Palliative care in Edmonton

The Palliative Care Program at the Edmonton General Hospital, Edmonton, Canada provides a comprehensive multidisciplinary service to terminally III patients in the area. The political, clinical, educational, and research developments impacting on this program are described.     

大动脉脉冲速率对终末期肾功能衰竭维持性血液透析患者预后的影响

目的:分析随血压水平下降相应的动脉脉冲速率(PWV)的变化对终末期肾功能衰竭(ESRF)患者预后的意义。方法:52例维持性血液透析患者,年龄(62±13)岁,共观察(17±9)个月,观察伴随血压下降PWV的变化,通过调整干体重控制患者血压水平,共有12例患者死亡,其中7例死于心血管并发症,5例死于非心血管并发症。结果:Cox分析结果提示(1)随血压水平下降,PWV水平保持不变(无相应下降);(2)左心室容积增加;(3)年龄大;(4)存在基础心脏原发病,是不依赖于患者血压水平变化而独立影响患者病死率的因素。随血压变化PWV水平保持不变的病例死亡的危险系数为0.288(95%可信区间0.084～0.987),P<0.05。结论:对于ESRF患者,随血压水平下降,动脉PWV变化不明显能作为ESRF维持性血液透析患者远期病死率指示标准。     

73例终末期肾衰竭并发神经精神症状的临床分析

目的分析终末期肾衰竭并发神经、精神症状的原因。方法凹顾性分析本院73例出现神经、精神症状的终末期肾衰竭患者的资料。结果终未期肾衰竭并发神经、精神症状的原因：①多因原发病所致酸中毒、电解质紊乱、尿毒症毒素莆积幽索引起;②与透析有关：失衡综合征、透析不充分;③脑血管器质性病变。结论终未期肾衰竭患者出现神经、精神紊乱症状与多闪素有关,应积极治疗原发病,选择恰当的透析方式、频率,预防透析性脑病的发生。     

Palliative nursing care for the patient experiencing end-stage renal failure

Caring for the patient with end-stage renal disease poses many challenges for the bedside nurse. Yet, how do we care for patients who continue to seek hemodialysis with a guarded prognosis? A discussion about palliative care and specific interventions used to help improve quality of life for the end-stage renal patient is provided. A case example accompanies this article, and highlights the interventions used successfully for one such patient.     

99Tc-Ca-Gluconate renal scintigraphy in patients with chronic renal failure

Summary From use of⁹⁹Tc-Ca-Sn-gluconate in patients with various degrees of renal failure the following conclusions were drawn: 1. a good relationship exists between the parenchymal and vascular patterns in scintigraphy and the functional renal impairment; 2. the morphological definition is good, since in most cases a differential diagnosis can be made between diffuse parenchymal disease and space-occupying lesions even at very low glomerular filtration rate values; 3. this technique is supplementary to i.v. pyelography in patients with relatively good glomerular filtration rate values and is a reliable alternative to i.v. pyelography in those with low creatinine clearance values.     

Palliative care: an evolving field in medicine

Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems: physical, psychosocial, and spiritual. This article discusses illness trajectories and prognostic estimates, prognostic tools, educating physicians and nurses in palliative care, research in palliative medicine, and palliative care in hospitals and the community.     

Palliative care in Denmark

The palliative effort in Denmark has increased during recent years. Many initiatives to improve conditions for patients who need supportive and palliative care have been introduced. All hospitals offer symptom control and open admission. The Social Security Authority has passed an act giving relatives the opportunity to nurse a patient who wishes to die at home without losing their income. Three hospices have been established, all on a non-statutory basis. This article describes the different initiatives and future plans.     

Palliative care in dementia

Abstract

The main goals of care in progressive dementias (Alzheimer's disease, vascular dementia, dementia with Lewy bodies, and fronto-temporal dementia) are maintenance of quality of life, dignity, and comfort. Three main areas are important for quality of life in individuals with dementia: meaningful activity, medical issues, and behavioral symptoms. Meaningful activities should be provided even in advanced dementia because there is no evidence that it progresses to persistent vegetative state. They should be individualized and prevent isolation of patients in their rooms or placement of patients in corridors. It is important to distinguish behavioral symptoms that occur when the patient is solitary (agitation and apathy) and when the patient interacts with others (most commonly rejection of care). Behavioral symptoms of dementia should be first managed by non-pharmacological strategies: meaningful activities for agitation and apathy and modification of caregiving strategies for rejection of care. Depression is an important risk factor for both of these syndromes and should be treated even in advanced dementia. In individuals with advanced progressive dementia, management of chronic medical problems should be modified, cardiopulmonary resuscitation is not indicated, transfer to a hospital for treatment of intercurrent infections may not be indicated, antibiotic treatment is less effective and not necessary to maintain comfort, and tube feeding does not provide any benefit but poses a burden for the patient. Food refusal may be managed by diet modification, antidepressants, or dronabinol administration, and aspiration may be minimized by diet modification and some medications.     

肾活检在急性肾功能衰竭诊治中的意义

目的　探讨急性肾功能衰竭 (ARF)误诊原因及肾活检在ARF诊治中的意义。方法　分析临床诊断与病理诊断的符合率及误诊原因 ,总结肾活检后诊断和治疗的修正率及早期治疗对预后的影响。结果　 78例ARF中临床与病理诊断符合者 5 2例 (6 6 .7% ) ;肾活检前病因诊断错误或病因不明者 2 6例(33.3% ) ;肾活检后 2 6例 (33.3% )的治疗方案被更改。结论　对急性肾功能衰竭患者临床病因诊断有困难者 ,应及时行肾活检 ,以明确诊断、指导治疗与判断预后     

Continuous renal replacement therapy is associated with less chronic renal failure than intermittent haemodialysis after acute renal failure

Objective Acute renal failure can be treated with continuous renal replacement therapy (CRRT) or intermittent haemodialysis (IHD). Whether this choice affects renal recovery has been debated, since it has implications on quality of life and costs. Our objective was to determine the impact of CRRT and IHD on renal recovery. Design Nationwide retrospective cohort study between the years 1995 and 2004. Follow-up ranged between 3 months and 10 years. Setting Thirty-two Swedish intensive care units. Patients and participants Eligible subjects were adults treated in Swedish general intensive care units with RRT. A total of 2,642 patients from 32 ICUs were included. We then excluded patients with end-stage renal disease (252) and patients lacking a diagnosis in the in-patient register (188). Thus, 2,202 patients were studied. Follow-up was complete. Interventions None. Measurements and results The primary outcome was renal recovery. Secondarily we studied the mortality of the cohort. There were no differences between IHD and CRRT patients regarding baseline characteristics, such as age, sex and comorbidities. Of the 1,102 patients surviving 90 days after inclusion in the cohort, 944 (85.7%) were treated with CRRT and 158 (14.3%) were treated with IHD. Seventy-eight patients (8.3%; confidence interval, CI, 6.6–10.2), never recovered their renal function in the CRRT group. The proportion was significantly higher among IHD patients, where 26 subjects or 16.5% (CI 11.0–23.2) developed need for chronic dialysis. Conclusions The use of CRRT is associated with better renal recovery than IHD, but mortality does not differ between the groups. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

经皮肾穿刺活检在急性肾功能衰竭诊治中的地位

目的探讨急性肾功能衰竭（ARF）患者的病理类型及病因分布,评价肾活检在肾脏病诊治中的作用与地位。方法对30例ARF具有肾穿刺活检适应证的患者,在B超介入定位下行经皮肾穿刺活检,并做光镜、免疫病理检查及结合临床特点进行分析。结果 30例ARF患者肾穿刺均能成功取得肾小球,标本合格率为97%,病理分析显示：硬化性肾炎2例（6.67%）;原发性肾小球肾炎17例（56.67%）,其中IgA肾病3例,肾小球轻微病变5例,膜性肾病2例,局灶节段性硬化性肾炎2例,毛细血管内增生性肾炎2例,新月体肾炎3例;继发性肾小球肾炎8例（26.62%）,其中狼疮性肾炎6例,过敏性紫癜肾炎2例;急性肾小管坏死2例（6.67%）;急性间质性肾炎1例（3.33%）。并发症主要有肉眼血尿2例,肾周血肿1例,未发生误穿其他脏器、感染及严重大出血等并发症。结论对ARF患者行肾活检检查有助于明确病因及病理类型,对指导治疗及判断预后均有非常重要的作用。     

Palliative care in Italy: the current situation

Palliative care was initiated in Italy towards the end of the 1970s, mainly through the efforts of Professor Ventafridda and his colleagues. This article describes some of the most important steps made in this country to gain widespread acceptance for the principles and practice of palliative care. After about 15 years the Italian situation is still confusing. While some Regions have made progress, others are far from reaching even minimal goals. The efforts of many charities and of the Italian Society for Palliative Care and the Italian School for Palliative Medicine, have been huge, but still not sufficient to promote widespread involvement of the National Health Authorities. In the absence of clear Regional and central laws, the recent changes in the Italian health system combined with increasing financial difficulties threaten the advances already made.     

血液透析治疗重症鱼胆中毒的临床疗效分析

目的观察血液透析治疗重症鱼胆中毒合并急性肾功能衰竭的临床疗效。方法回顾性分析14例重症鱼胆中毒所致急性肾功能衰竭,予以血液透析为主的综合治疗,并比较血透前后肾功能、肝功能变化;观察中毒至首次血透的时间、服鱼胆量对疗效的影响。结果14例重症鱼胆中毒患者死亡1人,病死率为7.1%,其余13例患者痊愈;血透治疗后,患者肾功能、肝功能明显好转,较血透前显著下降(P<0.01);首次血透时间愈早,疗效愈好(P<0.01);服不同量鱼胆的患者,其血透次数和肾功能恢复的时间均差异无统计学意义(P>0.05)。结论及时充分的血液透析能有效地治疗重症鱼胆中毒致急性肾功能衰竭。     

Chronic Heart Failure Patients' Perceptions on their Palliative Care Needs

Objective

The aim of this study was to investigate the perceptions of patients with chronic heart failure regarding palliative care needs.

Palliative care in India

 While India has a long tradition of home-based spiritual and religious care of the dying, there has been no contemporary palliative care until relatively recently. The existing and planned palliative care services in India are presented, and future perspectives and the opportunities for training for both professionals and lay volunteers are discussed.     

Palliative care services in Belgium: benefits and shortcomings of a legal framework

All health services dealing with the terminally ill are called upon to dispense palliative care. We shall, however, be making a distinction between palliative care services and other forms of services: in fact, the main activity of a palliative care service is palliative medicine, which is dispensed by its trained and experienced personnel. In Belgium, the first specialist palliative care services developed autonomously, and the absence of a planning policy isolated them from the rest of the health system. The Belgian health authorities decided to put an end to this situation by legislation: the laws introduced determine the number, mission and modus operandi of the various palliative care services, as well as the links to be established between them (interaction of the home care support team and the mobile function in hospitals or institutions for the elderly and association for cooperation). The following is a presentation and critical analysis of this legislation.     

氨基末端脑钠肽前体在慢性肾功能衰竭合并心力衰竭的诊断价值

目的通过观察人血清估算肾小球滤过率(eGFR)与氨基末端脑钠肽(BNP)前体(NT-pro-BNP)之间的关系,比较慢性肾功能衰竭(CRF)合并心力衰竭患者不同eGFR水平NT-pro-BNP的诊断临床界值,研究肾功能对NT-pro-BNP应用于心力衰竭诊断的影响。方法对老年CRF合并心力衰竭未透析患者52例及无心力衰竭29例和老年健康体检者30例(正常对照组)采用酶联免疫吸附法测定血清NT-pro-BNP浓度,根据eGFR分组进行对比。结果 eGFR<30ml.min-1.(1.73m2)-1、30～60ml.min-1.(1.73m2)-1心力衰竭组NT-pro-BNP水平均高于eGFR<30ml.min-1.(1.73m2)-1、30～60ml.min-1.(1.73m2)-1无心力衰竭对照组和eGFR>60ml.min-1.(1.73m2)-1正常组(P<0.05),eGFR<30ml.min-1.(1.73m2)-1、30～60ml.min-1.(1.73m2)-1无心力衰竭对照组NT-pro-BNP水平较eGFR>60ml.min-1.(1.73m2)-1正常组显著升高(P<0.05)。eGFR<30ml.min-1.(1.73m2)-1心力衰竭组与无心力衰竭对照组NT-pro-BNP水平较eGFR30～60ml.min-1.(1.73m2)-1心力衰竭组与无心力衰竭对照组高(t=2.530,P<0.05;t=2.158,P<0.05)。心力衰竭组和无心力衰竭对照组eGFR与NT-pro-BNP水平呈负相关(心力衰竭组r=-0354,P<0.05,对照组r=-0.520,P<0.01)。eGFR30～60ml.min-1.(1.73m2)-1心力衰竭组ROC曲线下面积(AUC)为0.926,NT-pro-BNP410pmol/L作为临界值的敏感度为75.0%,特异度为92.9%;eGFR<30ml.min-1.(1.73m2)-1心力衰竭组AUC为0.950,NT-pro-BNP520pmol/L作为临界值的敏感度为82.1%,特异度为100.0%。结论 NT-pro-BNP水平与肾功能损害严重性微弱相关,在考虑肾功能的前提下可作为判断CRF患者是否合并心力衰竭的诊断指标。     

Palliative care case management in primary care settings: A nationwide survey

Background

In case management an individual or small team is responsible for navigating the patient through complex care. Characteristics of case management within and throughout different target groups and settings vary widely. Case management is relatively new in palliative care. Insight into the content of care and organisational characteristics of case management in palliative care is needed.

Objectives

To investigate how many case management initiatives for palliative care there are in the Netherlands for patients living at home; to describe the characteristics of these initiatives with regard to content and organisation of care.

Setting

Primary care.

Design and participants

A nationwide survey of all 50 coordinators of networks in palliative care in the Netherlands was conducted. Additional respondents were found through snowball sampling. We looked at 33 possible initiatives using interviews (n = 33) and questionnaires (n = 30).

Results

We identified 20 initiatives for case management. All stated that case management is supplemental to other care. In all initiatives the case managers are registered nurses and most possess higher vocational education and/or further training. All initiatives seek to identify the multidimensional care needs of the patients and the relatives and friends who care for them. Almost all provide information and support and refer patients who need care. Differences are found between the organisations offering the case management, their target groups, the names of the initiatives and whether direct patient care is provided by the case manager.

Conclusions

In the Netherlands, case management in palliative care is new. Several models of delivery were identified. Research is needed to gain insight into the best way to deliver case management. By describing characteristics of case management in palliative care, an important first step is made in identifying effective elements of case management.