bluuebunny/crossref_metadata_2025 huggingface dataset:
Analysis of microembolic particles originating in extracorporeal circuits
Authors: Uretzky Gideon , Landsburg Giora , Cohn Daniel , Wax Yochanan , Borman Joseph B
Published: November 2007

Silicone tubing is utilised increasingly in extracorporeal circulation (ECC), particularly for prolonged bypass in cases of left ventricular failure following open heart surgery. We compared the spectrum of particle formation in the EC circuit, due to roller pump damage, resulting from wear of silicone tubing with that of polyvinyl chloride (PVC) tubing. The EC circuit was primed with plasmalyte solution for pump runs of up to 24 hours. Samples of the perfusate were taken from either system at prefixed times. Number and size of the particles were determined by means of a Coulter counter, while their chemical composition was analysed by X-ray dispersion (EDXA). The tubing was examined by scanning electron microscopy. When using PVC tubing, the amount of particles of all sizes rose above acceptable standards shortly after activating the roller pump. Following this early upsurge, the number of particles continued to increase for the remainder of the pump run, albeit at a more moderate rate. The silicone tubing continuously generated a marked quantity of particular matter at a steadily increasing rate. Electron microscopic examination of the silicone tubing revealed multiple particles emanating from the inner surface of the tube. The results suggest that filtration of the initial priming fluid may be advisable before connecting the patient to an EC circuit using PVC tubing. The multitude of particles liberated by the silicone tubing implies that its usage in ECC should be curtailed. Utilisation of noncrushing head pumps is recommended in ECC.
Carbon dioxide flushing prior to priming the bypass circuit. An experimental derivation of the optimal flow rate and duration of the flushing process
Authors: Hargrove Martin , McCarthy Annette P , Fitzpatrick Gerard J
Published: November 2007

The practice of flushing the cardiopulmonary bypass circuit and oxygenator with carbon dioxide (CO 2) has been shown to reduce priming time. However, the optimal flow rate of CO2 and the time for which it must be flushed through the circuit in order to remove the air, have not been determined. In this experiment, CO2 was passed through the arterial filter and arteriovenous (AV) loop at various flow rates and serial gas samples were taken from the circuit. The residual concentration of air in each sample was measured using a gas chromatograph. It was shown that as the flow rate of CO2 was increased, the time taken to remove the residual air decreased. Flushing the circuit with CO2 at a flow rate of 6 l/min for four minutes ensures a residual air concentration of less than 0.01%.
Pseudoperitonitis following cardiac surgery
Authors: Gould K. , Freeman R.
Published: November 2007

Peritonitis is a well-recognized complication of peritoneal dialysis, a procedure often used to manage patients in acute renal failure following cardiac surgery. Postoperative ileus, with associated overgrowth of bowel flora, may account for the apparently high rate of positive effluent cultures due to Gram-negative bacilli in such cases. In the absence of other clinical signs an erroneous diagnosis of peritonitis may be made and result in unnecessary antimicrobial chemotherapy.
A successful modification of ultrafiltration for cardiopulmonary bypass in children
Authors: Naik SK , Knight A. , Elliott MJ
Published: November 2007

Total body water (TBW) is increased after cardiopulmonary bypass (CPB) resulting in tissue oedema and organ dysfunction. Ultrafiltration has been used to reduce this accumulation of water, although conventional ultrafiltration seemed ineffective in reducing the rise in TBW after CPB in our clinical experience. We describe a modified technique in which ultrafiltration is performed in the first 10 minutes after the patient is weaned from bypass, returning nearly all the blood in the circuit to the patient and elevating the haematocrit (Hct) to any predetermined level. We carried out a pilot study on 21 children aged 4-144 months undergoing open-heart surgery and CPB for congenital heart defects. They were divided into three comparable groups: (1) controls (n = 6); (2) conventional ultrafiltration (n = 7); and (3) modified ultrafiltration (n = 8). TBW (bio-impedance), Hct, osmolality, mean corpuscular volume and mean corpuscular haemoglobin concentration were recorded at frequent intervals. Control patients showed elevation of TBW by 18.2% median (range 14.5-20.3), conventional ultrafiltration by 12.4% (7.9-15.0), modified ultrafiltration by 5.7% (4.5-7.1) (p < 0.0001 compared to controls, p < 0.005 compared to conventional ultrafiltration, Mann-Whitney U test). Hct could be elevated to preoperative levels only by the modified method. Mean corpuscular volume, and mean corpuscular haemoglobin concentration osmolality were unaltered. Ultrafiltration by the modified method was more effective than conventional ultrafiltration in reducing the rise in TBW and elevating Hct after CPB.
Comparison study of the Hepcon System Four and the Hemostasis Management System
Authors: Harloff Michael , Taraskiewicz John , Fotouhi Carol
Published: November 2007

Milwaukee Heart Surgery Associates, in affiliation with St Mary's Medical Center, were asked to be clinical investigators for a comparison study of the current Hepcon System Four (HSF) and the next generation Hemostasis Management System (HMS) manufactured by HemoTec, Inc.

The HSF has been in place at St Mary's Medical Center for the past three years in a programme that performs approximately 900-1100 cardiac procedures a year. Heparin assays and high range activated clotting times (HR-ACTs) are performed routinely on all patients placed on cardiopulmonary bypass (CPB).

This study will evaluate the results based upon the two systems run in tandom on a series of patients undergoing cardiac surgery with no exclusions, i.e. valve repair or replacement and myocardial revascularization. The study sets out to determine whether or not the new generation HMS has any distinct advantages over the HSF and whether it is or is not suitable for this clinical setting.
Comparison of the standard roller pump and a pulsatile centrifugal pump for extracorporeal circulation during routine coronary artery bypass grafting
Authors: Driessen JJ , Fransen G. , Rondelez L. , Schelstraete E. , Gevaert L.
Published: November 2007

The present prospective study compared the standard nonpulsatile twin roller pump with the Sarns centrifugal pump, in the pulsatile mode, as arterial pumps for extracorporeal circulation during coronary artery bypass grafting (CABG). The study was conducted in two consecutive groups of 25 patients receiving a standard anaesthetic and surgical protocol. The investigated parameters included haemodynamic profiles, oxygen exchange, blood gas and acid-base homeostasis, haematology, coagulation and complement consumption. With comparable settings for pump flow, gas flow and delivered oxygen concentrations, there was no difference between the groups in the main haemodynamic parameters during cardiopulmonary bypass (CPB). However, a tenfold lower dose of sodium nitroprusside was required to keep systemic vascular resistance within physiologic limits during CPB in the centrifugal group (C group) compared with the roller group (R group). During rewarming oxygen extraction was higher in the C group than in the R group. During the first eight hours after CPB no differences in haemodynamics, oxygenation parameters and pulmonary shunt between the groups were observed. During, as well as after, CPB there was no significant difference in blood gas and acid-base homeostasis between either group. Average postoperative blood loss via chest tubes, total transfusions of blood products, haemoglobin and coagulation did not differ between the two groups. However, the white blood cell count, corrected for changes in haematocrit, decreased during the early phase of CPB in the R group, but not in the C group. It was concluded that, since no major differences in clinical outcome were observed in the present study, the Sarns centrifugal pump is a safe alternative to the roller pump during routine cardiac surgery and should be further studied in a larger number of patients.
Platelet consumption during neonatal extracorporeal life support (ECLS)
Authors: Plötz Franz B , Wildevuur Walter R , Wildevuur Charles RH , Delius Ralph E , Bartlett Robert H
Published: November 2007

This paper reports the results of a retrospective study of blood use and blood loss in 40 neonates during extracorporeal life support (ECLS). Immediately after onset of bypass 39±2.5ml platelets, 59.4±6.5ml packed red blood cells (PRBC) and 15.0±5.4ml fresh frozen plasma (FFP) per patient were needed. The average daily amount given per patient was 49.0±3.0ml of platelets and 48.0±3.4ml and 9.6±3.9ml of PRBC and FFP respectively. The 10 patients who had bleeding complications received 50.0±6.3ml/day of platelets compared to 49.0±3.4ml in the other patients. The majority of blood loss during the entire period of ECLS was from samples, averaging 43.0 ± 1.5ml/day. Neck wound drainage, 6.7±2.5ml/day per patient, lasted for the entire period.
Heparin surface treatment does not impair gas and heat transfer of an extracorporeal circuit
Authors: Boonstra PW , Akkerman C. , Tigchelaar I. , Gu YJ , Huyzen R. , Eijgelaar A.
Published: November 2007

Surface treatment of a cardiopulmonary bypass circuit with heparin improves its haemocompatibility. However, potential side effects of this layer of heparin are impairment of O2 transfer and CO2 transfer in the oxygenator and heat transfer in the heat exchanger.

Therefore we studied these side effects during extracorporeal circulation with moderate hypothermia in 30 patients who underwent elective coronary artery bypass grafting surgery. All patients were heparinized systemically. In 15 patients (Duraflo II-group) we used an extracorporeal circuit (including a Bentley Bos-CM50 membrane oxygenator) which was treated with heparin. The results of this group were compared with those obtained from another group of 15 patients (control-group), who were operated upon with an identical extracorporeal circuit but without heparin surface treatment.

We found no significant differences between the two groups in O2 transfer, CO2 transfer or heat transfer during normothermia or hypothermia.

We concluded that neither O2 transfer and CO2 transfer of the oxygenator nor heat transfer of the heat exchanger were impaired by Duraflo II heparin surface treatment during clinical cardiopulmonary bypass with moderate hypothermia.
The effects of pulsatile flow on the leukocyte depleti ng qualities of the Pall LG6 leukocyte depleting arterial line filter: a laboratory investigation
Authors: Gourlay T. , Fleming J. , Taylor KM
Published: November 2007

The Pall LG6 arterial line filter has, in a previous publication, demonstrated its inherent leukocyte depleting qualities. This initial study was however carried out under continuous flow conditions. The present study was designed to assess the effectiveness of the LG6 filter in performing this leukocyte removal function under the more dynamic conditions of pulsatile flow. In addition to leukocyte depletion, the general blood handling and degree of energy absorbtion associated with the LG6 and Stat-Prime filters was also assessed. The results demonstrated that the LG6 filter was unaffected by the flow regime employed in terms of leukocyte removal and platelet depletion. There was a higher level of measured haemolysis associated with the use of pulsatile rather than nonpulsatile flow, however, this was the case with both filter types and was not found to be the case when generated values were computed. The LG6 filter absorbed more energy than the Stat-Prime filter as reflected by energy equivalent pressure (EEP) measurement, but this difference did not reach a level which was considered to be clinically significant.
Ischaemia/reperfusion in the posthypoxaemic re-oxygenated myocardium: haemodynamic study in the isolated perfused rat heart
Authors: Corno Antonio , Motterlini Roberto , Brenna Laura , Santoro Francesco , Samaja Michele
Published: November 2007

In order to study the haemodynamics of reperfusion injury in the post hypoxaemic heart, we exposed buffer-perfused isolated rat hearts to either: (1) 20-minute low-flow ischaemia or (2) 20-minute hypoxaemia followed by re-oxygenation and further ischaemia/reperfusion. In group 2, the myocardial contractility recovered less (p <0.002) than in group 1. This model therefore represents with sufficient reliability the clinical situation where hypoxaemic hearts are re-oxgenated before ischaemia/reperfusion and receive more severe injury than hearts exposed to ischaemia/reperfusion only. To locate the major site of the injury, further data were obtained (1) with infusion of superoxide dismutase and catalase during hypoxaemia and in the first five minutes of re-oxygenation, and (2) by eliminating re-oxygenation. It appears that the major determinant of reperfusion injury in hypoxaemic hearts is to be looked for in the events underlying hypoxaemia or re-oxygenation, and is mediated by oxygen- derived free radicals.
Cold or warm start of cardiopulmonary bypass- influence on microcirculatory blood flow
Authors: Boldt J. , Knothe Ch. , Hammermann H. , Stertmann W.A. , Hempelmann G.
Published: November 2007

In a randomized study of 30 patients undergoing elective aortocoronary bypass grafting, either cold start of cardiopulmonary bypass (CPB) (prime: room temperature [approximately 20°C], n = 15) or normothermic start of CPB (prime: warmed up to the patients' blood temperature, n = 15) were performed. After warm start, CPB was continued using almost normothermia (lowest nasopharyngeal temperature: 35.8 ± 0.4°C), after cold start hypothermia was used (lowest nasopharyngeal temperature: 28.8 ± 0.2°C). Changes in microcirculatory perfusion were assessed by measuring skin capillary blood flow at the patient's forearm and forehead using laser Doppler technique. Laser Doppler flow (LDF) was continuously monitored before onset of CPB (=baseline values), 30 seconds, one, five, 10, 15 and 20 minutes after start of CPB.

Mean arterial blood pressure (MAP) and systemic vascular resistance (SVR) were reduced by CPB in both groups, with the more pronounced reduction in the normothermic patients. Haemoglobin and plasma viscosity were without differences between the groups. The lowest blood temperature in the hypothermic patients was 21.0 ± 0.3°C, and the lowest rectal temperature in these patients was 29.0 ± 0.3°C (20 minutes after start of CPB). Forehead- and forearm-LDF increased significantly in both groups by start of CPB. In the hypothermic patients, this increase was significantly lower, and LDFs were already reduced below baseline values five to 10 minutes after onset of CPB (LDF-forehead -18%, LDF-forearm -72%). In the normothermic patients, LDFs remained elevated during the first 20 minutes after the beginning of bypass (LDF- forehead +38%; LDF-forearm +35%) and were significantly higher than baseline ' even after CPB (hypothermia: LDF-forehead -34%; LDF-forearm -31%). Except for the blood temperature, none of the measured haemodynamic

and laboratory values could be related significantly to changes of LDFs (analyses of covariance).

It is concluded that skin microcirculatory perfusion as assessed by laser Doppler flowmetry was less altered when using warm start and maintenance of perfusion than after cold start and hypothermic CPB. Whether this improvement in microperfusion after warm start of CPB takes place also in other (more vital) organs has to be elucidated in further studies.
Clinical significance of heparin in the residual pump oxygenator blood, reinfused postoperatively after cardiopulmonary bypass
Authors: Singh G. , Gayler M. , Wyatt R. , Spyt TJ
Published: November 2007

Postcardiopulmonary bypass (CPB) heparin levels and thrombin time were measured in 20 patients following routine open cardiac operations.

There was a statistically significant increase in heparin concentration and thrombin time ratio on completion of transfusion of the residual pump oxygenator blood. An hour after the end of the transfusion there was no statistically significant difference in the heparin concentration and thrombin time ratio compared to values before and immediately after transfusion.

We also observed a significant decrease in the chest drainage over a period of four hours which was unrelated to plasma heparin level. Measurements of thrombin time in the post bypass period closely follow plasma heparin levels. If postoperative bleeding arose it was due to inadequate surgical haemostasis or coagulation defect other than residual heparinization. Thus this confirms further that heparin is not the sole aetiological factor in postoperative bleeding post-CPB.
The role of N-acetylcystein administration on the oxidative response of neutrophils during cardiopulmonary bypass
Authors: Andersen LW , Thiis J. , Kharazmi A. , Rygg I.
Published: November 2007

The role of N-acetylcystein (NAC) administration on the oxidative response of neutrophils during cardiopulmonary bypass (CPB) was evaluated in a double-blind study. Twenty-four adult patients undergoing coronary artery bypass were included in the study. Twelve patients received NAC as a bolus of 100 mg/kg followed by a continuous infusion of 20 mg/kg/h in the bypass circuit from the beginning to the end of bypass. A further 12 patients received placebo. Citrated blood samples for measurement of oxidative burst response of neutrophils were obtained at different time points during bypass. The oxidative burst response of neutrophils in the patients receiving NAC was significantly low at all times during bypass. Based on these findings NAC appears to act as an oxygen free radical scavenger during open-heart surgery.
The influence of vascular pressure and different primes on the fluid balance of, and oxygen supply to, the patient during CABG
Authors: Sirs JA , Glenville B. , Stanbridge RL , Sogliani F. , Stavrides G. , Griffiths AW Harrop , Jones J. , Macleod K. , Akins A. , Powell J. , Davis S.
Published: November 2007

Detrimental changes of blood and erythrocyte rheology, and fluid exchange between the vascular and interstitial spaces, which influence the rate that oxygen is supplied to the patient, occur during cardiac bypass surgery. Venous flow is subject to a pulsatile and uncertain variation, because the vena cava is more than 30 mmHg below atmospheric pressure. This occurs because the patient is about 1 m above the air-blood surface of the bypass reservoir. Before any reliable study of fluid exchange can be undertaken this effect must be controlled. It was then established that optimum oxygen exchange occurs when equilibration of the plasma oncotic pressure and the capillary hydrostatic pressure is achieved without alteration of the interstitial fluid volume. At the lower arterial blood pressures used during bypass, it is necessary to reduce the plasma oncotic pressure by using an appropriate volume of crystalloid prime.
Continuous retrograde cerebral perfusion supplies substrates for brain metabolism during hypothermic circulatory arrest
Authors: Buket Suat , Alayunt Alp , Discigil Berent , Apaydin Anil , Yuksel Munevver , Durmaz Ege Isa
Published: November 2007

Ten patients underwent replacement of ascending aorta and/or aortic arch with aneurysm or dissection, using hypothermic circulatory arrest (HCA) with retrograde cerebral perfusion (RCP). RCP was administered through the superior vena cava cannula continuously during HCA (15°C to 20°C). Mean HCA time was 32 minutes (range, 18-45 minutes). To assess the metabolic changes during RCP, blood samples were taken from carotid arteries and the superior vena cava cannula simultaneously, five minutes after the onset and five minutes prior to termination of continuous retrograde cerebral perfusion (CRCP) for analysis of blood gas and glucose level. One patient died intraoperatively due to left ventricular failure. Nine patients survived their operations and all except one with stroke due to partial intimal flap obstruction of innominate artery awoke neurologically intact within four to six hours. One patient died on the postoperative fifth day due to septic shock following resection of ischaemic bowel due to dissection involving the mesenteric artery. Oxygen saturation, pH and glucose level were all found to be lower in blood back-bleeding from the carotid arteries than in blood perfused through the superior vena cava cannula at all sampling times during HCA and CRCP (p < 0.05). Although oxygen and glucose extraction is not only from brain tissue, these data demonstrate the efficacy of CRCP in supplying substrates for brain protection. CRCP is a reliable method as an adjunct to HCA for brain protection.
The acute phase response to cardiopulmonary bypass in children
Authors: Mitchell IM , Brady L. , Black J. , Jamieson Mpg , Pollock Jcs , Logan RW
Published: November 2007

The endocrine phase of the stress response to cardiopulmonary bypass in children is known to be subtly different from that seen in adults. The aim of this investigation was to determine whether there are similar differences in the acute phase response. Thirteen children were studied (mean age 2.65 years). Each child had congenital heart disease and underwent corrective cardiac surgery. Blood samples taken two days prior to operation and at 6, 9, 12, 24, 48 and 120 hours after were analysed for C-reactive protein, albumin, caeruloplasmin, zinc and copper concentrations. Metal:carrier protein molar ratios were also calculated.

Results demonstrate changes which, although similar to those seen in adults, differed both quantitatively and qualitatively. This is explained by the concept of immaturity leading to a generally poor capacity for protein synthesis and a relative inability to respond to altered circumstances.
Potential problem when using the new lower-prime hollow-fibre membrane oxygenators with uncoated stainless steel heat exchangers
Authors: Palanzo David A , Manley Norman J , Montesano Ralph M , Quinn Michael , Elmore Barbara-Anne , Gustafson Patricia A , Zarro Debra L , Meloy Patrick C
Published: November 2007

A prospective study was conducted to evaluate the trans-oxygenator pressure gradient across three different hollow-fibre membrane oxygenators during routine cardiopulmonary bypass (CPB). Sixty consecutive open-heart surgery patients were randomly divided into three groups each receiving a different model of membrane oxygenator. Inlet and outlet pressures, as well as patients' pressures, blood flow, revolutions per minute and tympanic membrane temperature were recorded every 15 min during CPB. Within the study groups, there were subsets of patients who exhibited high trans- oxygenator pressures. Although most of these episodes were transient and resolved over a period of time, there were several cases during which the high trans-membrane pressures persisted, resulting in decreasing oxygenator performance. In one such case, oxygenator change-out was required. After extensive analysis and review, the only similarities or correlation that could be made were with the marriage of the newer lower- prime hollow-fibre membrane oxygenators (with corresponding narrow blood path) and the integral uncoated stainless steel heat exchangers. Further study needs to be performed to pinpoint the mechanism and pathophysiology that are involved in this phenomenon.
Syringe drivers in palliative care: a review
Authors: Oliver DJ
Published: November 2007

The continuous subcutaneous administration of drugs is both convenient and practical. Portable, battery-driven syringe drivers enable predictable amounts of analgesics or antiemetics to be delivered parenterally. The methods and drugs used are reviewed, including drug compatibility and potential problems.
The palliative management of malignant pericardial effusion: a case history
Authors: Dunlop Robert J , Davies Robert J
Published: November 2007

A case history illustrating the way in which malignant pericarditis may mimic advanced malignancy and yet be effectively palliated by specialist interventions is presented. The distinguishing clinical features and the need to seek these diligently are highlighted. A brief review of treatment options is included.
The use of opioid analgesics in the last 24 hours of life of patients with advanced cancer
Authors: Lombard DJ , Oliver DJ
Published: November 2007

The use of opioids, both parenteral and oral, in the last 24 hours of life is presented. Of patients with advanced cancer in a hospice, 66% were able to take oral medication in the last day of life and the need for parenteral medication over long periods is small.
Nonmetastatic manifestations of malignancy: hormonal
Authors: Stein Robert C
Published: November 2007

Symptomatic endocrine abnormalities in malignant disease may arise either from deficiency states or from the inappropriate or ectopic secretion of a hormone. The clinical picture of the commoner syndromes is described in this review, together with the surgical or medical palliation which may assist the patient.
A comparison of hospice and home care patients: patterns of referral, patient characteristics and predictors of place of death
Authors: Dunphy Kilian P. , Amesbury Brendan D.W.
Published: November 2007

A retrospective review was performed of all patients cared for by St Joseph's Hospice, Hackney, London, in either the hospice or the home care setting, during the first six months of 1988. Patients referred to the two services were compared and home care patients further analysed to establish predictors of those who could be successfully managed at home. The results showed that those patients referred to the home care service were younger and more likely to be married. Hospitals were more likely to refer to the hospice, while community services referred more often to home care. Home care patients were likely to have a longer prognosis but were more likely to be recorded as experiencing anxiety/depression at presentation. Patients referred for home care were significantly more likely to die at home than in hospital. Those who did die at home were more likely to be married, less likely to be described as their own main carer and less likely to have been recorded as suffering moderate/severe pain at presentation.
The use of epidural morphine at a palliative care centre
Authors: Ottesen Stig , Minton Michael , Twycross Robert G.
Published: November 2007

Four cases are reported where pain control was achieved with epidural morphine after failure with oral morphine. The indications were unacceptable adverse effects with oral morphine or morphine resistant pain. The rationale for the use of the epidural route is discussed. We believe that there is a place for epidural analgesia in selected patients at palliative care centres. Nurses need training in epidural drug administration to enable them to be involved in this form of treatment.
Nursing stress and stress reduction in palliative care
Authors: Harris Ross D , Bond Malcolm J , Turnbull Rosemary
Published: November 2007

Nurses in palliative care face particular challenges related to their work with terminally ill patients and their families. Several studies have suggested that workplace stress is a health risk to staff in this specific nursing situation. This study reports the results of a short educational programme for nurses in palliative care designed to identify and modify levels of perceived stress. The findings support the view that hospice nursing does create specific problems for staff which can be identified. Furthermore, if a training programme for nurses is introduced to address these problems the resultant stress can be reduced.
Evaluation of the palatability of Oramorph- a proprietary preparation of oral morphine sulphate
Authors: Griffith S. , Dewberry HM , Titcombe JM , McNamara Pjg , Harcourt Jmv , Twycross RG
Published: November 2007

The palatability of Oramorph, a proprietary preparation of morphine sulphate (Boehringer Ingelheim), was compared with an aqueous solution produced by the hospital pharmacy. Thirty patients receiving regular oral morphine sulphate for either pain relief or dyspnoea entered a double-blind, randomized, comparator- controlled crossover trial. Taste preference and other factors were evaluated using Visual Analogue Scales (VAS). Eighteen patients preferred the taste of Oramorph and 12 the hospital formulation. The mean preference in Oramorph's favour, however, did not reach statistical significance (p = 0.3). When each patient's scores were examined separately, 17 expressed a preference, the magnitude of which was of clinical importance, (score of > 30mm on the VAS). Eleven of these were for Oramorph and six for aqueous morphine. When the pleasantness of taste for each solution was assessed independently, a similar result was obtained, with 20 patients rating Oramorph as having a more pleasant taste than aqueous morphine. Ten patients found the reverse to be true. The majority, 22 patients, found Oramorph to be less bitter than aqueous morphine. There was no difference between the smell and texture of the two solutions.
The development of palliative care services and the place of death of cancer patients
Authors: Johnson H. , Oliver D.
Published: November 2007

Within a health district, the introduction of a symptom control team (SCT) as a home care service was followed by a transient increase in home deaths and a transient decrease in hospital deaths. The introduction of a hospice was followed by a decrease in hospital deaths and an initial downward trend in home deaths which reversed after the third year. The SCT and hospice are involved in 43-47% of all cancer deaths, and over 50% of deaths involving the SCT occur at home. A future role for the increased involvement of services in the hospital rather than at home is identified, with current figures showing a 70% involvement in home deaths but only a 43% involvement in institution deaths.
Disseminated bullous impetigo in an adult patient with advanced cancer
Authors: Cox Neil H , Regnard Claud
Published: November 2007

We describe details of an adult patient with metastatic breast carcinoma who developed blisters due to disseminated bullous impetigo. We discuss the differential diagnosis and the importance of appropriate treatment.
Use of midazolam in palliative care
Authors: McNamara Paul , Minton Michael , Twycross Robert G
Published: November 2007

Objective: To review the use of midazolam (a water-soluble benzodiazepine) in terminally ill patients.

Design: A retrospective study of 104 patients.

Results: Midazolam was used intravenously as sedation before minor procedures in three patients. Because of prolonged sedation in two patients, the following regimen is now used: 1 mg intravenously stat, followed by 1 mg/min, or 0.5mg/min in those over 65. In other situations, midazolam was used subcutaneously (SC), usually via a syringe driver. For muscle relaxation the median dose was 30mg SC/24h (27 patients; range 10-60mg). When treating terminal agitated delirium the median dose was 35mg SC/24h (61 patients; range 10-240mg). For multifocal myoclonus or as prophylaxis against fits the median dose was 30mg SC/24h (12 patients; range 15-80mg).
Palliative care in Hong Kong
Authors: Tsao SY , Leung A.
Published: November 2007

Palliative care is still a new concept in Hong Kong. Limited resources mean it will be several years before the first hospice is established and initially, palliative care services need to be established within hospitals. Although death and dying are still taboo subjects amongst the Chinese, the commitment to palliative care is growing.
Training for palliative medicine. II: How should palliative physicians be trained? An observational study of the clinical skills needed by senior palliative physicians
Authors: Daley Andrew G , Lennard Rosemary F
Published: November 2007

Palliative medicine is a new specialty in the UK. Formal training schemes are slowly evolving but some debate exists as to what precise experience such schemes provide. Five senior palliative physicians were observed in their clinical work in order to obtain information about the nature of the clinical problems that they were routinely managing and hence about where emphases in training should lie.

The doctors were observed dealing with 262 problems in 112 patients. The results demonstrate the wide range of problems in symptom control that palliative physicians manage, highlight the significant incidence of nonmalignant problems which require a broad knowledge of medicine, and show the large number of psychosocial problems for which communication skills, knowledge of psychiatry and awareness of community services are needed. The authors suggest seven areas which higher training must cover. They note that no other higher specialist training will provide the skills needed, and that no one background or qualification emerges as the 'best' prior to higher specialist training.
Palliative medicine - just another specialty?
Authors: Kearney M.
Published: November 2007

It is argued that palliative medicine may be in danger of developing into a specialty of 'symptomatology'. Such a specialty would be confined by the limits of the medical model and its particular view of illness. The potential for physicians working in palliative medicine to go beyond symptom control to creating conditions where healing at a deep personal level may occur for the individual patient, and the practical and personal implications of this, are discussed.
Attitudes of general practitioners in Bizkaia, Spain, towards the terminally ill patient
Authors: de Maturana Alberto Lopez , Morago Vicente , Emeterio Encarnación San , Gorostiza Javier , Arrate Adela Olaskoaga
Published: November 2007

This paper reports the results of a survey of general practitioners in Biscay which investigated the types of narcotics used in the treatment of chronic malignant pain, the degree of their use and the difficulties encountered both in the use of narcotics and the general care of the terminally ill patient. We found that (1) 50% of the doctors surveyed used narcotics in the treatment of at least 60% of their patients with terminal disease; (2) morphine is the most frequently used narcotic, usually being given orally, and (3) those who completed the questionnaire showed themselves to be highly motivated when treating terminally ill patients. However, they considered that their motivation exceeded their level of competence and, according to the majority, collaboration between the different health services and the formation of interdisciplinary teams would be the best way to facilitate an increase in competence.
Questioning diagnosis disclosure in terminal cancer patients: a prospective study evaluating patients' responses
Authors: Centeno-Cortés Carlos , Núñez-Olarte Juan M
Published: November 2007

This study attempted to assess the degree of knowledge of the diagnosis, and the attitude towards that information, in a group of terminally ill cancer patients. We also tried to determine the influence of the knowledge of the diagnosis on other patient psychosocial needs.

We assessed 97 patients (64 in an oncology service, 33 in a palliative care unit) by means of a semistructured personal interview, and a psychosocial needs questionnaire. Data collected showed that 68% of patients had not been informed of their diagnosis; 60% of this group had a high degree of suspicion of their diagnosis,but 42% of noninformed patients did not want to receive more information.

Information on diagnosis appears to be beneficial in establishing satisfactory relationships and communication between patients and relatives and staff. We have tried to answer the most relevant issues related to diagnosis disclosure in our clinical setting, questioning the feasibility of truth telling within our cultural boundaries.
Radiotherapy for painful bone metastases
Authors: Needham PR , Hoskin PJ
Published: November 2007

Bone metastases are a frequent cause of morbidity in patients with malignant disease. Pain is the commonest symptom; it can be treated successfully in the majority of patients by local external beam irradiation. Controversy exists over which regimen should be used, with a single dose necessitating only one treatment visit to the radiotherapy department, or a fractionated course requiring several visits. Many radiotherapists continue to use fractionated regimens despite the current evidence that single fractions are as effective. Many reasons exist for this, including departmental policy and training, fears of recurrence, problems with retreatment of previously treated areas, fears of increased early and late morbidity, and attempts at promoting recalcification. The majority of these reasons are theoretical and have yet to be substantiated.

In many patients, symptomatic bone metastases are widespread, and hemibody irradiation, although more toxic, should be considered in order to avoid the need for repeated courses of local treatment.
Anticipatory grief: a theoretical challenge
Authors: Evans Alison J
Published: November 2007

The theories of loss and grief described by Freud and Bowlby have provided considerable interest in anticipatory grief. Anticipatory grief is assumed to be akin to post-death grief, but commencing prior to the loss of the loved one. 'Grief work' completed during the anticipatory period is purported to mitigate against abnormal grief reactions after death and enhance adjustment to loss. Research conducted to investigate the link between anticipatory grief and postbereavement adjustment has not, however, yielded conclusive findings.

It is argued that the intellectual vision of researchers has been obscured by the traditional view of grief leading to conceptual confusion in the theoretical literature and equivocal findings of the empirical investigations. The limited view of the 'death event' as the only loss incurred fails to consider the past, present and future losses that may occur as a result of terminal disease. The physiological, psychological, interpersonal and sociocultural factors evident in the terminal situation serve to highlight the existence of many previously unconsidered variables which may determine the anticipatory grief experience. Until the influence of these determining variables is acknowledged and researchers learn to look beyond the parameters of the traditional models of grief, the costs and/or benefits of the anticipatory period will remain largely undefined. A good starting point may be the adoption of the alternative label, 'terminal response'.
The impact on community palliative care services of a hospital palliative care team
Authors: Bennett Michael , Corcoran Gerard
Published: November 2007

This retrospective study examined the influence of a hospital palliative care team on the activity of a local hospice home care team over a four-year period from May 1989 to April 1993 in East Leeds. The increasing referral to death interval observed in home care patients over this period appears to be due to the presence of the hospital team.

The increasing work-load of the home care team generated by the hospital team is discussed with reference to solutions to meet this increasing demand. A district or regional planning strategy is recommended to co-ordinate existing and potential palliative care services.
Measuring the costs and quality of palliative care: a discussion paper
Authors: Tierney AJ , Sladden S. , Anderson J. , King M. , Lapsley I. , Llewellyn S.
Published: November 2007

In an era of ever increasing emphasis on cost-effectiveness of health care, and with the introduction of the internal market, there is now an urgent need for information on the costs and quality of palliative care. This paper highlights the complexities involved in acquiring and measuring such information and discusses methods which were tried out in an exploratory study. The study took the form of in-depth case studies in two hospices, one in the voluntary sector and one in the NHS.
Corticosteroids and peptic ulceration
Authors: Ellershaw John E , Kelly Moira J
Published: November 2007

The relationship between corticosteroids and peptic ulceration, together with the major complications of gastrointestinal haemorrhage and perforation, remains an area of clinical concern. This paper reviews the literature regarding peptic ulceration and corticosteroids. Risk factors related to an increased incidence of peptic ulceration in patients prescribed corticosteroids are discussed. These include: total dose of corticosteroid, previous history of peptic ulceration, advanced malignant disease and concurrent prescribing of nonsteroidal anti-inflammatory drugs (NSAI Ds). It is suggested that prophylaxis should be considered for those patients with two or more risk factors. Choice and efficacy of prophylaxis is also considered.
Respiratory symptoms in children dying from malignant disease
Authors: Hain Richard DW , Patel Nina , Crabtree Sarah , Pinkerton Ross
Published: November 2007

Shortness of breath and other respiratory symptoms frequently complicate the symptomatic management of terminally ill adults. The extent of the problem in children is not known, but anecdotal evidence from nurses and physicians experienced in paediatric oncology has suggested that respiratory problems are less frequent in children dying from malignant disease than in adults. This is a retrospective review of all children dying from cancer under the care of the symptom care team at the Royal Marsden Hospital between 1982 and 1993. The results show that respiratory symptoms were recorded during the last three months of life in 40% of analysable case histories. The nature of respiratory symptoms in paediatric cancer patients is discussed.
The McGill Quality of Life Questionnaire: a measure of quality of life appropriate for people with advanced disease. A preliminary study of validity and acceptability
Authors: Cohen S Robin , Mount Balfour M , Strobel Michael G , Bui France
Published: November 2007

This is the first report on the McGill Quality of Life Questionnaire (MQOL), a questionnaire relevant to all phases of the disease trajectory for people with a life-threatening illness. This questionnaire differs from most others in three ways: the existential domain is measured; the physical domain is important but not predominant; positive contributions to quality of life are measured. This study was conducted in a palliative care setting. Principal components analysis suggests four subscales: physical symptoms, psychological symptoms, outlook on life, and meaningful existence. Construct validity of the subscales is demonstrated through the pattern of correlations with the items from the Spitzer Quality of Life Index. The importance of measuring the existential domain is highlighted by the finding that, of all the MQOL subscales and Spitzer items, only the meaningful existence subscale correlated significantly with a single item scale rating overall quality of life.
The life so short, the craft so hard to learn: a model for post-basic education in palliative care
Authors: Macmillan Frances Sheldon , Smith Pauline
Published: November 2007

This paper seeks to review the available educational palliative care experiences at post-basic level and explores different possibilities for current and future programmes. Central to this review is the exploration of the values and beliefs that underpin educational practice, and the relationship of these to palliative care practice. There are gaps in espoused theory, and theory in the practice of both is of critical importance. We locate our own values and beliefs in the new paradigm of human inquiry and propose that this paradigm and its methodologies have a considerable contribution to make to the development of both palliative care education and practice.
Continuing education and short courses
Authors: Smith Anthony M
Published: November 2007

Requirements for healthcare professionals in the United Kingdom to undertake continuing education are discussed. For nurses, midwives and many career- grade doctors, formal arrangements are in place; for other professionals, continuing education is recommended but not yet a formal requirement.

In order to explore what is available, courses, conferences and seminars advertised in the Hospice Information Service's publication Choices for the academic year September 1994 to July 1995 are reviewed in terms of number, intended audience, participants and duration. Comment is offered on size of events and their financing.

Issues of approval, quality assurance and evaluation are addressed. Suggestions are offered with regard to future financing of courses, and co- ordination of planning and provision. It is suggested that the National Council for Hospice and Specialist Palliative Care might encourage increasing co operation between units in the provision of education.
Oral morphine as symptomatic treatment of dyspnoea in patients with advanced cancer
Authors: Boyd Kirsty J , Kelly Moira
Published: November 2007

We report an open, uncontrolled study to evaluate the effectiveness of regular oral morphine as symptomatic treatment of dyspnoea in patients with advanced cancer receiving standard clinical care. Fifteen patients were assessed initially, and then 48 h and 7-10 days after starting treatment with oral morphine or having their dose increased. Dyspnoea, measured on a visual analogue scale (0-100), fell by a median of 14 (95% confidence interval -1.5, 25.5; Wilcoxon statistic 32.0; P = 0.06) in the nine who completed all three assessments. The three patients who died during the study did not show symptomatic benefit and, like the three who withdrew, experienced increased sedation and/or dizziness. Sedation was significantly increased at 48 h; median rise 10.5 (95% confidence interval 7, 25; Wilcoxon statistic 74; P = 0.007). Baseline respiratory function (FEV 1, FVC, peak flow) was poor and the patients' respiratory rate was unaffected. Regular, titrated oral morphine may improve dyspnoea in some patients with advanced cancer but can cause significant short-term adverse effects. Oral morphine should be given to these patients as a therapeutic trial. Patients should be advised about side-effects and carefully monitored. Larger studies are needed to establish which patients are most likely to benefit and optimal dosage regimens.
Relocation stress syndrome: the case of palliative care patients
Authors: Porock Davina , Martin Karen , Oldham Lynn , Underwood Rod
Published: November 2007

Transfer of patients from palliative care services to nursing homes is necessary at present when a patient is relatively stable, but does not have adequate support systems at home. With the ageing of the population and the increasing incidence of cancer, the need for inpatient palliative care beds is growing with corresponding pressure for patients to be transferred to nursing homes. Transfer to a nursing home in the general population has been described extensively in the gerontology literature where a critical early phase of relocation has been identified by a high incidence of morbidity and mortality. The vulnerability of terminally ill patients means that they are at increased risk of suffering from stress associated with a transfer. The prognosis of a patient may be shorter than the time required for adjustment to the patient's new home. The issues surrounding transfer of palliative care patients to nursing homes and possible strategies designed to reduce distress associated with transfers are explored.