A critical realist evaluation of a music therapy intervention in palliative care

Background

Music therapy is increasingly used as an adjunct therapy to support symptom management in palliative care. However, studies to date have paid little attention to the processes that lead to changes in patient outcomes. To fill this gap, we examined the processes and experiences involved in the introduction of music therapy as an adjunct complementary therapy to palliative care in a hospice setting in the United Kingdom (UK).

Methods

Using a realistic evaluation approach, we conducted a qualitative study using a variety of approaches. These consisted of open text answers from patients (n?=?16) on how music therapy helped meet their needs within one hospice in Northern Ireland, UK. We also conducted three focus groups with a range of palliative care practitioners (seven physicians, seven nursing staff, two social workers and three allied health professionals) to help understand their perspectives on music therapy’s impact on their work setting, and what influences its successful implementation. This was supplemented with an interview with the music therapist delivering the intervention.

Results

Music therapy contains multiple mechanisms that can provide physical, psychological, emotional, expressive, existential and social support. There is also evidence that the hospice context, animated by a holistic approach to healthcare, is an important facilitator of the effects of music therapy. Examination of patients’ responses helped identify specific benefits for different types of patients.

Conclusions

There is a synergy between the therapeutic aims of music therapy and those of palliative care, which appealed to a significant proportion of participants, who perceived it as effective.

     

Melanoma

The incidence of melanoma in the US is rising at a rate second only to that of lung cancer in women. Early stage melanoma is curable, but once metastatic, it is almost uniformly fatal. The immunotherapy of melanoma is a new and exciting therapeutic modality that is being extensively investigated worldwide. Interferon-alpha has an approximately 16% response rate in metastatic melanoma. In the randomised trials to date, no combination of chemotherapeutic or hormonal agent with interferon-alpha has proven to be superior to dacarbazine, the reference agent for the treatment of metastatic melanoma. The role of interferon-alpha-2b in the adjuvant therapy of localised melanoma at high risk for relapse has recently been established, with the results of 2 large randomised trials conducted by the US Intergroup, one showing improvement in both relapse-free survival and overall survival, and the other in relapse-free survival only. Interferon-gamma has not been effective in the adjuvant setting or in metastatic disease, but is part of combination protocols used for regional therapy for extremity melanomas. Interleukin-2 has an overall response rate of 15 to 20% in metastatic melanoma and produces some complete and durable remissions. The US Food and Drug Administration has recently approved the use of high-dose bolus administration of recombinant interleukin-2 for the therapy of metastatic melanoma. Results of combination chemotherapy and immunotherapy regimens containing interleukin-2 (biochemotherapy) are promising, and ongoing research will determine whether a survival impact will be confirmed in randomised studies. Vaccine therapy is another exciting area of research, and clinical trials are ongoing in both metastatic melanoma and as adjuvant therapy. A bewildering array of vaccines (whole cell, carbohydrate and peptide) is available, and it remains to be seen which of these numerous preparations will be most effective. Adjuvant therapy trials with a ganglioside GM2 vaccine and others are ongoing. Numerous peptide vaccines are also being investigated for metastatic melanoma, singly and in combination with other immunotherapeutic agents.     

Focal liver masses: differential diagnosis with pulsed Doppler US

Duplex Doppler ultrasound (US) was used in 68 consecutive patients with focal liver lesions, including 12 hepatocellular carcinomas, one cholangiocarcinoma, 37 metastases, 15 hemangiomas, one hemangioendothelioma, and two focal nodular hyperplasias. Of the hepatocellular carcinomas, six were diffusely hyperechoic, two were hypoechoic, two were single hyperechoic lesions, and two were multifocal and hyperechoic. All ten tumors with Doppler shifts of 5 kHz or above proved to be hepatocellular carcinomas. The other two hepatocellular carcinomas showed Doppler shifts of 3 kHz. In contrast, no hemangioma showed shifts above 0.7 kHz, and ten of the 15 gave no detectable signal. Of the metastases, 20 gave no signal and 17 had signals of up to 4 kHz. Three-kilohertz signals were also obtained from a cholangiocarcinoma, a hemangioendothelioma, and focal nodular hyperplasia. Correlation with angiographic findings suggested that the high-velocity Doppler signals were associated with large pressure gradients due to arteriovenous shunting. Duplex Doppler US can therefore aid in the differential diagnosis of diffuse and focal liver lesions.     

Sentinel Lymph Node Biopsy for Atypical Melanocytic Lesions with Spitzoid Features

Introduction Sentinel lymph node biopsy (SLNB) is routinely used as a staging procedure for melanomas, however may also assist in understanding the biology of atypical and controversial spitzoid melanocytic skin lesions.Methods Five hundred and forty-nine sentinal lymph node excisions were performed over a 5-year period. Fourteen patients with controversial melanocytic lesions were identified and of these ten underwent SLNB. The histology of the primary skin lesion and corresponding sentinal lymph nodes were evaluated and correlated with outcome.Results Thickness of the primary melanocytic lesion ranged from 1.22 to 4 mm. Fifty percent of patients were less than 17 years of age. Ten patients underwent SLNB and three cases (30%) displayed metastatic disease in the SLNB specimen. All three patients were under 17 years of age and all underwent completion axillary dissection. One completion axillary dissection had an additional node with metastasis on routine H&E and immunohistochemical staining. No capsular invasion was seen. All three cases with metastatic disease received adjuvant systemic therapy and remain disease free at 29, 49 and 57 months follow-up. All patients with a negative SLNB remain disease free at mean follow-up of 28.1 months (range: 13–40 months).Conclusion Our results confirm that some of these spitzoid lesions metastasize to regional lymph nodes and SLNB is a valuable adjunct tool in staging these lesions. However, molecular studies and a prolonged follow-up are needed to determine whether these lesions, especially those occurring in children are comparable to stage matched overt melanoma in adults.     

Surface shield: device to reduce personnel radiation exposure

A simple device is described that can reduce personnel exposure from scatter radiation by up to 75%. The device consists of an oblong piece of shielding (0.75-mm lead equivalent) that is taped to the side of the patient during percutaneous renal stone removal and other interventional procedures. Contrary to other shields and barriers, this does not interfere with access to the patient. Scatter exposure data from phantom studies are presented and the rationale for surface shielding discussed.     

Medical versus surgical management of biliary tract disease in pregnancy

BACKGROUND: The management of symptomatic cholelithiasis during pregnancy remains controversial. We compared outcomes after medical versus surgical management of biliary tract disease in pregnant patients. METHODS: We reviewed the clinical course of patients with symptomatic cholelithiasis during pregnancy from 1992 to 2002 at two university hospitals. RESULTS: Seventy-six women with 78 pregnancies were admitted with biliary tract disease. Of the 63 women who presented with symptomatic cholelithiasis, 10 underwent surgery while pregnant. There were no deaths, preterm deliveries, or intensive care unit admissions. Fifty-three patients were treated medically. Their clinical courses were complicated by symptomatic relapse in 20 patients (38%), by labor induction to control biliary colic (8 patients), and by premature delivery in 2 patients. Each relapse in the medically managed group accounted for an additional five days in hospital. CONCLUSION: Surgical management of symptomatic cholelithiasis in pregnancy is safe, decreases days in hospital, and reduces the rate of labor induction and preterm deliveries.     

Zinc enhances long-term potentiation through P2X receptor modulation in the hippocampal CA1 region

Zn²⁺ is an essential ion that is stored in and co‐released from glutamatergic synapses and it modulates neurotransmitter receptors involved in long‐term potentiation (LTP). However, the mechanism(s) underlying Zn²⁺‐induced modulation of LTP remain(s) unclear. As the purinergic P2X receptors are relevant targets for Zn²⁺ action, we have studied their role in LTP modulation by Zn²⁺ in the CA1 region of rat hippocampal slices. Induction of LTP in the presence of Zn²⁺ revealed a biphasic effect – 5–50 μm enhanced LTP induction, whereas 100–300 μm Zn²⁺ inhibited LTP. The involvement of a purinergic mechanism is supported by the fact that application of the P2X receptor antagonists 2′,3′‐O‐(2,4,6‐trinitrophenyl) ATP (TNP‐ATP) and periodate‐oxidized ATP fully abolished the facilitatory effect of Zn²⁺. Notably, application of the P2X₇ receptor‐specific antagonist Brilliant Blue G did not modify the Zn²⁺‐dependent facilitation of LTP. Exogenous ATP also produced a biphasic effect – 0.1–1 μm ATP facilitated LTP, whereas 5–10 μm inhibited LTP. The facilitatory effect of ATP was abolished by the application of TNP‐ATP and was modified in the presence of 5 μm Zn²⁺, suggesting that P2X receptors are involved in LTP induction and that Zn²⁺ leads to an increase in the affinity of P2X receptors for ATP. The latter confirms our previous results from heterologous expression systems. Collectively, our results indicate that Zn²⁺ at low concentrations enhances LTP by modulating P2X receptors. Although it is not yet clear which purinergic receptor subtype(s) is responsible for these effects on LTP, the data presented here suggest that P2X₄ but not P2X₇ is involved.     

Human Monoclonal Anti-D with Reactivity against Category DVI Cells Used in Blood Grouping and Determination of the Incidence of the Category DVI Phenotype in the DU Population

B-lymphoblastoid cell lines transformed by Epstein-Barr virus were produced from cells obtained from a hyperimmunised donor with serum anti-D activity against category DVI red cells and enriched for this activity by rosetting with category DVI red cells. Three clones produced IgG1 anti-D and had stable cell growth and continuous secretion of antibody in prolonged culture. The monoclonal antibodies reacted with category DVI red cells, when assessed manually and in an automated blood grouping system, and are useful blood grouping reagents for the detection of the category DVI phenotype. Using a radiometric technique, the number of antibody molecules bound to category DVI red cells from 5 individuals was estimated to range from 2,800 to 11,200 per cell. Five percent of blood donors classed as Du in the south western region were found to have the category DVI phenotype.     

Trends in laparoscopic splenectomy for massive splenomegaly

HYPOTHESIS: During the past 10 years, expertise with minimally invasive techniques has grown, leading to an increase in successful laparoscopic splenectomy (LS) even in the setting of massive and supramassive spleens. DESIGN: Retrospective series of patients who underwent splenectomy from November 1, 1995, to August 31, 2005. SETTING: Academic tertiary care center. PATIENTS: Adult patients who underwent elective splenectomy as their primary procedure (n = 111). MAIN OUTCOME MEASURES: Demographics, spleen size and weight, conversion from LS to open splenectomy, postoperative length of stay, and perioperative complications and mortality. Massive splenomegaly was defined as the spleen having a craniocaudal length greater than 17 cm or weight more than 600 g, and supramassive splenomegaly was defined as the spleen having a craniocaudal length greater than 22 cm or weight more than 1600 g. RESULTS: Eighty-five (77%) of the 111 patients underwent LS. Of these 85 patients, 25 (29%) had massive or supramassive spleens. These accounted for 40% of LSs performed in 2004 and 50% in 2005. Despite this increase in giant spleens, the conversion rate for massive or supramassive spleens has declined from 33% prior to 1999 to 0% in 2004 and 2005. Since January 2004 at our institution, all of the massive or supramassive spleens have been removed with a laparoscopic approach. Patients with massive or supramassive spleens who underwent LS had no reoperations for bleeding or deaths and had a significantly shorter postoperative length of stay (mean postoperative length of stay, 3.8 days for patients who underwent LS vs 9.0 days for patients who underwent open splenectomy; P<.001). CONCLUSIONS: Despite conflicting reports regarding the safety of LS for massive splenomegaly, our data indicate that with increasing institutional experience, the laparoscopic approach is safe, shortens the length of stay, and improves mortality.