Integration of palliative care practices into the ongoing care of children with cancer: individualized care planning and coordination

Most parents of children with cancer have dual primary goals: a primary cancer-directed goal of cure and a primary comfort-related goal of lessening suffering. Early introduction of palliative care principles and practices into their child's treatment is respectful and supportive of these goals. The Individualized Care Planning and Coordination Model is designed to integrate palliative care principles and practices into the ongoing care of children with cancer. Application of the model helps clinicians to generate a comprehensive individualized care plan that is implemented through Individualized Care Coordination processes as detailed here. Clinicians' strong desire to provide compassionate, competent, and sensitive care to the seriously ill child and the child's family can be effectively translated into clinical practice through these processes.     

Health-related quality of life in adolescents at the time of diagnosis with osteosarcoma or acute myeloid leukemia

Although measuring health-related quality of life (HRQoL) in adolescents with cancer helps clinicians to personalize care for their patients, no previous studies have included HRQoL measurement at the time of diagnosis of osteosarcoma (OS) or acute myeloid leukemia (AML). The purpose of this study was to evaluate the feasibility of measuring adolescents' HRQoL at the time of their diagnosis of OS or AML, and to compare their ratings with those of their parents and of similarly diagnosed but younger patients aged 8–12 years. Participants included 126 patients (79 adolescents) and 130 parents (78 parents of adolescents); most completed the HRQoL instrument/s within 48 h of the first chemotherapy cycle. Ninety-three percent of adolescents diagnosed with OS and 93% of those diagnosed with AML completed the HRQoL instruments. Agreement between the adolescents and their parents ranged from 0.29 to 0.71 (OS) and 0.44 to 0.62 (AML). In all domains, OS adolescents had significantly lower PedsQL v.4.0 scores than adolescents with AML. Our findings demonstrates the feasibility of measuring HRQoL in adolescents with OS or AML (and their parents) at the time of diagnosis, and thus their HRQoL ratings can be used to inform their cancer care from diagnosis forward.     

Psychometric and Clinical Assessment of the 10-Item Reduced Version of the Fatigue Scale—Child Instrument

Fatigue is one of the most debilitating conditions associated with cancer and anticancer therapy. The lack of reliable and valid self-report instruments has prevented accurate assessment of fatigue in pediatric oncology patients. The purpose of this study was to identify the most sensitive and specific score, that is, the “cut score,” on the Fatigue Scale-Child (FS-C) to identify those children with high cancer-related fatigue in need of clinical intervention. We first used Rasch methods to identify the items on the FS-C that distinguished children with high cancer-related fatigue from other children; our findings indicated that the FS-C needed to be reduced from 14 items to 10 items. We then assessed the 10-item FS-C for its psychometric properties and applied the receiver operating characteristics curve analysis to the FS-C responses from 221 children (aged 7–12 years) receiving anticancer treatment. The cut score identified with 75% sensitivity and 73.5% specificity was 12; 73 (33%) patients scored 12 or higher. Findings from this validated instrument provide a needed guide for clinicians to interpret fatigue scores and provide clinical interventions for this debilitating condition to their pediatric patients with cancer.     

Point of care estimation of haemoglobin in neonates

OBJECTIVE: To evaluate whether measurement of haemoglobin concentration in neonates using point of care testing agrees with laboratory measurement. DESIGN: 127 paired blood samples taken from babies on a neonatal intensive care unit for full blood count and blood gas analysis by point of care testing were reviewed according to current practice. A comparison was made between the laboratory and blood gas analyser haemoglobin measurements to assess limits of agreement and look for any systematic difference. SETTING: Neonatal Unit, Jessop Wing, Royal Hallamshire Hospital, Sheffield, UK PATIENTS: Babies staying on the neonatal unit, who currently have contemporaneous blood samples taken for full blood count and blood gas analysis by point of care testing. INTERVENTION: Results from blood samples were reviewed. MAIN OUTCOME MEASURE: Comparison between laboratory and point of care testing haemoglobin concentrations. RESULTS: The mean laboratory haemoglobin concentration was 155 g/l (range 30-226 g/l); the mean point of care testing haemoglobin concentration was 157 g/l (range 30-228 g/l). The mean (SD) difference between paired samples was 2 (11) g/l; 95% CI -4.0 to 0.1 g/l; and limits of agreement -23 to 19 g/l. CONCLUSIONS: The blood gas analyser on the neonatal unit at Royal Hallamshire Hospital, Sheffield, gives a useful estimation of haemoglobin concentration compared with laboratory measurement, with smaller sample volume. Although this does not replace a full blood count, it is a useful adjunct to neonatal care monitoring.     

Assessing functional mobility in survivors of lower-extremity sarcoma: reliability and validity of a new assessment tool

BACKGROUND: Reliability and validity of a new tool, Functional Mobility Assessment (FMA), were examined in patients with lower-extremity sarcoma. FMA requires the patients to physically perform the functional mobility measures, unlike patient self-report or clinician administered measures. PROCEDURE: A sample of 114 subjects participated, 20 healthy volunteers and 94 patients with lower-extremity sarcoma after amputation, limb-sparing, or rotationplasty surgery. Reliability of the FMA was examined by three raters testing 20 healthy volunteers and 23 subjects with lower-extremity sarcoma. Concurrent validity was examined using data from 94 subjects with lower-extremity sarcoma who completed the FMA, Musculoskeletal Tumor Society (MSTS), Short-Form 36 (SF-36v2), and Toronto Extremity Salvage Scale (TESS) scores. Construct validity was measured by the ability of the FMA to discriminate between subjects with and without functional mobility deficits. RESULTS: FMA demonstrated excellent reliability (ICC [2,1] >or=0.97). Moderate correlations were found between FMA and SF-36v2 (r = 0.60, P < 0.01), FMA and MSTS (r = 0.68, P < 0.01), and FMA and TESS (r = 0.62, P < 0.01). The patients with lower-extremity sarcoma scored lower on the FMA as compared to healthy controls (P < 0.01). CONCLUSION: The FMA is a reliable and valid functional outcome measure for patients with lower-extremity sarcoma. This study supports the ability of the FMA to discriminate between patients with varying functional abilities and supports the need to include measures of objective functional mobility in examination of patients with lower-extremity sarcoma.     

Variation in Salmonella enterica Serovar Typhi IncHI1 Plasmids during the Global Spread of Resistant Typhoid Fever

A global collection of plasmids of the IncHI1 incompatibility group from Salmonella enterica serovar Typhi were analyzed by using a combination of DNA sequencing, DNA sequence analysis, PCR, and microarrays. The IncHI1 resistance plasmids of serovar Typhi display a backbone of conserved gene content and arrangement, within which are embedded preferred acquisition sites for horizontal DNA transfer events. The variable regions appear to be preferred acquisition sites for DNA, most likely through composite transposition, which is presumably driven by the acquisition of resistance genes. Plasmid multilocus sequence typing, a molecular typing method for IncHI1 plasmids, was developed using variation in six conserved loci to trace the spread of these plasmids and to elucidate their evolutionary relationships. The application of this method to a collection of 36 IncHI1 plasmids revealed a chronological clustering of plasmids despite their difference in geographical origins. Our findings suggest that the predominant plasmid types present after 1993 have not evolved directly from the earlier predominant plasmid type but have displaced them. We propose that antibiotic selection acts to maintain resistance genes on the plasmid, but there is also competition between plasmids encoding the same resistance phenotype.     

Trauma and motorcyclists: born to be wild, bound to be injured?

BACKGROUND: Regrettably motorcyclists frequently suffer related significant injuries. Doctors who manage trauma will encounter victims of motorcycle accidents and many aspects of care are unique to these patients due to the protective and performance enhancing equipment used by motorcyclists. This review examines the patterns of major injuries suffered by motorcyclists, the unique aspects of airway, circulatory and spine management, and suggests some interventions, which may allow primary injury prevention for the future. DATA SOURCE: Literature searches of the PubMed, EMBASE and Cochrane library with hand searches and author's experience. INTERVENTIONS: None. DATA SYNTHESIS AND CONCLUSIONS: The airway and (cervical and thoracolumbar) spine cannot be managed effectively in the helmeted patient with a speed hump in place and intubation by direct laryngoscopy is almost impossible with a speed hump in place. Helmets should be removed and the speed hump cut from the leathers. Leathers act as fracture splints, particularly for pelvis and lower extremities. Removal or extensive cutting away of the lower portion of leathers should be considered as part of "circulation", and only take place in a medical facility and in anticipation of circulatory deterioration. Motorcyclists sustaining thoracic spinal damage more frequently than cervical and spinal fractures at multiple levels are common. Back protectors are used commonly and these may be left in situ for extrication on a spinal board, but they should be removed in-hospital to allow full assessment. Injury prevention will require coordinated research and development of a number of key pieces of equipment and design in particular helmets, speed humps and clothing/textiles. In managing the injured motorcyclist in the pre or in-hospital settings, health professionals require greater awareness of the implications of such devices, which at the present time appears largely restricted to motorcycling enthusiasts.     

Choosing a theoretical framework to guide HESI exit examination research

This article responds to issues raised in 2004 by Spurlock and Hanks, who interpreted data that were presented in four published studies describing the validity of the Health Education Systems, Inc. (HESI) Exit Examination. The argument for using classical testing theory as the preferred theoretical framework to a clinical disease detection model is advanced. While the Spurlock and Hanks article promotes a philosophical bias against the establishment of progression policies within schools of nursing, this article offers another assessment of the merits of detecting at-risk students so timely remediation can occur prior to administration of the National Council Licensure Examination for Registered Nurses (NCLEX-RN). From data presented in the four validity studies, the HESI Exit Examination was reported to be 96.36% to 98.30% accurate in predicting NCLEX-RN success, and those original findings are reaffirmed.     

Development of a reinforced porcine elastin composite vascular scaffold

Elastin, a principal structural component of native arteries, has distinct biological and mechanical advantages when used as a biomaterial; however, its low ultimate tensile strength has limited its use as an arterial conduit. We have developed a scaffold, consisting of a purified elastin tubular conduit strengthened with fibrin bonded layers of acellular small intestinal submucosa (aSIS) for potential use as a small diameter vascular graft. The addition of aSIS increased the ultimate tensile strength of the elastin conduits nine-fold. Burst pressures for the elastin composite vascular scaffold (1,396 +/- 309 mmHg) were significantly higher than pure elastin conduits (162 +/- 36 mmHg) and comparable to native saphenous veins. The average suture pullout strength of the elastin composite vascular scaffolds was 14.612 +/- 3.677 N, significantly higher than the pure elastin conduit (0.402 +/- 0.098 N), but comparable to native porcine carotid arteries (13.994 +/- 4.344 N). Cyclic circumferential strain testing indicated that the composite scaffolds were capable of withstanding physiological loading conditions for at least 83 h. Implantation of the elastin composites as carotid interposition grafts in swine demonstrated its superiority to clinically acceptable ePTFE with significantly longer average patency times of 5.23 h compared to 4.15 h. We have developed a biologically based elastin scaffold with suitable mechanical properties and low thrombogenicity for in vivo implantation, and with the potential for cellular repopulation and host integration reestablishing an appropriate elastic artery.     

Treatment with GH and IGF-1 in critical illness

Trauma, sepsis, and surgery are associated with global hypercatabolism and a negative nitrogen balance. When critical illness is prolonged the relentless loss of lean tissue becomes functionally important. Protein catabolism in the critically ill patient is associated with complex changes in the growth hormone (GH)/insulin-like growth factor-1 (IGF-1) axis. Many small clinical studies indicate that treatment with recombinant human (rh) GH would be a safe and effective means of limiting the deleterious effects of the catabolic response. Unexpectedly, however, two large prospective randomized controlled trials (PRCTs) demonstrated that administration of rhGH to long-stay critically ill adults increases morbidity and mortality. Some progress has been made in understanding the mechanisms underlying this observation.