Family meetings in palliative care: Multidisciplinary clinical practice guidelines

Background  

Support for family carers is a core function of palliative care. Family meetings are commonly recommended as a useful way for health care professionals to convey information, discuss goals of care and plan care strategies with patients and family carers. Yet it seems there is insufficient research to demonstrate the utlility of family meetings or the best way to conduct them. This study sought to develop multidisciplinary clinical practice guidelines for conducting family meetings in the specialist palliative care setting based on available evidence and consensus based expert opinion.     

High-dose etoposide and cyclophosphamide without bone marrow transplantation for resistant hematologic malignancy

Seventy-five patients with resistant acute leukemia or lymphoma received high-dose cyclophosphamide and etoposide to explore the activity of this combination in resistant hematologic malignancies, and to determine the maximum doses of these drugs that can be combined without bone marrow transplantation. Etoposide was administered over 29 to 69 hours by continuous infusion corresponding to total doses of 1.8 g/m2 to 4.8 g/m2. Cyclophosphamide, 50 mg/kg/d, was administered on 3 or 4 consecutive days total 150 to 200 mg/kg ideal body weight). At all dose levels myelosuppression was severe but reversible. Mucosal toxicity was dose-limiting with the maximum tolerated dose level combining etoposide 4.2 g/m2 with cyclophosphamide 200 mg/kg. Continuous etoposide infusion produced stable plasma levels that were lower than would be achieved after administration by short intravenous infusion, and this could explain our ability to escalate etoposide above the previously reported maximum tolerated dose. There were 28 complete (35%) and 12 partial (16%) responses. Median duration of complete response (CR) was 3.5 months (range 1.1 to 20+). Seventeen of 40 patients (42%) with acute myelogenous leukemia (AML) achieved CR, including 6 of 20 (30%) with high-dose cytosine arabinoside resistance. We conclude that bone marrow transplantation is not required after maximum tolerated doses of etoposide and cyclophosphamide. This regimen is active in resistant hematologic neoplasms, and the occurrence of CR in patients with high-dose cytosine arabinoside-resistant AML indicates a lack of complete cross-resistance between these regimens.     

Psychosocial screening in children with wartime-deployed parents

Children of U.S. military families are exposed to unique challenges and stressors directly related to their parents' wartime deployments, potentially placing them at higher risk for psychosocial disruption. The objective of this study was to investigate the effects of parental wartime military deployment on psychosocial symptoms as measured by parent and youth self-report on the Pediatric Symptom Checklist. During annual physicals at a large military pediatric clinic, parents (216) and youth (198) were surveyed about emotional and behavioral difficulties and the current status of parental deployment. Parents reported more child psychosocial symptoms, and youth self reported more psychosocial symptoms if there was a currently deployed parent. Youth self-reports may be another way to identify psychosocial symptoms in at-risk military youth. These findings accentuate the importance of training providers who care for military youth to recognize and respond to their unique needs during parental deployment.     

Mitral valve prolapse: Recent concepts and observations

The conditions associated with prolapse of the posterior leaflet of the mitral valve are multiple. The mechanisms of mitral valve prolapse as well as the pathogenesis of pain and ectopic impulse formation are reviewed. Propranolol appears to be the drug of choice for the symptomatic treatment of patients with this syndrome since it decreases myocardial oxygen demand and wall tension thus reducing or abolishing the discrepancy between myocardial oxygen demand and supply within the mitral apparatus. It has also been reported to modify the auscultatory findings associated with this condition.

The frequency of this mitral valve abnormality in patients with obstructive coronary artery disease is reviewed. It appears that prolapse of the posterior leaflet scallops in patients with significant obstructive coronary artery disease represents an intermediate stage before mitral insufficiency occurs. This group of patients with papillary muscle dysfunction includes those with prolapsed leaflets without mitral insufficiency, those with systolic murmurs and compensated heart failure and others with progressive cardiac decompensation and severe mitral regurgitation.     

Effects of small doses of L-thyroxine and triiodo-L-thyronine on pituitary LH content of thyroidectomized rats.

Pituitary LH was studied by means of a specific radioimmunoassay (RIA) in male rats at different time intervals after thyroidectomy (T), and in rats which were T at least 30 days before and were then treated with different doses of L-thyroxine or triiodo-L-thyronine. A decrease in the pituitary LH of the T animals, with respect to the intact age-paired controls, was demonstrable from 13 days after the operation, when total pituitary LH content was taken into consideration, or from 5 days after T, when the LH concentration (mug/mg pituitary) was considered. Doses of thyroid hormones lower than the daily maintenance dose for the rat produced very little effect on the pituitary LH levels of T animals. However, a single dose of 1.75 mug of T4 or 0.2 mug of T3 (doses approximately equivalent to the T4 and T3 maintenance dose for T rats) induced such a rapid and intense increase in the pituitary LH content that it no longer differed from that of the intact age-paired controls by 12 hours. Surprisingly, 5.0 mug of T4 and 1.0 mug of T3 did not produce any increase in the pituitary LH content of T rats.     

Effects of the pacing site in sinus node reentrant tachycardia.

His bundle recordings and premature atrial stimulation from coronary sinus, mid-right atrium and high-right atrium were performed in a patient with repetitive supraventricular tachycardias. Regardless of the paced site, there was a range of coupling intervals during which testing stimuli elicited short runs of premature beats. The corresponding P waves were positive in leads I, II and III and had a high-to-low right atrial activation sequence. Their morphology was similar to that of sinus beats. However, sustained tachycardia occurred only when pacing was performed from the coronary sinus. Therefore, it is postulated that the site of stimulation might be important in the genesis and (perhaps) perpetuation of this arrhythmia by changing the site and (or) mode of entry into the area where this type of tachycardia occurs. Though sinus node reentry was the most likely mechanism, it could not be determined whether the circuit involved the sinus node per se or the so called perinodal fibers.     

Effects of pacing site on QRS morphology in Wolff-Parkinson-White syndrome, with special reference to 'pseudo-tachycardia-dependent block in accessory pathway and 'atrial gap'.

In a patient with a Wolff-Parkinson-White (WPW) syndrome type A mid-right atrial stimulation at a rate of 73/min produced a lesser degree of ventricular pre-excitation than when a slower sinus rhythm was present. This paradoxical effect was not related to tachycardia-dependent block in the accessory pathway because pre-excitation again increased at faster pacing rates. It was partly the result of a (proportionally) greater prolongation of intra-atrial conduction time to the accessory pathway than to the atrioventricular node and partly of a faster atrioventricular nodal conduction time. The latter, in turn, could be attributed either to later-than-normal arrival of excitation at the atrioventricular node, at a time when this structure was more recovered, or to a change in the site or mode of entry into the atrioventricular node. A gap in the atria was present because at a St1-St2 interval shorter than that which A2 had been blocked in the accessory pathway conduction was again possible, but with longer A1-A2 intervals. Finally, at similar, short, coupling intervals the impulse penetrated the atrioventricular node from the mid-right atrium but not from the coronary sinus. The unusual findings in this case support a recent assumption that in patients with WPW type A atrial stimulation should be performed from the coronary sinus to minimize the potential sources of error which can be produced by intra-atrial delay.     

Retrograde His bundle deflection in bundle-branch re-entry.

Atrial echo beats resulting from a reciprocating mechanism involving the bundle-branches were produced by premature atrial impulses in a patient with an A-V nodal bypass tract. The mechanism of the arrhythmia was suggested by the presence of a retrograde His bundle deflection which appeared 'sandwiched' in between a QRS complex with complete right bundle-branch morphology and a negative P wave. Though at a shorter cycle length the His bundle was still activated retrogradely echo beats were not seen because the retrograde H deflection occurred too early, when both bypass tract and A-V node were still effectively refractory. At the faster driven rate concealed retrograde activation of the right branch (by the premature impulse) was responsible for the right bundle-branch block patterns shown by the post-premature driven beat.     

A systematic review of intracranial chondrosarcoma and survival

Most data regarding survival in patients with chondrosarcoma are limited to case studies and small series performed at single institutions. A systematic review was performed to study the relationship between potential prognostic factors and survival. The survival rates were analyzed according to modality of treatment, treatment history, histological subtype, and histological grade. A total of 560 patients with intracranial chondrosarcoma were analyzed. Median follow-up time was 60 months. The 5-year mortality among all patients was 11.5% with median survival of 24 months. Mortality at 5 years was significantly greater for patients with tumors of higher grade, or of the mesenchymal subtype, or who had received surgical resection alone. The results of our systematic review provide useful data in predicting survival among intracranial chondrosarcoma patients.     

Dose dependence of the growth rate of multicellular tumour spheroids after irradiation

The present study investigated differences in the growth rate of multicellular tumour spheroids of the MCF-7 line of human breast cancer before and after their irradiation. Growth of the spheroids was analysed according to a model based on a Gompertz function. In this model, normalization to a common initial volume is achieved in a way that enables meaningful comparisons to be made between the results obtained for each spheroid. For irradiated spheroids the model includes an additional term to take account of sterilized cells. We found that the growth rate observed before irradiation is not fully recovered by irradiated spheroids and that growth recovery reduces with higher irradiation doses. Surviving fractions obtained at doses below 3 Gy are comparable with those found in clonogenic assays on spheroids of the same cellular line. At larger doses, discrepancies between the different studies are considerable.