CD4 counts >50 cells/μl, there was no association seen between timing of ART and mortality.
A Sorting Nexin 17‐Binding Domain Within the LRP1 Cytoplasmic Tail Mediates Receptor Recycling Through the Basolateral Sorting Endosome
Authors: Farfán Pamela , Lee Jiyeon , Larios Jorge , Sotelo Pablo , Bu Guojun , Marzolo María‐Paz
Published: April 2013

Sorting nexin 17 (SNX17) is an adaptor protein present in early endosomal antigen 1 (EEA1)‐positive sorting endosomes that promotes the efficient recycling of low‐density lipoprotein receptor‐related protein 1 (LRP1) to the plasma membrane through recognition of the first NPxY motif in the cytoplasmic tail of this receptor. The interaction of LRP1 with SNX17 also regulates the basolateral recycling of the receptor from the basolateral sorting endosome (BSE). In contrast, megalin, which is apically distributed in polarized epithelial cells and localizes poorly to EEA1‐positive sorting endosomes, does not interact with SNX17, despite containing three NPxY motifs, indicating that this motif is not sufficient for receptor recognition by SNX17. Here, we identified a cluster of 32 amino acids within the cytoplasmic domain of LRP1 that is both necessary and sufficient for SNX17 binding. To delineate the function of this SNX17‐binding domain, we generated chimeric proteins in which the SNX17‐binding domain was inserted into the cytoplasmic tail of megalin. This insertion mediated the binding of megalin to SNX17 and modified the cell surface expression and recycling of megalin in non‐polarized cells. However, the polarized localization of chimeric megalin was not modified in polarized Madin‐Darby canine kidney cells. These results provide evidence regarding the molecular and cellular mechanisms underlying the specificity of SNX17‐binding receptors and the restricted function of SNX17 in the BSE.
The ERM Proteins Ezrin and Moesin Regulate Retrograde Shiga Toxin Transport
Authors: Kvalvaag Audun Sverre , Pust Sascha , Sundet Kristine Ingrid , Engedal Nikolai , Simm Roger , Sandvig Kirsten
Published: April 2013

The ERM proteins (ezrin, radixin and moesin) are known for connecting the actin cytoskeleton to the plasma membrane. They have been found to associate with lipid rafts as well as to be important for endosomal sorting and receptor signaling. However, little is known about the role of ERM proteins in retrograde transport and lipid homeostasis. In this study, we show that ezrin and moesin are important for efficient cell surface association of Shiga toxin (Stx) as well as for its retrograde transport. Furthermore, we show that depletion of these proteins influences endosomal dynamics and seems to enhance Stx transport toward lysosomes. We also show that knockdown of Vps11, a subunit of the HOPS complex, leads to increased retrograde Stx transport and reverses the inhibiting effect of ezrin and moesin knockdown. Importantly, retrograde transport of the plant toxin ricin, which binds to both glycolipids and glycoproteins with a terminal galactose, seems to be unaffected by ezrin and moesin depletion.
Biodegradable Nanoparticles Surface Modification Techniques With cIBR Peptide Targeting to LFA-1 Expressing Leukemic Cells
Authors: Phongpradist Rungsinee , Chittasupho Chuda , Intasai Nutjeera , Siahaan Teruna J. , Berkland Cory J. , Charoenkwan Pimlak , Anuchapreeda Songyot , Ampasavate Chadarat
Published: April 2013

The lymphocyte function associated antigen-1 (LFA-1) is evaluated for a targeting carrier in leukemia. The cIBR peptide was utilized as the targeting moiety for the drug carrier in direct targeting to LFA-1 expressing cancer cells. This study aims to evaluate the effects of the cIBR peptide conjugation on the specific targeting delivery to the leukemic cell line. Poly (D, L lactide-co-glycolide) (PLGA) nanoparticles were conjugated to the cIBR peptide by three different approaches (coupling, head, and tail) in order to evaluate the nanoparticles' characters, targetability, uptake, drug releasing, and cytotoxicity of each approach. The prepared PLGA nanoparticles were spherical lin shape with a size range of 200–450 nm. The targetability and uptake of three types of cIBR-conjugated nanoparticles (cIBR-NPs) were evidenced and quantified by flow cytometry. The coupling approach presented the highest targetability, uptake, drug releasing, and cytotoxicity followed by the head and tail approaches, respectively. The peptide conjugation method onto the nanoparticles surface was proven to be a key factor for the nanoparticles' physicochemical characteristicss and their efficient delivery.
Development of a Prognostic Model for Breast Cancer Survival in an Open Challenge Environment
Authors: Cheng Wei-Yi , Yang Tai-Hsien Ou , Anastassiou Dimitris
Published: April 2013

A computational modeling approach that combined several molecular features yielded a robust breast cancer prognostic model that was independently validated in a new patient data set.
A Novel Adenovirus Species Associated with an Acute Respiratory Outbreak in a Baboon Colony and Evidence of Coincident Human Infection
Authors: Chiu Charles Y. , Yagi Shigeo , Lu Xiaoyan , Yu Guixia , Chen Eunice C. , Liu Maria , Dick Edward J. , Carey Kenneth D. , Erdman Dean D. , Leland Michelle M. , Patterson Jean L.
Published: April 2013

Adenoviruses (AdVs) are DNA viruses that infect many vertebrate hosts, including humans and nonhuman primates. Here we identify a novel AdV species, provisionally named “simian adenovirus C (SAdV-C),” associated with a 1997 outbreak of acute respiratory illness in captive baboons (4 of 9) at a primate research facility in Texas. None of the six AdVs recovered from baboons (BaAdVs) during the outbreak, including the two baboons who died from pneumonia, were typeable. Since clinical samples from the two fatal cases were not available, whole-genome sequencing of nasal isolates from one sick baboon and three asymptomatic baboons during the outbreak was performed. Three AdVs were members of species SAdV-C (BaAdV-2 and BaAdV-4 were genetically identical, and BaAdV-3), while one (BaAdV-1) was a member of the recently described SAdV-B species. BaAdV-3 was the only AdV among the 4 isolated from a sick baboon, and thus was deemed to be the cause of the outbreak. Significant divergence (<58% amino acid identity) was found in one of the fiber proteins of BaAdV-3 relative to BaAdV-2 and -4, suggesting that BaAdV-3 may be a rare SAdV-C recombinant. Neutralizing antibodies to the other 3 AdVs, but not BaAdV-3, were detected in healthy baboons from 1996 to 2003 and staff personnel from 1997. These results implicate a novel adenovirus species (SAdV-C) in an acute respiratory outbreak in a baboon colony and underscore the potential for cross-species transmission of AdVs between humans and nonhuman primates.

IMPORTANCE
Adenoviruses (AdVs) are DNA viruses that infect many animals, including humans and monkeys. In 1997, an outbreak of acute respiratory illness from AdVs occurred in a baboon colony in Texas. Here we use whole-genome sequencing and antibody testing to investigate new AdVs in baboons (BaAdVs) during the outbreak, one of which, BaAdV-3, came from a sick animal. By sequence analysis, BaAdV-3 may be a recombinant strain that arose from a related BaAdV found in baboons nearby in the colony (who were not sick) and yet another unknown AdV. We also found antibodies to these new BaAdVs in baboons and staff personnel at the facility. Taken together, our findings of a new AdV species as the cause of an acute respiratory outbreak in a baboon colony underscore the ongoing threat from emerging viruses that may carry the potential for cross-species transmission between monkeys and humans.
Peritoneal catheter for massive cardiac ascites
Authors: Aisenberg Gabriel M
Published: April 2013

Cardiac ascites represents 5% of all causes of ascites. Diuretics and salt restriction remain the cornerstone of management. Large volume paracentesis is needed among patients who do not respond to conservative management. The use of peritoneal catheters to continuously drain steady amounts of ascitic fluid has been generally used in malignant ascites. When the ascites of any other origin is massive and requires many consecutive days of large-volume paracentesis, the use of a catheter may represent a more convenient strategy. We present a patient with cardiac ascites that was successfully managed with a peritoneal catheter.
Cardiovascular disease: thinking beyond atherosclerosis
Authors: Vilardouro Paiva Luis Manuel , Costa Marco , Barra Sergio , Providencia Rui
Published: April 2013

A 56-year-old female patient was referred to our institution for atypical chest pain and palpitations. Physical examination, resting ECG and transthoracic echocardiogram were unremarkable. Stress perfusion scintigraphy was positive for anterior and apical myocardial ischaemia. A subsequent coronary angiogram showed no signs of atherosclerotic coronary artery disease; however, it revealed a coronary arteriovenous fistula and multiple other fistulous connections between the proximal segment of the left coronary artery and the pulmonary artery trunk. We present a rare case of a symptomatic coronary fistula that was percutaneously closed using an Amplatzer Vascular Plug, which resulted in clinical improvement and late fistula occlusion. This case report underlines the importance of thinking beyond atherosclerosis in the evaluation of chest pain syndromes. Moreover, it describes some of the angiogram caveats in assessing the coronary fistula number and morphology, as well as the cardiac-catheter potential for multiple pathway coronary artery fistulae closure.
ADVANCE CARE PLANNING AND END-OF-LIFE CARE IN ADVANCED RENAL FAILURE
Authors: Davison Sara
Published: April 2013

People with advanced chronic kidney disease (CKD) have high mortality; substantial physical, emotional and spiritual suffering; and tremendous end-of-life (EOL) care needs. However, their illness trajectories and needs differ from those with advanced cancer and current palliative care models do not meet these needs. Over the last two decades, much research and evidence on advance care planning (ACP) and EOL issues in CKD have accumulated. As a result, integrated renal palliative care services are slowly being developed internationally. Kidney Disease: Improving Global Outcomes (KDIGO), the independent, not-for-profit, organisation that conducts formal international guideline development in CKD, agrees that a comprehensive analysis of ACP and EOL/supportive care for CKD patients is timely and represents an area of great clinical need. KDIGO is therefore partnering with experts from around the world to hold the first consensus forum on renal supportive care. The goal is to (1) summarise the state of knowledge; (2) discuss what recommendations can be derived from the available knowledge; and (3) assess what needs to be undertaken to improve the evidence-base for ACP and EOL clinical management. The overall aim is to work towards global guidelines for the implementation of renal supportive care. This would help improve worldwide practice, referral, and overall access to ACP and palliative care services for patients with CKD. This session will highlight these recent advances in ACP and EOL care and will suggest how new knowledge may be integrated into care for patients with advanced CKD.
FULFILLING THE END OF LIFE WISH OF AN AWAKE CRITICALLY ILL PATIENT PRIOR TO WITHDRAWAL OF ORGAN SUPPORT
Authors: Philpot S , Johns S
Published: April 2013

Background

A high proportion of hospital deaths occur in Intensive Care. Most of these patients are unable to communicate immediately prior to their death due to illness, sedation, intubation and mechanical ventilation.

Aim

To describe how we were able to fulfil the dying wish of an ICU patient to spend an afternoon at home with family, despite ongoing requirement for intensive organ supports. We describe the positive impact of the visit on the patient, her family, and staff.

Method

A 58-year-old lady spent over 4 months in our Intensive Care Unit following a bilateral lung transplant which was complicated by respiratory and renal failure. She was dependent upon mechanical ventilation and continuous renal replacement therapy, but was able to fully communicate her wishes. A decision was made to withdraw cardio-respiratory and renal support on the grounds of futility of ongoing active management.

Results/Discussion

The patient was safely transported. During the visit, she commented to her family that she was at peace, and ready to die, something that she had not previously felt. This provided closure for the patient and her family, and significantly helped her family come to terms with her impending withdrawal of respiratory support. She was transported back to the Intensive Care Unit after her home visit, and died the following day after withdrawal of respiratory support.

Conclusion

Extra-ordinary measures taken to fulfil the dying wishes of our patient were able to significantly improve the dying experience for her and her family.
IS IT APPROPRIATE TO INITIATE PALLIATIVE CARE IN A PAEDIATRIC INTENSIVE CARE UNIT (PICU)?
Authors: Crowe L , Herbert A , Mattke A
Published: April 2013

Background

Paediatric Palliative care is being redefined as medical technology and advancements can at times ‘make death an option’. Children with life limiting conditions can now be on palliative care for years making the boundaries for limitations challenging. The team at the Mater Children's PICU work closely with the Paediatric Palliative Care Service and are a major source of early referrals for children with complex and life limiting conditions.

Aim

Review the referral process for children to the Queensland paediatric palliative care service from PICU.

Methods

Using our electronic chart system we identified 54 patients who had been referred to the palliative care service since 2008. Using thematic analysis we reviewed who initiated discussions, what patient descriptors were associated with referral, common themes and outcomes.

Results

The majority of children referred had complex medical needs. PICU referral to Palliative Care introduced a greater focus on quality of life and the concept of limiting aggressive care.

Discussion

PICU is often viewed as an acute medical environment and not one where palliation discussions for complex long term patients occur. However we found that due to the critical nature of PICU it is often time for a holistic review of the medical history; child and family goals and a focus on quality of life.

Conclusion

The PICU team have extensive experience in talking about end of life issues and are ideally placed to work with the Palliative Care Service to initiate referrals, enhance management of subsequent crises and maximise quality of life in PICU and on discharge.
TELEPHONIC ADVANCE CARE PLANNING FACILITATED BY HEALTH PLAN CASE MANAGERS
Authors: Boettcher I , Turner R
Published: April 2013

Background

Priority Health Case Managers (CMs) work telephonically with frail patients that have multiple co-morbidities. CMs have lacked facilitation skills for Advance Care Planning (ACP) discussions in this vulnerable population. Following a 6-month pilot of telephonic ACP (TACP) in the Medicare population, TACP was implemented for the entire Medicare CM staff.

Aim

To engage identified patients in First Steps© and Last Steps© TACP.

Methods

CMs were trained and certified by Respecting Choices© to facilitate ACP discussions telephonically with both First Steps© and Last Steps© protocols. CMs identified appropriate patients using hospitalisation and emergency room utilisation data, severity of illness and diagnostic criteria. The primary goal was to complete both the ACP discussion and document for each protocol on identified patients. CMs also attempted to schedule facilitated conversations with the health care advocate present.

Results

In one calendar year, 155 patients were identified for TACP using established criteria. 59% indicated they had an existing document identifying preferences for medical care. 35% declined TACP. Last Steps© discussions occurred in 15% of the patients. TACP resulted in eight new or updated documents.

Discussion

Following TACP implementation to the Medicare CM team and evaluation of the results, processes and methods were instituted to increase engagement and completion of discussions and documents. These included enhancements to the electronic assessment and ongoing support of the CM team to increase engagement of patient and advocate.

Conclusion

Dissemination of the project to the entire Medicare CM team demonstrates opportunities and lessons learned for facilitated TACP discussions.
THE PRACTICALITIES OF CROSS BOUNDARY WORKING IN RESPECT OF ACP FOR CARE HOME WITH NURSING RESIDENTS
Authors: Thorn M , Bloomer C
Published: April 2013

Background

Within a care home with nursing reviewing the use of ACP to prevent inappropriate hospital admissions at end of life and the use of ACP to prevent delayed discharge from a General Hospital back to the care home.

Review of admission data from a care home to general hospital and on the number of admissions resulting in hospital deaths compared to care home deaths during the last 2 years.

Aim

To highlight the importance of ACP, relationships with the hospital discharge team and community multi-disciplinary teams and how it successfully prevents inappropriate delayed discharges back to the care home setting.

Method

We reviewed hospital admissions over the last 2 years, including who had an ACP, the interactions between the care home with the hospital, the length of hospital stay, and an audit of the feedback received from relatives and residents.

Also looking at more recent work providing ‘step up’ and ‘step down’ beds to support a local district general hospital and how having an ACP in place benefits patients.

Results

This review is on-going (will be completed by end of March 2013) but early results suggest that where an ACP is in place the resident returns to the care home more quickly and both resident and family are more satisfied with the episode of care.

Discussion

Challenges in the practicalities such as extracting information from different teams of professionals involved in the resident's care. The importance of building positive relationships with hospital wards and discharge teams.

Ensuring correct documentation re ACP goes into hospital with resident.

Conclusion

The benefits of developing good cross boundary relationships with hospital teams and the importance of ACP helping prevent delayed discharges.
LOW FOOD INTAKE IN OLDER PEOPLE WITH DEMENTIA
Authors: Rajaram S , Chua H C
Published: April 2013

Aim

The aim of the study was to investigate the risk factors associated with older people in acute care setting for developing low food intake.

Background

Eating difficulties among patients with dementia have been identified in Western countries and they progress when dementia advances. Previous studies have indicated that low food intake and weight loss is not a result of people with dementia not willing to eat independently.

Design

The study consisted of nurses observing meal time observations. Observation was done for 3 days during lunch and dinner time.

Methods

17 participants were selected from patients with dementia from 2 geriatric units in an acute care hospital. Data was collected using the Barthel index, Mini Mental State Examination (MMSE) and Edinburgh Feeding Evaluation in Dementia (EdFED)

Results

The prevalence of low food intake at meals in patients with dementia in the acute care unit was about 10%. Eating difficulty, no feeding assistance, moderate dependence, few family visits, being female and older were six independent factors associated with low food intake.

Conclusion

Nurses needed to assess the patients feeding ability to continue to self feed. To supervise the feeding of the patients with moderate dependency and appropriate verbal or physical assistance at meal times is recommended.

Relevance to clinical practice: Strategies to encourage families to visit their older relatives in acute care units is encouraged and recommended.
DIAGNOSING DYING: WHEN WE MISS THE BOAT
Authors: Corke Charlie
Published: April 2013

As good as Advance Care Planning (by both doctors and patients) may become we will still be confronted by the acutely deteriorating patient who will die without treatment—but might well have their death miserably prolonged by treatment. These decisions confront us on a daily basis.

Good medicine requires doctors to assist patients to make good decisions (a decision ie, right for that patient at that time).

This requires skills that are rarely taught but can be learned.

The decision making process in a high risk situation (death vs suffering) is complex.

The decision-making process requires two important components:

an understanding of the natural history of the disease that the patient has (without undue optimism)

an understanding of the person themselves (their values, wishes and fears).

Balancing the person (with their values, wishes and fears) with the medical situation that they find themselves in often reveals a clear treatment choice.

The thought process can help both the patient and the doctor arrive at a ‘good’ answer—and hopefully informs a shared decision.

The ‘When Enough-is-Enough’ course teaches this concept in a straightforward way that empowers junior doctors to explore their patient's values.

The concept is not new: In the early 1900s the great physician, Sir William Osler stated:

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”

His words are more pertinent today than ever.
SPECIALIST PALLIATIVE CARE SERVICE RESPONSIBILITY TO SUPPORT PRIMARY CARE PROVIDERS IN CARE PLANNING AND END OF LIFE CARE: A REVIEW
Authors: Cole M
Published: April 2013

Background

Following a gradual but consistent increase in requests from within Castlemaine Health, a review of service provision by the Community Palliative Care Service (CPCS) was undertaken to determine a sustainable level of support to Primary Care Services.

Aim

Although this is a small rural service, the CPCS should provide support to primary care services during an episode of a person's care. This includes promotion of a palliative approach across all care settings and to the community in general.

Methods

Data for the previous 2 years was reviewed to identify episodes of shared care or consultation to primary care providers; Key stakeholders interviewed and responses grouped into themes of need/support; Education provided and evaluated; Stakeholder review to determine perceived benefit.

Results

The number of shared care or ‘consultation’ episodes was not reflected in the data due to limited reporting fields and inconsistency of data entry. Stakeholders agreed that palliative care occurs across all settings but recognition by primary care staff continues to be low. There was a perceived need to increase staff confidence in abilities, recognising transition of care (phases) and reviewing Advance Care Plans. Two education programmes were provided with 47 staff attending. On 10 point scale there was a shift of +2/+2.2 respectively in knowledge of after education.

Discussion

Access to Palliative Care Staff on a regular basis increases staff confidence within Primary Care Services.

Conclusion

Increased support and direct promotion of the Palliative Care Service is beneficial for assessment and care planning across Primary Care Services.
ETHICAL ISSUES FOR JAPANESE NURSES IN END-OF-LIFE CARE: FROM ANALYSIS OF THE ANGUISH OF NURSES IN AN ACUTE WARD
Authors: Kiyama M , Morishita N , Tajima H
Published: April 2013

Background

In Japan, many clinical nurses experience ethical dilemmas in daily nursing practice that cannot be resolved easily. Nurses feel strong regret in particular in cases in which the patient is at the end of life. Accordingly, based on one end-of-life case we elucidated the aspects of the patient's condition and the thoughts and disorientation of the nurses.

Aim

To consider ethical issues for clinical nurses in end-of-life care.

Methods

We surveyed seven nurses on the nursing team involved in this case, through group interviews. The interviews concerned topics including nursing policies and plans, the content of conferences, and the dilemmas nurses experienced.

Results

Through data analysis, we identified 63 codes, 25 subcategories, and six core categories. While admitted, the patient constantly used the nurse-call for various reasons. She made particularly many calls during the postoperative acute stage and the postoperative recovery stage. In the postoperative acute stage, the nurses anticipated a danger when hearing the nurse-call, immediately answered the call, and went to her room to take appropriate action. However, during the postoperative recovery stage, the nurses were not aware of her sense of anxiety and were confused by the patient's frequent nurse-calls, even during recovery.

Discussion

Gaps developed between the patient's thoughts and the ethical assumptions of nurses in end-of-life care. This gap was due to differences in each other's goals.

Conclusion

This study will support promotion, from the nurse's point of view, of the provision of medical care that satisfies patients, which has not advanced smoothly in Japan.
KNOWLEDGE AND PERCEPTION ON END-OF-LIFE- CARE, DEATH AND DYING AMONG PALLIATIVE NURSES
Authors: Subramanian P , Chinna K
Published: April 2013

Background

Every individual deserved to have good death. Good death is ‘peaceful and dignified’ without unnecessary suffering of dying. Nursing perspective of ‘a good death’ is centred in the ability to provide comfort to all involved. Even though many studies have highlighted nurses' perspectives on end-of-life-care, this is the first study conducted among Malaysian nurses'.

Aim

This study aims to investigate palliative nurses' knowledge and perception on end-of-life-care, death and dying.

Methods

A survey was conducted using questionnaire among 177 palliative nurses working in a urban hospital,

Results

Majority of the respondents (75%) had good knowledge on end of life care but have poor perception on end-of-life- care (57%), experiences towards moment of death (56%) and experience at the end-of-life (86%). Only 31 (15.5%) scored good perception on the overall care. The χ2statistic showed a significant relationship between age and work experience with nurses and perception on end-of-life- care at p value of <0.05.

Discussion

Although efforts are being made to improve nurses knowledge on end of life care, practicing nurses still lack of knowledge in providing end-of-life -care and the study findings shows poor perception on end of life care, death and dying. One of the reasons could be due to lack of experience with majority of nurses have less than 1 year experience and below 30 years old.

Conclusion

Continued practice development is needed in improving end- of- life- care.
ADVANCE CARE PLANNING IN JAPANESE HOSPITALS-USEFULNESS OF END-OF-LIFE CARE TEAM
Authors: Yokoe Y , Nishikawa M , Kubokawa N , Fukuda K , Hattori H , Yong-Jae H , Miura H , Endo H , Nakashima K
Published: April 2013

Background

Although advance care planning (ACP) in hospitals is important, the best means of promoting it in Japan remain to be clarified.

Aim

The primary aim of this study was to evaluate the usefulness of end-of-life care teams (EOLCTs) for both cancer and non-cancer patients. The secondary aim was to evaluate the usefulness of narrative life reviews and ACP conducted by full-time EOLCT nurses using qualitative analysis.

Methods

We conducted the ‘three-pillar strategy for decision making’ for the families of 209 patients. There are three large pillars, (1) patient's wishes; (2) family's wishes; and (3) medical judgment. There are also three key pillars in regard to patients' wishes: (1) ‘Present’: Regardless of the patient's competence/incompetence, any subtle signs shown by the patient must be noted; (2) ‘Past’: ACP and narrative life reviews must be checked; and (3) ‘Future’: The best future interests must be considered. The patient's wish is the most important pillar.

Results

Intervention by the three-pillar strategy in EOLCT decision making tended to increase the number of home deaths in accordance with patients' wishes in collaboration with the home care support ward. Narrative life reviews by nurses led to enhancement of ACP.

Discussion

The most important finding was that patients' and their families' wishes were respected.

Conclusion

The three-pillar strategy used by EOLCT in decision making was useful in enhancing hospitals' ACP.
‘ADVANCE CARE YARNING’ BOOKLET
Authors: Jones L , Burgess S , Seal M
Published: April 2013

Background

Aboriginal Community Health Worker Shane Burgess was employed in 2010 as a Project Officer for the Respecting Patient Choices programme under the Ambulatory and Primary Health Care Directorate. Shane realised that raising awareness throughout the Aboriginal community about the importance of advance care planning requires organisations and staff to have appropriate resources. He hoped such resource might help overcome the great dilemmas around health decisions and moving from country.

Aim

To produce a culturally appropriate resource for the Aboriginal Community around advance care planning.

Methods

Shane met with Aboriginal Health Workers and made `well received' progress with the vision for an ‘Advance care yarning’ booklet.

Consultation with Aboriginal Health Care Workers about the booklet was favourable. The regional media team assisted with the booklet formatting, using a beautiful painting by Aboriginal artist Marlene from Alice Springs. Permission has been obtained for longevity of images used.

Results

A Booklet was published with the approval of Aboriginal people and senior Aboriginal Management in Health. Language, artwork and photographs were changed to appeal specifically to the Aboriginal Community

Discussion

TheRPC Advance Care Planning booklet(Austin Health) was modified to relate to both remote and metropolitan Aboriginal communities. Over 2000 copies have been requested from Aboriginal services and other health services across Australia. The booklet is utilised in current training and development programmes

Conclusion

A tool is now provided where there was a gap for engaging and informing Aboriginal people about advanced care planning for Advanced Care Directives.

The booklet has been well received and has been republished.