Reflecting on Palliative Care Integration in Canada: A Qualitative Report

Studies have identified integrated interdisciplinary care as a hallmark of effective palliative care. Although models attempt to show how integration may function, there is little literature available that practically explores how integration is fostered and maintained. In this study we asked palliative care clinicians across Canada to comment on how services are integrated across the healthcare system. This is an analysis of qualitative data from a larger study, wherein clinicians provided written responses regarding their experiences. Content analysis was used to identify response categories. Clinicians (n = 14) included physicians, a nurse and a social worker from six provinces. They identified the benefits of formalized relationships and collaboration pathways with other services to streamline referral and consultation. Clinicians perceived a need for better training of residents and primary care physicians in the community and more acceptance, shared understanding, and referrals. Clinicians also described integrating well with oncology departments. Lastly, clinicians considered integration a complex process with departmental, provincial, and national involvement. The needs and strengths identified by the clinicians mirror the qualities of successfully integrated palliative care programs globally and highlight specific areas in policy, education, practice, and research that could benefit those in Canada.     

Differences in baseline characteristics between patients prescribed sitagliptin versus exenatide based on a US electronic medical record database

Introduction  

Sitagliptin, an oral dipeptidyl peptidase-4 inhibitor, and exenatide, an injectable glucagon-like peptide-1 receptor agonist, are incretin-based therapies for the treatment of type 2 diabetes. This study examined differences in baseline characteristics between patients with type 2 diabetes initiating sitagliptin vs. exenatide treatment in clinical practice settings in the US.     

Fine-scale linkage disequilibrium mapping of age-related macular degeneration in the complement factor H gene region

AIM: To present results from a nested association study of the complement factor H (CFH) gene region using a novel methodology that uses a high-resolution genetic linkage disequilibrium map to estimate a point location for a causal mutation. METHOD: Age-related macular degeneration (AMD) case-control data from a genomewide single-nucleotide polymorphism (SNP) panel were used to identify the target interval to be genotyped at higher density in a second independent panel. The pattern of linkage disequilibrium (LD) and segmental duplications across this region are described in detail. RESULT: Data were consistent with other studies in that strong association between the Y402H variant and AMD is observed. However, composite likelihood analysis, which combines association data from all SNPs in the region, and uses genetic locations on a high-resolution LD map, gave a point location for a causal variant between exons 1 and 2 of the CFH gene. CONCLUSION: The findings are consistent with evidence that, in addition to the widely described Y402H variant, there is at least one and, most probably, several other mutations in the CFH gene which determine disease manifestation in AMD. A genetic model in which multiple mutations contribute to a varying degree to disease aetiology has been previously well described in ophthalmic genetics, and is typified by the COL2A1 and ABCA4 genes.     

Benign Tumours of Nasopharynx—Revisited

Benign tumours of nasopharynx are extremely rare; seen predominantly in children and young adults. Patients usually present with seemingly innocuous symptoms and an error in judgement can be catastrophic. This is a retrospective analysis of patients diagnosed to have benign tumours of nasopharynx by histopathological examination in our tertiary care referral centre. The period of study is from September 2009 to August 2010. Eight patients with complete clinical data were identified and included in the study. All the patients were males with a mean age of 21.37 years (range 10–43). Following surgical excision patients were followed up for a mean period of 6.5 months (range 3–14). The Clinical profile, investigation modalities, treatment options are being analysed here.     

Improved Measurement of Pressure Gradients in Aortic Coarctation by Magnetic Resonance Imaging

Objectives. This study evaluated whether magnetic resonance imaging (MRI) and magnetic resonance (MR) phase velocity mapping could provide accurate estimates of stenosis severity and pressure gradients in aortic coarctation.

Background. Clinical management of aortic coarctation requires determination of lesion location and severity and quantification of the pressure gradient across the constricted area.

Methods. Using a series of anatomically accurate models of aortic coarctation, the laboratory portion of this study found that the loss coefficient (K), commonly taken to be 4.0 in the simplified Bernoulli equation ΔP = KV², was a function of stenosis severity. The values of the loss coefficient ranged from 2.8 for a 50% stenosis to 4.9 for a 90% stenosis. Magnetic resonance imaging and MR phase velocity mapping were then used to determine coarctation severity and pressure gradient in 32 patients.

Results. Application of the new severity-dependent loss coefficients found that pressure gradients deviated from 1 to 17 mm Hg compared with calculations made with the commonly used value of 4.0. Comparison of MR estimates of pressure gradient with Doppler ultrasound estimates (in 22 of 32 patients) and with catheter pressure measurements (in 6 of 32 patients) supports the conclusion that the severity-based loss coefficient provides improved estimates of pressure gradients.

Conclusions. This study suggests that MRI could be used as a complete diagnostic tool for accurate evaluation of aortic coarctation, by determining stenosis location and severity and by accurately estimating pressure gradients.

(J Am Coll Cardiol 1996;28:1818–26)>     

High incidence of subacute sclerosing panencephalitis in south India

During 1983-7 a clinical diagnosis of subacute sclerosing panencephalitis (SSPE) was confirmed by the detection of measles virus haemagglutination inhibiting antibody in the cerebrospinal fluid (CSF) in 81 subjects resident in Tamilnadu. The antibody titre (reciprocol of the end-point dilution) in the CSF ranged from 2 to 32 and in the sera from 8 to 2048. The CSF:serum ratios of titres were 1:4-1:64 in 80 cases and 1:128 in one case. The median age at onset of SSPE was 10 years and 97% of cases were diagnosed at stage 2 and beyond. Based on the geographic distribution of 72 cases in an estimated population of 8.4 million, the annual incidence of SSPE was calculated to be 2.14 per million population, or 4.3 cases per million children below 20 years. Assuming that only 10% of all cases would have reached the level of laboratory diagnosis, the incidence may be as high as 21 cases per million population.     

Relative Bioavailability of Ondansetron 8-mg Oral Tablets versus Two Extemporaneous 16-mg Suppositories: Formulation and Gender Differences

Study Objective . To compare the relative bioavailability of two 16-mg extemporaneously prepared suppository formulations with that of an 8-mg commercially available oral tablet. Design . Prospective, crossover bioavailability study. Setting . Inpatient clinical research center. Subjects . Sixteen young, nonsmoking, healthy volunteers. Interventions . Blood samples were obtained 24 and 48 hours after administration of an 8-mg oral ondansetron tablet and 16-mg suppository, respectively. Two 16-mg suppository formulations were compounded using commercially available Fattibase and Polybase. Measurements and Main Results . Ondansetron was well absorbed by both routes of administration. The following pharmacokinetic parameters (mean ± SEM) were obtained for the 8-mg tablet, 16-mg Fattibase suppository, and 16-mg Polybase suppository, respectively: area under the curve (AUC) in men 154.2 ± 21.77, 253.4 ± 72.3, 304.8 ± 62.2 ng·hr/ml; AUC in women 353.6 ± 32.7, 561.6 ± 103.6, and 768.7 ± 117.9 ng·hr/ml; maximum concentration (C_max) in men 45.5 ± 7.0, 40.6 ± 10.4, and 51.2 ± 6.7 ng/ml; C_max in women 51.4 ± 4.8, 47.1 ± 3.9, and 82.9 ± 6.6 ng/ml. Times to C_max (T_max; mean ± SEM) for men were 1.5 ± 0.3, 4.4 ± 0.5, and 2.9 ± 0.3 hours; T_max for women were 1.8 ± 0.3, 4.1 ± 0.4, and 4.4 ± 0.6 hours for the three formulations, respectively. Women had a consistently higher AUC for all three formulations than men (p < 0.05). Conclusion . With the exception of the 16-mg Polybase formulation in women, the two suppositories closely approximated the pharmacokinetics of the 8-mg oral tablet. These results suggest that gender may be a significant factor in ondansetron's disposition.