bluuebunny/crossref_metadata_2025 huggingface dataset:
Myriocin, a Serine Palmitoyltransferase Inhibitor, Blocks Cytokinesis in Leishmania (Viannia) braziliensis Promastigotes
Authors: Castro Erica V. , Yoneyama Kelly G. , Haapalainen Edna F. , Toledo Marcos S. , Takahashi Helio K. , Straus Anita H.
Published: April 2013

We studied the effect of myriocin, an inhibitor of serine palmitoyltransferase, on cultured Leishmania (Viannia) braziliensis promastigotes. Myriocin significantly reduced synthesis of inositol phosphorylceramide, the major sphingolipid expressed in promastigotes as characterized by thin layer chromatography and electrospray ionization mass spectrometry. Log‐phase promastigotes treated with 1 μM myriocin showed a 52% reduction in growth rate and morphological alterations such as more rounded shape and shorter flagellum. Promastigotes treated with myriocin also displayed a variety of aberrant cell phenotypes. The percentage of cells with one nucleus and one kinetoplast (1N1K), following treatment with 1 or 5 μM myriocin, decreased from 89% (control value) to 27% or 3%, respectively. The percentage of cells with two nuclei (2N2K) varied from 7% (control value) to 19% and 6% for 1 or 5 μM myriocin‐treated parasites, respectively. High percentage of myriocin‐treated parasites exhibited large atypical cells presenting three or more nucleus (32% and 89% for 1 or 5 μM myriocin, respectively). Transmission electron microscopy following treatment with 1 μM myriocin showed the presence of 4N parasites possibly as a result of an incomplete cytokinesis. Addition of 3‐ketodihidrosphingosine to myriocin‐treated promastigotes rescue parasite growth and morphology. Addition of ethanolamine did not rescue the myriocin effect on parasite. Our findings indicate that sphingolipids are essential for the completion of cytokinesis, and may play a major role in cell proliferation in L. (V.) braziliensis, thus, differing from data described for Leishmania major sphingolipid‐free mutant, where addition of ethanolamine rescue wild‐type parasite characteristics.
Inferring shifts in tree species distribution using asymmetric distribution curves: a case study in the Iberian mountains
Authors: Urli Morgane , Delzon Sylvain , Eyermann Audrey , Couallier Vincent , García‐Valdés Raúl , Zavala Miguel Angel , Porté Annabel J.
Published: April 2013

Questions

The objectives of this study were to examine altitudinal shifts in tree species distributions over one decade to quantify the potential for tree migration.

Location

Spain.

Methods

We analysed presence–absence data using two successive surveys of the Spanish Forest Inventory in five Fagaceae tree species (two temperate: Fagus sylvatica and Quercus petraea, one sub‐Mediterranean: Q. faginea and two Mediterranean: Q. suber and Q. ilex) in two mountain ranges (the Pyrenees and the Iberian system). Half of the fitted altitudinal distributions were skewed and required use of an asymmetric model for unbiased estimates of optimum altitude and changes in the probability of presence along the altitudinal gradient. For each species and mountain range, shifts were considered to have occurred when the difference in optimum altitude was significant or when differences in probability of occurrence between the two surveys demonstrated the occurrence of colonization or extirpation events.

Results

Overall, depending on species and mountain range, shifts in optimum altitude ranged between −34 m and +181 m. The altitudinal distribution of the Mediterranean species at the core of their latitudinal distribution range presented no sign of change. For the temperate and sub‐Mediterranean Fagaceae species, the patterns demonstrated the existence of distribution changes over a 10‐yr period. The largest, although not statistically significant, upward shift in optimum altitude was observed for Q. petraea in the Iberian system. More interestingly, its distribution indicated colonization events at higher altitudes. For Q. faginea in the Pyrenees, the shift in optimum altitude was the second largest and statistically significant, and was associated with large extirpation events at the lower altitudes. No evidence of shifts was observed for F. sylvatica.

Conclusion

This work demonstrates that changes in altitudinal distribution could occur over a 10‐yr time period for tree species located at the southern limit of their distribution, such as some temperate and sub‐Mediterranean oaks, whereas no movement was detected for Mediterranean oaks in the core of their distribution area.
The mycorrhizal‐associated nutrient economy: a new framework for predicting carbon–nutrient couplings in temperate forests
Authors: Phillips Richard P. , Brzostek Edward , Midgley Meghan G.
Published: April 2013

Understanding the context dependence of ecosystem responses to global changes requires the development of new conceptual frameworks. Here we propose a framework for considering how tree species and their mycorrhizal associates differentially couple carbon (C) and nutrient cycles in temperate forests. Given that tree species predominantly associate with a single type of mycorrhizal fungi (arbuscular mycorrhizal (AM) fungi or ectomycorrhizal (ECM) fungi), and that the two types of fungi differ in their modes of nutrient acquisition, we hypothesize that the abundance of AM and ECM trees in a plot, stand, or region may provide an integrated index of biogeochemical transformations relevant to C cycling and nutrient retention. First, we describe how forest plots dominated by AM tree species have nutrient economies that differ in their C–nutrient couplings from those in plots dominated by ECM trees. Secondly, we demonstrate how the relative abundance of AM and ECM trees can be used to estimate nutrient dynamics across the landscape. Finally, we describe how our framework can be used to generate testable hypotheses about forest responses to global change factors, and how these dynamics can be used to develop better representations of plant–soil feedbacks and nutrient constraints on productivity in ecosystem and earth system models.
Utility of Intrathoracic Impedance Monitoring in Pediatric and Congenital Heart Disease
Authors: LaPAGE MARTIN J. , von ALVENSLEBEN JOHANNES , DICK MACDONALD , SERWER GERALD , BRADLEY DAVID J.
Published: April 2013

Background

The utility of cardiac device‐based intrathoracic monitoring (OptiVol, Medtronic Inc., Minneapolis, MN, USA) for congestive heart failure (CHF) exacerbation has not been evaluated in pediatric or congenital heart disease patients.

Methods

This was a retrospective study of all patients at a single center with an endocardial OptiVol capable device. OptiVol index values were collected in 2‐week bins from January 2007 to December 2010. The clinical outcomes were CHF exacerbation defined as hospitalization or medication change for CHF and device‐treated ventricular arrhythmia based on remote or in‐office device interrogation. Clinical and OptiVol data were collected by separate investigators blinded to the other parameter. OptiVol data were correlated to the clinical outcomes to determine sensitivity and predictability for multiple threshold values in the entire cohort and pediatric and congenital subgroups.

Results

Forty‐seven patients were included. A total of 1,106 months of OptiVol data were collected. Median age of the cohort was 18 years (range 6–58 years). There were 23 pediatric, median age 13 years (range 6–16), at device implant, and 18 patients, median age 31 years (range 13–58), considered at risk for heart failure at implant. There were three heart failure exacerbations and 17 treated ventricular arrhythmias. The study population‐specific positive predictive value (PPV) of OptiVol was low (sensitivity 33% and PPV ≤4.4%) for both CHF exacerbation and arrhythmias in all analyzed groups.

Conclusions

The sensitivity and positive predictive value of intrathoracic impedance monitoring was low in this population of adult congenital and pediatric patients. Recent improvements to the OptiVol algorithm may decrease these deficiencies.
Pollen and seed transmission of Cucumber green mottle mosaic virus in cucumber
Authors: Liu H. W. , Luo L. X. , Li J. Q. , Liu P. F. , Chen X. Y. , Hao J. J.
Published: April 2013

Cucumber green mottle mosaic virus (CGMMV) is transmitted mechanically in cucurbits, but whether it is transmitted via pollen to healthy plants and onto the subsequent generation of seedlings is unknown. Greenhouse experiments were conducted to investigate the importance of this route of infection. Cucumber seedlings at the 3‐true‐leaf stage were mechanically inoculated with CGMMV. At anthesis, scanning electron microscopy (SEM) and reverse transcription polymerase chain reaction (RT‐PCR) were used to verify the presence of CGMMV. Pollen was collected from the flowers of the infected plants and used to fertilize non‐inoculated plants. The rate of CGMMV transmission to the resulting fruits ranged from 17·1 to 51·2% compared with 33·3–100% for mechanically inoculated plants. Seeds were harvested from the cucumber fruits of both treatments and tested for the presence of CGMMV by RT‐PCR. The CGMMV‐positive seeds harvested from the two treatments were sown separately. The seed transmission rates for the inoculated and non‐inoculated plants were 16·7–100% and 12·8–76·7%, respectively. It was concluded that CGMMV can be transmitted both horizontally via cucumber pollen and vertically, to the next generation, in infected seeds. In addition the rate of seed transmission was much higher than previous reports. These findings have important implications for the disease management of CGMMV.
Large-Scale Circulation in a Rectangular Enclosure With Periodic Boundary Temperature
Authors: Sitarski D. , Lee R. J. , Saylor J. R. , McHugh John P.
Published: April 2013

An experiment in a rectangular basin of water is used to demonstrate that a large-scale circulation will result from a zero-mean thermal forcing. The thermal force is a spatially periodic pattern of heating and cooling at the top surface, achieved with an interdigitated array of hot and cold tubes. The experimental results show a very robust, steady flow with ascending flows at each end of the tank and a single descending jet near the left wall. These results suggest that small-scale forcing in surface-driven flows may result in significant large-scale subsurface motion.
Management of a full-thickness burn to the foot following sciatic nerve palsy secondary to primary total hip replacement
Authors: Jabir Shehab , Frew Quentin , El-Muttardi Naguib , Dziewulski Peter
Published: April 2013

Sciatic nerve palsy following total hip replacement is a rare but serious complication. The neurological sequelae that follow range from pure sensory loss to combined motor and sensory loss involving most of the lower limb. The loss of nociceptive feedback predisposes patients to accidental damage to the lower limb. We present the case of a lady with sciatic nerve palsy who sustained full-thickness burn injuries to her foot via a hot water bottle. The dilemma between debridement and grafting following a recent history of surgical trauma (ie, total hip replacement) versus secondary healing via dressings and regular review is discussed. Although grafting is the standard treatment in such burns, we recommend secondary healing over grafting provided the burns are not extensive. This enables potential recovery of sensation and reduces operative trauma to the limb which may retard resolution of the neuropraxia.
Gross cerebellar paraneoplastic neurological disorder in a patient with an occult breast cancer
Authors: Poudel Chandra K , Achar K N
Published: April 2013

Paraneoplastic neurological disorders are relatively rare conditions posing both diagnostic as well as therapeutic challenges. A previously fit 66-year-old woman presented with subtle cerebellar symptoms which progressed rapidly over the course of days. Chest x-ray and routine blood tests were unremarkable. CT of the head with contrast showed no abnormality. Lumbar puncture showed no evidence of infection or oligoclonal bands. She was transferred to a neurological centre from a remote and rural setting. Subsequent MRI was reported to be normal as well. Tumour markers were negative but the paraneoplastic anti-Yo antibody was positive. A whole body CT scan revealed a spiculated left breast lesion which turned out to be malignant on fine needle aspiration. She underwent left mastectomy, had plasmapharesis and received high-dose intravenous Ig for her paraneoplastic neurological symptoms. She remained neurologically stable and underwent rehabilitation in her local hospital before getting discharged home.
An ulcerated nodule on the nose
Authors: Maybury Catriona M , Craythorne Emma , Martin Blanca
Published: April 2013

A 75-year-old retired nurse, originally from Barbados, presented to her general practitioner (GP) with a scaling ulcerated nodule on the left side of her nose. She was taking medication for type 2 diabetes, hypertension and glaucoma, but was otherwise well with no systemic symptoms. Her GP diagnosed a patch of eczema; however, a trial of topical steroids was not effective and she was referred to dermatology. A skin biopsy confirmed the clinical suspicion that this patient had a nodular basal cell carcinoma (BCC). BCCs account for 75% of all skin cancers; they very rarely metastasise, but can spread to invade local structures. Our patient has type VI skin. Skin cancer is rare in patients with skin type VI; however, in this group, morbidity and mortality are disproportionately high in relation to cancer incidence.
Pitfalls in the use of laparoscopic staplers to perform subtotal cholecystectomy
Authors: Chaudery Muzzafer , Hunjan Tia , Beggs Andrew , Nehra Dhiren
Published: April 2013

Laparoscopic subtotal cholecystectomy (LSC) is considered to be a safe option in severe cholecystitis with non-discernible anatomy within the Calot’s triangle where there is a potential risk of causing injury to the common bile duct. Here we present two cases of gallstone pancreatitis associated with use of an endoscopic stapler during LSC.
Heritable retinoblastoma and accelerated aortic valve disease
Authors: Abeyratne L R , Kingston J E , Onadim Z , Dubrey S W
Published: April 2013

Heritable retinoblastoma is associated with a germline mutation in the tumour suppressor geneRBI. The Rb protein (pRb) arises from theRB1gene, which was the first demonstrated cancer susceptibility gene in humans. 1 Second primary malignancies are recognised complications of retinoblastoma. Furthermore, pRb is implicated in valve remodelling in calcific aortic valve disease. 2 3 We report a family with hereditary retinoblastoma and associated secondary primary malignancies. There are two interesting aspects to this family. The first is the concept of ‘cancer susceptibility genes’; the RBI gene being the first reported in humans. A further feature of note is that two family members also have bicuspid aortic valves. We discuss a potential association between the gene defect responsible for retinoblastoma (with its associated propensity for further malignancies) and accelerated deterioration of the bicuspid aortic valve in the proband carrying this gene defect.
ADVANCE CARE PLANNING IN PAEDIATRICS: THE CARE PROVIDERS' PERSPECTIVE
Authors: Lotz J D , Jox R J , Borasio G D , Führer M
Published: April 2013

Background

Research on advance care planning (ACP) has focused on adults, but ACP is also being practiced in pediatrics (pACP). Health care providers may have to deal with unknown diagnoses and prognoses, patients without decision making capacity and a complex social network. However, research on pACP has widely neglected the professionals' perspective.

Aim

Investigating the experiences and needs of both the facilitators and the recipients of ACP.

Methods

We conducted 17 semi-structured interviews with experts in the care of severely ill children and adolescents. Interviewees were from different professions, settings and institutions. The interviews were evaluated using inductive categorisation and thematic comparative analysis.

Results

Pediatric ACP concerns all care providers. Particularly important issues are: An interdisciplinary care conference, repeated discussions with the parents, a continuous point of contact as well as emergency planning. Advance directives (AD) should be individualised, validated by the treating physician (shared decision making) and be available. Perceived challenges are: Parents' reluctance to think ahead, uncertain prognoses and uncertainty about involving the child. Conflicting interests exist between emergency physicians who are uncomfortable with accepting a child's AD when they are called in, and non-medical providers who are uncomfortable with accepting an AD without the verification by a physician.

Discussion

This is the first European study that investigates the perspective of professionals on pACP. There is a need for pACP, but the perspectives differ between care providers.

Conclusion

This study helps in understanding the needs of the different care providers as well as barriers to pACP.
WHAT ARE THE POLICY LEVERS FOR ADVANCE CARE PLANNING UNDER ACTIVITY: BASED FUNDING
Authors: Kearney J
Published: April 2013

No abstract
IMPLEMENTATION OF THE LIVERPOOL CARE PATHWAY IN THE ACUTE SETTING IMPROVED END OF LIFE CARE
Authors: Fullerton S , Bhagat Sandeep
Published: April 2013

Background

The care of dying patients and families represents an important aspect of health service provision. 1500 patients a year die in Eastern Health beds, only 40% of whom are seen by the hospital based palliative care consultation team (HBPCCT). There is room to improve the quality of care offered to dying patients and families outside a specialist palliative care setting. The Liverpool Care Pathway (LCP) is an integrated, evidence-based, multidisciplinary document representing the ‘Gold Standard’ in quality end-of-life-care provision.

Aim

To implement and evaluate the LCP in acute wards in EH.

Methods

Wards with the highest numbers of deaths were identified. After consultation, the LCP was implemented. Surveys of staff were carried out before and after implementation.

Results

More than 200 patients and families have been cared for on the LCP. Some patients were discharged back to residential care and some to palliative care beds. Only 9% of the 88 surveyed staff who had used the LCP felt that it had not helped improve the care of dying patients and families in EH, and 6% of staff felt that the LCP had not helped staff in caring for dying patients.

Conclusions

Staff feel that the introduction of the LCP improved end of life care at EH. Use of LCP did not prevent transfer from acute beds to specialist palliative care beds.
VICTORIAN END-OF-LIFE CARE PATHWAYS COORDINATING PROGRAM
Authors: Duck C , Boughey M , Quinn K , Hall J
Published: April 2013

Background

The Victorian End-of-Life Care Pathways Coordinating Program was established in response to the recommendations of the Department of Health funded projectEnd of Life Care Pathways in Victoria: Report and Recommendations(2011).

Aims

▸ To provide a centralised and coordinated approach to end-of-life care pathway activity in Victoria, focusing on the gold standard Liverpool Care Pathway (LCP).

▸ To support services in planning, implementing and evaluating all end-of-life care pathways (EoLCPs).

Methods

We investigated end-of-life care (EoLC) activity across Victoria and ways in which emerging activity could be encouraged, supported and sustained.

Results

EoLC activity varies considerably across services and regions, ranging from preliminary exploration to pathways that are firmly embedded in organisational policy, culture and practice. Many of the pathways are registered LCPs or adaptations of the LCP. Others include the Residential Aged Care End of Life Care Pathway.

Resources (current and in development) include:

Victorian LCP and Victorian Model Pathway (endorsement from Marie Curie Palliative Care Institute Liverpool is in progress)

Suites of generic materials applicable to all EoLCPs

National benchmarking through the National Palliative Care Reference Group

Opportunities for clinicians implementing EoLCPs to share experiences, including:

–

Databank of EoL activity in Victoria (publically available)

–

E-News

–

Workshops.

Discussion

End-of-life care is core business and an integral part of accreditation in most health settings.

Conclusion

This programme supports Victorian health services to develop expertise, confidence and consistency in caring for patients and families in the last hours and days of life.
CPR POLICY AND PRACTICE IN AUSTRALIAN RESIDENTIAL AGED CARE FACILITIES (RACFS)
Authors: Sellars M , Silvester W , Fullam R , Sjanta R , Jackson L , Mawren D , Mountjoy R
Published: April 2013

Background

International literature suggests current Cardiopulmonary Resuscitation (CPR) policy and practice is highly variable and often ad-hoc in aged care settings. At present, there is no comparable published research on CPR policy and practice in Australian RACFs.

Aim

To conduct a national survey on staff knowledge and attitudes, and policies and practices regarding CPR in Australian RACFs.

Methods

An online survey was distributed to Australian RACF managers to examine the above.

Results

Of 541 RACF managers, only 19% agreed that CPR should be initiated in a witnessed cardiac arrest yet 83% reported that their facility would provide CPR. However, no CPR was administered in 75% of the facilities in the last 12 months and only once in 15%. Only 63% of facilities had a CPR policy and, of these 44% believe that the policy is inadequate. 98% agreed that it is important to discuss resuscitation status with the resident or family, 96% agreed that a resident CPR plan would help to reduce staff uncertainty and 82% supported the introduction of government CPR guidelines. 75% of respondents believed that survival rate of CPR in RACFs is <10% and 35% (correctly) that survival is <2%.

Discussion

CPR policy and practice is highly variable between RACFs in Australia, is inconsistent with the recognised outcomes and does not always reflect managerial attitudes and beliefs regarding CPR.

Conclusion

The development of a national CPR guideline in Australian RACFs, and provision of education, will assist services in providing consistent and appropriate CPR practices to residents.
THE STATE OF PLAY: CURRENT ADVANCE CARE PLANNING (ACP) PRACTICE IN RESIDENTIAL AGED CARE IN ONE REGULAR AUSTRALIAN AREA HEALTH SERVICE
Authors: Dellit J , Shepherd K , Urban A
Published: April 2013

Background

Respecting Patient Choices (RPC) model of ACP has been established in Australia for 10 years. Peninsula Health has 35 residential aged care facilities (RACF) in its catchment area, yet few residents present to acute care with an ACP.

Aim

To assess the current levels of ACP implementation including the degree of variation from the RPC model of evidence-based practice in the aged care sector.

Methods

30 participating RACFs underwent a comprehensive survey conducted via interview and a random 10% sample health record audit to collect data. Data was collated and graphed across 30 domains of enquiry into ACP practice.

Results

The survey revealed a state of broad variance in how ACP is implemented and practiced. Only 21% indicated they routinely invite the resident to participate in ACP discussions. 20% of audited health records showed any evidence of the resident's involvement in ACP and only 41% had evidence of a substitute decision maker. Only 24% files evidenced recording of medical end of life care wishes (figure 1).

Figure 1

Discussion

Significant gaps were identified in the nature and content of discussions undertaken and in the recorded level of involvement enabled from residents or their representatives.

Conclusion

This study reveals that Aged Care Facilities need significant support to enable a transition to best practice in ACP.
HEART AND SOUL: EFFECTIVE ADVANCE CARE PLANNING PROGRAMME PROVIDES INTERNATIONAL MODEL
Authors: Malley P , Jane Markley M , Rastas L
Published: April 2013

Background

Aging with Dignity introduced the ACP toolFive Wishesin the USA in 1998 with a focus on personal care, family relationships, dignity, and spirituality. The concept is now helping to shape international efforts. Programme expansion includesVoicing My Choices:A Planning Guide for Adolescents and Young Adults,developed with the National Institutes of Health.

Aim

Describe a non-traditional, and replicable, approach to ACP that has proven effective and is positively influencing the development of ACP programmes internationally.

Methods

Compilation of data on issues identified as ‘most important’ at the end-of-life, examination of an ACP resource that responds to these issues, review of data from recent NIH study of perceptions of ACP by adolescents and young adults, and an overview of the influence on international ACP efforts.

Results

More than 19 million Five Wishes documents, available in 27 languages, are in circulation. More than 35 000 partner organisations include hospitals, health systems, and places of worship. Known sites of replication efforts include Australia, China, Taiwan, Norway, and Italy.

Discussion

Having a user-friendly and easy-to-understand tool that encourages people to discuss their personal, emotional, and spiritual needs along with their medical wishes results in increased completion of usable and meaningful advance care plans.

Conclusion

People respond well to ACP when matters of the heart and soul are included in the process, as well as when patients and families are empowered to make their own decisions. Lessons learned in this initiative provide helpful guidance for international efforts to encourage ACP.
THE LEGAL CONSEQUENCES OF PHYSICIANS WHO PRACTICE EUTHANASIA IN ITALY: A REVIEW
Authors: Veshi D
Published: April 2013

Background

There was an increase in medical discoveries that led to the reconsideration of our lives.

Aim

The punishment of the physician who practices euthanasia in Italy.

Method

In Italy, where there no law about euthanasia, judges interpret the Criminal Code through the Constitutional right to health and the ‘European Convention on Human Rights and Biomedicine’ (‘Oviedo Convention’) of 7 April 1940.

Result

Passive euthanasia to an unconscious patient and active euthanasia to a conscious patient are considered as homicides. Moreover, active euthanasia to a non-consensual patient is considered as intentional homicide. But, passive euthanasia to a consensual patient is treated as assisted suicide. However, it should be emphasised that, except in cases of active euthanasia to non-consensual patient, judges enhance the internal legislation by interpreting it through the constitutional right to health and the ‘Oviedo Convention’ of April 4, 1997. Article 32 of the Italian Constitution recognises the ‘Right to health’ which grants patients the right to consent to or even withhold from medical treatment. Furthermore, article 9 of the ‘Oviedo Convention’ gives full legitimacy to the ‘Advance Directives’ by considering them as ‘statements of intent’ and not as ‘declaration of intent’.

Discussion

Interpreting the Italian Criminal Code with fundamental rights recognised in the Italian Constitution and in the ‘European Convention on Human Rights and Biomedicine’ is an effective way to fill the gap in the Italian legal framework.

Conclusion

This study supports the introduction of a clear law that disciplines End-of-life Decision Making in Italy.
DOES ADVANCE CARE PLANNING TRANSLATE INTO IMPROVED CARE IN A RURAL WESTERN AUSTRALIAN HOSPITAL SETTING?
Authors: Auret K , Sinclair C , Averill B , Evans S F
Published: April 2013

Background

Western Australia (WA) passed legislation supporting formal advance care planning (ACP) in 2010, allowing Advance Health Directive (AHD) and Enduring Power of Guardianship (EPG) forms. It is timely to audit the quality of end-of-life care provided in a rural area.

Aim

Report ACP uptake and impact on end-of-life care in a rural hospital setting.

Methods

This retrospective case notes-based audit of 90 admissions resulting in death was conducted in five rural hospitals in the Great Southern region of WA in 2012: the 100-bed regional centre (N=50) and four more remote ∼10-bed facilities (N=10). A palliative care nurse used an in-house designed audit tool to collect data on demographics, process and outcomes measures. A palliative physician double coded five randomly selected sets of notes.

Results

Most patients elderly (M=79.6 years), admitted via ED (58%), on average 13 days before death. Malignancy accounted for 40% of deaths. Some form of ACP was documented in 34%, with 9% having an AHD and 1% having an EPG. 50% died on the Liverpool end-of-life care pathway, those on the pathway scored higher on a composite measure of care quality (χ2(2,90)=31.6, p<0.001). ACP documentation did not predict likelihood of being commenced on the pathway (p>0.05) or scores on the composite measure (p>0.05).

Discussion

As ACP is promoted in our community, our rural hospital network must develop system-wide responses to guarantee ACP influences care.

Conclusion

This audit reports baseline data, which can be repeated following ACP-based interventions.
PALLIATIVE CARE: AN ALTERNATIVE TO EUTHANASIA
Authors: Omipidam B A
Published: April 2013

Background

Today, euthanasia has become the option for terminally ill persons, in order to die with dignity. Palliative care on the other hand seeks to re-assure people with terminal or chronic ailments that they are still worthy of living.

Aim

To show case Palliative care as an efficient alternative to euthanasia for terminally ill persons.

Methods

I examined request for euthanasia and or assisted suicide on the basis of personal interviews carried out on terminally ill patients in the six geo-political zones of Nigeria in the last 24 months; current arguments for and against the concept and views expressed by stake-holders on the concept.

Results

Outcome of the study carried out shows that request for euthanasia and or assisted suicide, are largely due to the fear of being a burden and abandoned by families and relatives.

Discussion

Since it deals with care rather than cure, a combination of doctors, nurses and social work palliative care specialists, Massage therapists, pharmacists, nutritionists, chaplains, amongst others, will re-assure terminally and chronically ill patients that they are not a burden, and that the remaining part of their lives are worth living.

Conclusion

Palliative care should be the focus of all government across the globe so that, terminally and chronically ill persons can be adequately catered for as they approach their end of life. If this is wholly embraced, the request for euthanasia and or assisted suicide will be condemned to the dustbin of history.
IMPACT OF AN ADVANCE CARE PLANNING CLINIC ON PATIENTS OF A REGIONAL CARE COORDINATION SERVICE
Authors: Ironside J , Appleton W , Dugdale P
Published: April 2013

Background

CHHS policy calls for staff to complete advance care plans (including a statement of choices) for patients with chronic disease. Numbers of completed plans are low, partly because some patients do not wish to complete one, and partly due to practical barriers to completion.

Aim

To overcome practical barriers to completion of advance care plans.

Methods

From April 2011 our Care Coordination Service established a fortnightly home- based Advance Care Planning Clinic, in which two staff visit patients at their home. In August 2012 this was supplemented by a fortnightly hospital-based clinic. Patients can be booked into either clinic. In the clinic, an Advance Care Plan is prepared comprising of a Statement of Choices and may include Enduring Power of Attorney, witnessed by an authorised clinic staff member. Partners are also offered the opportunity to complete their advance care plan at this time.

Results

In January–March 2011, prior to the commencement of the clinic, there were 54 patients receiving care coordination of whom 19 (35%) had a completed advance care plan, including a Statement of Choices. In October–December 2012 there were 89 patients who had received care coordination of whom 35 (39%) had a completed advance care plan.

Conclusion

The establishment of Advance Care Planning Clinics has been a practical way to help overcome multifactorial barriers to preparing a Statement of Choices, providing increased access opportunities and support for timely completion. This approach enabled staff to improve completion rates whilst managing a 65% caseload increase.
FROM NFR TO AND: A POSITIVE APPROACH TO END OF LIFE CARE DISCUSSIONS
Authors: Frost J , Campbell K
Published: April 2013

Background

We identified problems with paediatric end-of-life discussions, including language, content and location of documentation and information sharing with paramedics.

Aim

To improve communication between clinical staff and between clinical staff and families about end of life care choices.

Methods

We developed and implemented a novel approach: the Allow a Natural Death Policy and form. We collaborated with the NSW Ambulance Service to develop a system to communicate care choices to paramedics.

Results

We audited the medical records of 43 children who died at CHW January–September, 2011. The results were:

15 (35%) did not have any information about end of life care choices

28 (65%) had end of life care choices documented

Where no End of Life Care choices were documented:

10 (66%) were Coroners cases

8 (53%) had an admission of ≤1 day

8 (53%) died in PICU

6 (40%) died in Emergency Department

1 (7%) died in an inpatient ward

Compliance with completing the AND was high, with the following sections completed 100%:

Patient ID sticker

FACS information

Interpreter information

Goals of care

Response section

Standing order section

Medical Officer details

Paramedic data is yet to be audited.

Discussion

This project was well received by clinicians, paramedics and families. The audit demonstrated successful implementation.

Conclusion

Focussing on the positive choices for care, rather than the withdrawal of care, has made difficult discussions easier and junior staff clear guidelines.
COMMUNICATION AND COORDINATION DURING TRANSITION OF OLDER PERSONS BETWEEN NURSING HOMES AND HOSPITAL STILL IN NEED OF IMPROVEMENT
Authors: Kirsebom M
Published: April 2013

Background

It has previously been reported that transfers to hospital from nursing homes and discharge of patients from hospital are surrounded by communication difficulties. However, studies focusing on both hospital and nursing home registered nurses' experiences of communication and coordination within and between nursing homes and hospitals are uncommon.

Aim

To investigate registered hospital and nursing home nurses' experiences of coordination and communication within and between care settings when older persons are transferred from nursing homes to hospital andvice versa.

Methods

In 2008, three focus group discussions were conducted with registered nurses from hospitals and nursing homes (n=20). Data were analysed using content analysis.

Results

Nursing home registered nurses found it difficult to decide whether or not the older person should be referred to hospital from the nursing home. Hospital registered nurses reported often trying to stop premature discharges or having to carry out the discharge although it had not been fully prepared. Both hospital and nursing home registered nurses suggested increased collaboration to understand each other´s work situation better.

Conclusion

Communication and coordination among hospital and nursing home registered nurses need to be furthered improved. Registered nurses' coordination and planning in the nursing home are extremely important to future elder care. We recommend that the medical care plan be regularly updated and meticulously followed, the aim being to reduce the risk of inappropriate medical treatment and nursing care as well as unnecessary transfer and admission to hospital.
INFORMED CONSENT IN ADVANCE CARE PLANNING IN THE PALLIATIVE CARE SETTING: A DECISION AID LIBRARY FOR END OF LIFE CARE
Authors: Krones T , Loupatatzis B , Steffen-Bürgli B , Otto D , Brunner M , Biller-Andorno N , Eisele G , in der Schmitten J , Mitchell C , Obrist S , Poster D , Rordorf T , Schad K , Spirig R , Volandes A , Zaugg K , Zimmerli L
Published: April 2013

Background

Advance care planning has been discussed from a variety of perspectives. It aims to support a patient-centred process in which patients, together with their loved ones and their caregivers, are enabled to make informed decisions regarding future health care events. Although both accurate information about prospective health care problems and alternatives and help with personal decision making by advance care planning facilitators are crucial, the information given to patients in an ACP process is mostly rough, short, and left to physicians and thus does not fulfil the criteria of an ‘evidence based patient choice' nor even of general standards for “informed consent”

Aim

To construct an evidence based paper and video-based Decision Aid Library for End of Life Care for best patient information supporting the ACP facilitation process

Methods

We screened the literature for evidence-based information and evidence-based decision aids regarding (1) general Goals of Care, (2) Resuscitation (3) Tube Feeding (4) Antibiotics, (5) Ventilation (6) Dialysis Withdrawal and (7) last place of Care and constructed a library of evidence-based decision aids, qualitatively pretested by staff and patients.

Results

Following a methodical screening process, a library of evidence-based papers and videos was constructed, which is currently being qualitatively evaluated by staff and patients as the first step in a grant-funded randomised controlled trial on the effect on ACP for palliative care patients in Switzerland.

Discussion

We will discuss the content and qualitative results of the Decision Aid Library at the Melbourne Conference

Conclusion

From an ethical point of view, best information is crucial for making informed choices. If the decision aid library proves to be useful, evidence-based information and decisions aids should become part of ACP programmes.
ADVANCE CARE PLANNING AND PALLIATIVE CARE IN CHRONIC DISEASE SYMPTOM MANAGEMENT
Authors: Kubokawa N , Nishikawa M , Yokoe Y , Fukuda K , Hattori H , Yong-Jae H , Miura H , Endo H , Nakashima K
Published: April 2013

Background

Opioids are important in symptom management of dyspnoea in chronic diseases, for example, chronic obstructive pulmonary disease (COPD). Existing literature indicates that in the absence of advance care planning (ACP) for end-of-life decisions, we should consider whether concomitant opioid use is appropriate. In Japan, the appropriate timing of ACP for dyspnoea symptom management in chronic diseases is poorly understood.

Aim

The primary aim was to clarify whether ACP should be performed by the palliative care (PC) team concomitantly with morphine administration. The secondary aim was to clarify the opinion of home care support physicians on concomitant use of opioids and ACP.

Methods

We investigated the level of ACP conducted by PC teams among patients who were using opioids. We conducted an inventory survey on the concomitant use of morphine and ACP among 220 doctors, including 147 home care support physicians.

Results

ACP was conducted by PC teams for all patients who were using opioids. PC team members agreed to concomitantly perform ACP and opioid administration for dyspnoea in diseases such as COPD, 137 (62.3%) among 220 doctors, including 147 home care support physicians were agreed to.

Discussion

In comparison with PC team members, the ratio of home care support physicians who advocated ACP concomitantly with morphine for dyspnoea was low.

Conclusion

This study clarified the opinions of home care support physicians and PC team members on the concomitant use of opioids and ACP.
NATIONAL ASSESSMENT OF LIVING WILLS AND DO NOT RESUSCITATE ORDERS
Authors: Mirarchi F L , Costello E , Puller J , Cooney T , Kottkamp N , Markley M J
Published: April 2013

Background

Concern exists that living wills are misinterpreted and may result in compromised patient safety.

Aim

To determine whether adding code status to a living will improves understanding and treatment decisions.

Methods

An Internet survey was conducted of General Surgery and Family, Internal and Emergency Medicine residencies between May and December 2009. The survey posed a fictitious living will with and without additional clarification in the form of code status. An emergent patient care scenario was then presented that included medical history and signs/symptoms. Respondents were asked to assign a code status and choose appropriate intervention. Questions were formatted as dichotomous responses. Correct response rate was based on legal statute. Significance of changes in response due to the addition of either clinical context or code status was assessed by contingency table analysis.

Results

768 faculty and residents at accredited training centres in 34 states responded. At baseline, 22% denoted ‘full code’ as the code status for a typical living will and 36% equated “full care” with a code status DNR. Adding clinical context improved correct responses by 21%. Specifying code status further improved correct interpretation from 28% to 34%. Treatment decisions were either improved 12–17% by adding code status (‘Full Code,’ ‘Hospice Care’) or worsened 22% (‘DNR’).

Discussion

Further research is required to ensure safety, understanding, and appropriate care to patients.

Conclusion

Misunderstanding of advance directives is a nationwide problem. Addition of code status may help to resolve the problem.
CAN ADVANCE CARE PLANNING BECOME PART OF USUAL COMMUNITY PALLIATIVE CARE? USING A MULTI-SITE ACTION RESEARCH APPROACH TO IDENTIFY CONDITIONS FOR SUCCESS
Authors: Blackford J , Street A F
Published: April 2013

Background

Internationally the recommended system-wide approach to ACP has been successful in health care settings and communities with a homogenous population. A multi-faceted ACP was developed, trialled and evaluated in diverse Australian community palliative care services.

Aim

To identify the conditions for successful integration of ACP into Australian community palliative care services.

Methods

Using a multi-site action research approach data collected between 2008 and 2010 included medical record audit; document analysis; key individual health professional interviews (22); six clinician focus group interviews (38).

Results

Nine Australian community palliative care services participated; two sites later withdrew. The services differed in geographic location, staff profile, client and family demographics and services offered. The conditions for success were determined by an interconnected construction of supportive relationships between government (including National, State and local government authorities), health care organisations who manage the community service, and the microcosm of community palliative care practice. The specific conditions identified related to policy, financial resources, size of the service, and staffing profile, documentation processes, and geographic context.

Discussion

Nationally a consistent ACP policy environment alongside a supportive economic health care climate is required if ACP is to be routinised into health care services.

Conclusion

Individual clinicians or small community services may demonstrate short-term success in ACP but long-term it is contingent on conditions of stable health care infrastructure, supportive national policy adequate funding and stable workforce.
MEASURING AND IMPROVING COMMUNICATION ABOUT PALLIATIVE AND END-OF-LIFE CARE
Authors: Randall Curtis J
Published: April 2013

Description and Learning Objectives

There are major challenges confronting clinicians, researchers, and policy-makers regarding improving communication about palliative and end-of-life care with patients and families. There is also mounting evidence that the intensity of care at the end-of-life is increasing, despite the fact that most patients report they would prefer not to die in high-intensity medical settings. Recent research suggests that improved communication about palliative and end-of-life care is associated with reduced intensity of care at the end of life, improved quality of life for patients and families, improved quality of dying for patients, and reduced psychological symptoms for families. Yet, the most effective and cost-effective ways to achieve improved communication are not clear. One important step to improving communication is being able to reliably measure the quality of this communication. We will review recent studies identifying some successful methods to measure the quality of communication about palliative and end-of-life care and some interventions that have been documented to successfully improve these communication skills. We will also review preliminary results of a recently completed randomised trial of a communication skills building workshop for physicians and nurse practitioners using patient-level outcomes data to assess outcomes. Finally, we will discuss methods to help clinicians develop a personalised approach for conducting communication about palliative and end-of-life care in their own clinical practice.
END-OF-LIFE MEDICAL TREATMENT PREFERENCE DISCUSSIONS AND SURROGATE DECISION-MAKER APPOINTMENTS: EVIDENCE FROM ITALY, SPAIN, BELGIUM AND THE NETHERLANDS
Authors: Evans N , Pasman H R W , Vega Alonso T , Van den Block L , Miccinesi G , Van Casteren V , Donker G , Bertolissi S , Zurriaga O , Deliens L , Onwuteaka-Philipsen B ,   on behalf of EUROIMPACT
Published: April 2013

Background

Making treatment decisions in anticipation of possible future incapacity is an important part of patient participation in end-of-life decision-making.

Aim

To compare the prevalence of GP-patient end-of-life treatment discussions and patient surrogate appointments in Italy, Spain, Belgium and the Netherlands and examine associated factors.

Methods

A cross-sectional, retrospective survey was conducted with representative GP networks in four countries. GPs recorded the health and care characteristics in the last 3 months of life of patients who died non-suddenly. Prevalences were estimated and between country differences, and country-specific associated patient and care factors, were examined using logistic regressions.

Results

4396 non-sudden deaths were included. GP-patient discussion of treatment preferences occurred for 10%, 7%, 25% and 47% of Italian, Spanish, Belgian and of Dutch patients respectively. Furthermore, 6%, 5%, 16% and 29% of Italian, Spanish, Belgian and Dutch patients had a surrogate decision-maker. Despite some country-specific differences, previous GP-patient diagnosis discussions, more frequent GP contact, GP provision of palliative care, the importance of palliative care as a treatment aim and place of death were positively associated with preference discussions or surrogate appointments. A diagnosis of dementia was negatively associated with preference discussions and surrogate appointments. The single most important factor was prior GP-patient diagnosis discussion.

Discussion

The study revealed a higher prevalence of treatment preference discussions and surrogate appointments in the two northern European countries.

Conclusion

Delaying diagnosis discussions impedes anticipatory planning, whereas early discussions for all patients, particularly those with cognitive decline, and palliative care provision support patients' participation in decision-making.