Cancer and the treatment: does it make sense to patients?

This presentation begins to discuss the findings of an ongoing doctoral study that arose as the result of clinical experience, previous studies and ongoing reflection. Building on the work of Frankl this study explores the search for meaning in the context of living with cancer. In this study people with cancer share their experience of trying to make sense of their disease and the treatments they underwent. Some of the findings that have begun to emerge include: the search for meaning is ongoing, multifaceted and may be lived out in a variety of ways, living with cancer and the treatment it demands brings many changes some of which lead to a sense of loss of control, there are a multitude of relationships involved which may help or cause distress to the person dealing with cancer, the health care team while often supportive sometimes failed to see the needs of those they cared for, while people with cancer value the expertise and knowledge of the health care team they also want the team to demonstrate compassion and sensitivity while delivering care and information, while a few people had found particular meaning to aspects of their experience all recognized that the ongoing process of searching to find meaning continues after treatment finishes. It is hoped that by listening to the experiences of these individual people living with cancer the insights gained will support the health care team in their efforts to help those undergoing treatment for cancer.     

Diagnosing collagenous colitis: does it make a difference?

Collagenous colitis is part of the spectrum of disorders known as microscopic colitis, which also include lymphocytic colitis and a mixed disorder with both a collagen band present and also intra-epithelial lymphocytes. Collagenous colitis appears to be caused by mucosal injury from toxins in the faecal stream. The collagen band is a result of the underlying inflammatory process and not the cause of symptoms. The diagnosis is based on colonic mucosal pathology and a compatible clinical presentation. Treatment is empiric and ranges from no therapy, to anti-inflammatory or anti-secretory agents, to diverting ileostomy.     

Beating heart surgery: does it make a difference?

Beating heart techniques were introduced into coronary artery bypass graft (CABG) surgery in the mid 1990s in an attempt to decrease the complications associated with the use of cardiopulmonary bypass. Significant advances in technique and technology, including suction stabilizers and exposure devices, have now allowed all coronary vessels to be routinely approached without the support of cardiopulmonary bypass, while maintaining hemodynamic stability. Currently, approximately 25% of all CABG is performed without cardiopulmonary bypass in the United States. An extensive body of literature attests to the strong interest in the technique and the outcomes available for analysis. Although randomized trials do not yet show a mortality benefit, they are all underpowered to do so. A review of large retrospective databases does appear to demonstrate a mortality benefit, but patient selection contributes bias. Strong evidence of benefit exists for blood loss/transfusion, postoperative renal failure, sternal infection, myocardial injury, extubation time, length of stay, and cost savings. Particular benefit is apparent in high-risk patient subgroups, including the elderly, reoperative patients, and those with significant comorbidities. Off-pump CABG does appear to make a difference in improved outcomes by maintaining the excellent results of traditional on-pump CABG, but with less perioperative complications.     

Does it make sense to train plumbers as electricians?

There is an expanded need for implantable cardioverter-defibrillators and cardiac resynchronization pacemakers as part of the treatment of patients with left ventricular dysfunction. A large number of such patients present to heart failure (HF) specialists for recommendations related to their care. In this paper, a pathway is presented that would combine training in HF/transplantation and cardiac implantable electrical devices.     

The medical emergency team: does it really make a difference?

Abstract
Hospital systems are failing the critically ill. This has been well documented in many countries around the world, with detailed reports of suboptimal care prior to intensive care and high rates of serious adverse events, including death. These events are potentially preventable, but insufficient attention has been directed towards developing solutions to these important problems to date.
The medical emergency team (MET) is a system approach that promotes early and appropriate inter­vention in the care of critically ill hospital patients. The benefits of the MET in terms of absolute in-patient ­mortality and cardiac arrest rates are not yet well-defined, although preliminary studies are promising.
The MET does provide a potentially beneficial impact on many other aspects of patient care. These benefits include: (i) facilitating an integrated and coordinated approach to patient care across the hospital, (ii) increasing awareness of at-risk patients, (iii) encouraging early referral of seriously ill patients to clinicians with expertise in critical care and (iv) providing a foundation for quality initiatives for hospital-wide care of the seriously ill.
The MET also empowers nursing staff and junior medical staff to call for immediate assistance in cases where they are seriously concerned about a patient, but may not have the experience, knowledge, confidence or skills necessary to manage them appropriately. (Intern Med J 2003; 33: 511−514)     

Thrombosis prophylaxis in hospitalised medical patients: does prophylaxis in all patients make sense?

BACKGROUND: Most studies on thrombosis prophylaxis focus on postoperative venous thrombosis. In medical wards thrombosis prophylaxis is generally restricted to patients who are immobilised. Our primary aim was to investigate the incidence of venous thrombosis in a general internal ward, to assess whether more rigorous prophylaxis would be feasible. METHODS: We investigated the incidence of venous thrombosis in patients hospitalised from 1992 to 1996 and related our findings to literature reports. RESULTS: The incidence of symptomatic venous thrombosis in internal patients during hospitalisation was 39/6332 (0.6%). Among these 39 patients, 24 had a malignancy, whereas 876 out of all 6332 patients had a known malignancy. So, the incidence in this group with cancer was 2.7% compared with 0.3% (15/5456) in the non-cancer group (relative risk for venous thrombosis due to malignancy was 10.0 (95%C.I. 5.3-18.9). CONCLUSION: The incidence of venous thrombosis during hospitalisation in a department of general internal medicine is low and does not justify prophylaxis in all internal patients. Cancer is a strong risk factor for hospital-acquired thrombosis in the medical ward. Further studies may answer the question as to whether thrombosis prophylaxis in this subgroup is feasible.     

What does it take to make the perfect clot?

The coagulation process has been conceptualized as being primarily dependent on adequate levels of the coagulation proteins. This concept was based on the clear relationship between the bleeding tendency and factor levels in hemophilia. The field is now evolving toward conceptualizing coagulation as being actively regulated by the specialized cellular components of the process. Rather than conceiving coagulation as only a "cascade" of proteolytic reactions, the coagulation reactions occur as overlapping steps on cell surfaces. Components of the old "extrinsic'" and "intrinsic" pathways of coagulation can be thought of as participating in the initiation and propagation of coagulation reactions, respectively. Thus, these pathways are not redundant as they are portrayed in the cascade model, but play distinct and complementary roles. Our understanding of how specific cellular features control the processes of hemostasis and thrombosis is developing rapidly. This review discusses some aspects of the cellular control of coagulation.