Integrating palliative care in the intensive care unit

The admission of cancer patients into intensive care units (ICUs) is on the rise. These patients are at high risk for physical and psychosocial suffering. Patients and their families often face difficult end-of-life decisions that highlight the importance of effective and empathetic communication. Palliative care teams are uniquely equipped to help care for cancer patients who are admitted to ICUs. When utilized in the ICU, palliative care has the potential to improve a patient's symptoms, enhance the communication between care teams and families, and improve family-centered decision making. Within the context of this article, we will discuss how palliative care can be integrated into the care of ICU patients and how to enhance family-centered communication; we will also highlight the care of ICU patients at the end of life.     

Pain during topical photodynamic therapy: uncomfortable and unpredictable

Background The major drawback of the widely used photodynamic therapy (PDT) is treatment‐related pain. Objective Gain insight into the intensity of and predictive factors for painful burning sensation associated with PDT. Methods A prospective cohort study was performed at the department of Dermatology in the Maastricht University Medical Centre in Maastricht, a reference centre for dermatological oncology in The Netherlands. A total of 141 lesions in 108 patients were included, treated from November 2008 until June 2009 with PDT for superficial basal cell carcinoma, Bowen’s disease (BD) or actinic keratosis (AK). Painful burning sensation was scored based on an 11‐point pain intensity numeric rating scale (PI‐NRS) (0 = no pain; 10 = worst possible pain). Results The percentage of patients with a PI‐NRS score over six was 32.6% and 37.9% during the primary and follow‐up PDT session respectively. A total of 76.6% (95/124) of the patients was consistent in pain intensity score reporting. Factors associated with higher PI‐NRS scores were treatment of AK or BD, tumour localization in the head/neck region, patient’s age over 70, Fitzpatrick skintype I/II, photosensitizer 5‐aminolevulinic acid and use of oral analgesics. After mutual adjustment of these factors, Fitzpatrick skintype remained the only independent predictor of PI‐NRS scores during PDT. Conclusion It remains difficult to decide which patients should be considered for pain relieving measures. The solution remains to support all patients treated with PDT with pain relieving techniques or to let the support of pain relieving measures depend on the reported pain score for the primary session.     

Analysis of selection effects in New York City's Medicaid managed care population prior to mandatory enrollment

It is becoming increasingly apparent that over the next several years the majority of Medicaid patients in many states will become enrolled in managed care plans, some voluntarily, but most as the result of mandatory initiatives. An important issue related to this development is the extent to which this movement to managed care is accompanied by serious selection effects, either across the board during the phase in or among individual plans or plan types with full-scale implementation. This paper examines selection effects in New York City between 1993 and 1997 during the voluntary enrollment period prior to implementation of mandatory enrollment pursuant to a Section 1115 waiver. No substantial selection bias was documented between patients entering managed care and those remaining in the fee-for-service system among the largest rate groups, although some selection effect was found among plans and plan types (with investor-owned plans enrolling patients with lower prior utilization and expenses).     

The somatostatin analogue, octreotide, modifies both steroidogenesis and IGFBP-1 secretion in human luteinizing granulosa cells

The effect of the somatostatin analogue octreotide on the secretion of progesterone and insulin-like growth factor binding protein-1 (IGFBP-1) from human granulosa-luteal cells was investigated. Octreotide (10(- 11), 10(-10) and 10(-9) M) alone induced a significant decrease in progesterone secretion (maximum suppression 69 +/- 5% of control: P < 0.0001). In contrast, treatment with octreotide in combination with human chorionic gonadotrophin (HCG), at 1 IU/ ml potentiated the stimulatory effect of HCG on progesterone secretion (HCG alone 201 +/- 3% of control: HCG + octreotide 10(-9) M 318 +/- 16%: P < 0.001). Treatment with octreotide increased the secretion of IGFBP-1 (maximum stimulation 254 +/- 25% of control: P < 0.01). No effect of HCG was seen on secretion of IGFBP-1. These findings raise the possibility that somatostatin may have a modulatory role in regulating steroidogenesis by the human corpus luteum. Further studies are required to establish the physiological significance of any such function.      

T cells discriminate between differentially phosphorylated forms of alphaB-crystallin, a major central nervous system myelin antigen

Factors such as developmental stage or physiological and infectious stress may change patterns of post-translational protein modification. In order to determine whether such regulated types of modification may influence T cell responsiveness to self proteins we examined the T cell response of SJL (H-2s) mice to alphaB-crystallin, a small heat shock protein that can exist in differentially phosphorylated forms. Epitope mapping revealed the presence of two T cell epitopes that are presented by I-As. One major epitope including residues 41-56 contains an amino acid residue (Ser45) that can be phosphorylated as the result of aging or stress. Accordingly, T cells from SJL mice discriminate between preparations of alphaB-crystallin that differ in their extent of phosphorylation at the level of whole protein as well as at the level of determinant-specific responses. Phosphorylation at Ser45 does not prevent binding of the peptide 41-56 to I-As and computer-assisted modelling of the peptide-MHC complex suggests that the phosphate group of the bound peptide extends outwards from the peptide-binding cleft and may thus be available for direct contact with TCR. Together, our data provide evidence that stress-inducible phosphorylation of alphaB- crystallin creates neo-determinants for T cells and, therefore, may contribute to the breakdown of peripheral tolerance to this self protein.      

Variable effect of growth hormone on growth and final adult height in Scottish patients with Turner's syndrome

The aim of this work was to assess the outcome of recombinant growth hormone (rGH) therapy in a large unselected group (72) of patients with Turner's syndrome (TS), 26 of whom have reached final height. Growth data were collected from Scottish patients with TS and outcome was assessed in three ways: response to therapy in the first year, response in subsequent years and final height. Phenotypic, auxological, genetic and biochemical factors, all of which may have affected the first-year response, were investigated. Fifty-one percent of the cohort had a clinically "good" first-year response to therapy and 49% had a "poor" response; a "good" response was defined as a change in the TS standard deviation score (SDS) of +0.5 or more and a "poor" response as a change in the TS SDS of less than +0.5. The percentage of children showing a positive change in TS SDS after 2, 3 and 4 years of therapy declined (88%, 78%, 41%). Mean (range) final height was 142.6 (133.4–153.6) cm, mean (range) pretreatment TS SDS was -0.27 (-2.1 to +1.09) and mean (range) final TS SDS was -0.05 (-1.4 to +1.59). Thirteen (50%) patients attained a final height that was greater than projected, eleven did not attain their projected final height and two achieved their exact projected final height. Short girls with TS appear to benefit more from rGH supplementation than tall girls, but otherwise there was no significant correlation between any of the parameters studied and the response to treatment. It is concluded that large-scale prospective studies are still required to assess the impact of rGH on final height in TS and to identify factors responsible for the variability in response.     

A cross‐sectional study of psychological morbidity in patients with acne,psoriasis and atopic dermatitis in specialist dermatology and general practices

Background There is considerable evidence for an association of skin diseases with psychological morbidity. This relationship is best established for acne, psoriasis and atopic eczema. Previous studies have mostly been performed in specialist dermatological practice, and there is a lack of studies that include patients from general practice and a lack of controlled studies employing multivariate analysis. Aims/objectives This study aims to examine the relationship of acne, psoriasis and atopic eczema with psychological morbidities in patients recruited from general practice as well as specialist dermatology practice. Methods and subjects In this cross‐sectional study, 108 patients from general and specialist dermatology practices with the three diseases had disease severity assessed and completed measures of minor psychological disturbance (General Health Questionnaire‐12), anxiety and depression (Hospital Anxiety and Depression Scale), public self‐consciousness and social anxiety (Fenigstein Self‐Consciousness Scale), and neuroticism and extraversion/introversion (Eysenck Personality Inventory). Demographic data were also collected, along with self‐ratings of disease severity. Control subjects were 96 patients without skin disease recruited from the same general practices as the subjects. Results On univariate analyses, patients with skin disease had higher levels of minor psychological disturbance, public self‐consciousness and neuroticism than did controls. There were no differences in psychological measures between specialist and general practice patients or between patients with different skin diseases. On multivariate analyses, the significant differences did not persist. Conclusions This study demonstrates confounding in the relationship of skin diseases with psychological morbidity. The complex relationship of skin disease and psychological morbidity should be re‐examined.