Timely integration of palliative care. the reality check. a retrospective analysis.

PURPOSE: A large volume of literature suggests that timely integration of palliative care (PC) enhances the well-being, quality of life and satisfaction of patients and their families. It may also positively impact clinical outcomes and healthcare costs throughout the disease trajectory. Therefore, reviewing clinical practice to reflect real-life situations regarding timely PC integration is essential. METHODS: This study, conducted at the Vienna General Hospital between March 2016 and August 2022, retrospectively examined PC consultation (PCC) requests. It aimed to assess the timeliness of PC integration by analysing the duration between diagnosis and the first PCC request, as well as the interval between the first PCC request and death. RESULTS: This study included 895 PCCs. The median time from diagnosis to the first PCC was 16.6 (interquartile range (IQR): 3.9-48.4) months, while the median time from the first PCC to death was 17.2 (IQR: 6.1-50.7) days. The median time from diagnosis to first PCC was 10.4 months in females (confidence interval (CI): 6.0-14.8) compared to 10.6 months in males (CI: 8.1-13.1; p = 0.675). There were no gender disparities in the time from first PCC to death, with a median of 23.3 days (CI: 15.6-31.0) for females and 22.3 days (CI: 16.2-28.4) for males (p = 0.93). Fifty percent of patients died between 5 and 47 days after the first PCC. CONCLUSION: These findings highlight the discrepancy between the clinical perception of PC as end-of-life care and the existing literature, thereby emphasising the importance of timely PC integration.

Estrogen receptor α: a critical role in successful female cognitive aging.

Due to potential health risks, current recommendations are that individuals who wish to use hormone therapy to treat menopausal symptoms do so for the shortest period of time possible. In our investigation into how short-term use of estrogens in midlife following loss of ovarian function exerts long-term effects on female cognitive aging in rodents, we discovered a link between the ability of previous exposure to estradiol to enhance memory in the long term and its ability to increase estrogen receptor α (ERα) levels in the hippocampus, a brain area important for memory. Follow-up studies in model systems implicate a role for ERα in enhanced cognitive function independent of ovarian or exogenously administered estrogens. Results are consistent with clinical studies in which brain ERα levels in older women and men are related to cognitive functioning and risk of cognitive decline is associated with polymorphisms in the gene that transcribes ERα. Research in preclinical models reveals mechanisms through which ERα can be activated and affect cognition in the absence of ovarian estrogens, including ligand-independent activation via insulin-like growth factor-1 signaling and activation by brain-derived neuroestrogens. This report reviews preclinical and clinical data that collectively point to the importance of ERα in cognition and highlights the need to differentiate the role of estrogen receptors from their classical ligands as we seek approaches to facilitate successful cognitive aging.

Recurrent digital fibroma, focal dermal hypoplasia, and limb malformations.

Recurrent digital fibroma of infancy generally is considered a sporadic tumor of childhood. We describe the case of a mother with recurrent digital fibroma at a young age who gave birth to a daughter with focal dermal hypoplasia, coloboma of the iris and eyelids, anal atresia, and extensive limb malformations. When the infant was 3 months old, fibromas started to appear at the fingertips. The cases of three additional patients are described, with a similar combination of multiple digital fibromas, pigmented marks on the temporal region, and limb malformations. One of these patients has consanguineous parents. The clinical findings overlap partially with Gorlin-Goltz syndrome, which has been renamed by some authors "microphthalmia with linear skin defects" (MLS). Since the skin signs are clearly different, however-more like those of Setleis syndrome ("forceps mark" temporal dysplasia)-the patients described here seem to have a new combination of congenital malformations. Deletion of distal Xp, known to occur in some MLS patients, was not detected using cosmids in fluorescence in situ hybridization. This pattern of digital fibroma with congenital malformations seems to represent a new syndrome.

Influence of suture technique and suture material selection on the mechanics of end-to-end and end-to-side anastomoses.

Experiments were performed in dogs to evaluate the mechanics of 26 end-to-end and 42 end-to-side artery-vein graft anastomoses constructed with continuous polypropylene sutures (Surgilene; Davis & Geck, Division of American Cyanamid Co., Danbury, Conn.), continuous polybutester sutures (Novafil; Davis & Geck), and interrupted stitches with either suture material. After construction, the grafts and adjoining arteries were excised, mounted in vitro at in situ length, filled with a dilute barium sulfate suspension, and pressurized in 25 mm Hg steps up to 200 mm Hg. Radiographs were obtained at each pressure. The computed cross-sectional areas of the anastomoses were compared with those of the native arteries at corresponding pressures. Results showed that for the end-to-end anastomoses at 100 mm Hg the cross-sectional areas of the continuous Surgilene anastomoses were 70% of the native artery cross-sectional areas, the cross-sectional areas of the continuous Novafil anastomoses were 90% of the native artery cross-sectional areas, and the cross-sectional areas of the interrupted anastomoses were 107% of the native artery cross-sectional areas (p < 0.05). At physiologic pressures, there were no differences in compliance among the three types of anastomosis. These data suggest that when constructing an end-to-end anastomosis in a small vessel, one should use an interrupted suture line or possibly continuous polybutester suture. Forty-two end-to-side anastomoses demonstrated no differences in cross-sectional areas or compliance for the three suture techniques. This suggests that, unlike with end-to-end anastomoses, when constructing an end-to-side anastomosis in patients any of the three suture techniques may be acceptable.

Transsternal repair of coarctation and associated cardiac defects.

Over a 13-year period, 20 infants and children underwent transsternal approach for repair of coarctation and associated cardiac defects. Fifteen patients (75%) were operated on in the last 6 years. Thirteen patients (group 1) had intracardiac shunts and 7 (group 2), intracardiac obstruction or valvular insufficiency. Group 1 had a mean age of 0.8 +/- 1.9 years versus 4 +/- 3 years for group 2 (p = 0.05). There were 12 patients (92%), 7 months old or less in group 1. Aortic arch hypoplasia was present in 6 patients in group 1. A large patent ductus arteriosus was present in 5 of these 6 patients versus no patent ductus arteriosus in patients without aortic arch hypoplasia (p = 0.006). The mean pulmonary blood flow to systemic blood flow ratio in group 1 was 3.8 +/- 2 and the mean right ventricular to left ventricular ratio, 0.8 +/- 0.2. The coarctation repair fell mostly into three types: side patch aortoplasty (8), ductal tissue excision and patch aortoplasty of the concavity of the aortic arch (6), and subclavian aortoplasty (4). There was one early death (5%) which was due to sepsis in a newborn. Another newborn who had subclavian aortoplasty needed a left carotid artery--descending aorta bypass conduit early because of aortic arch hypoplasia. All patients were followed to 12 years (mean follow-up, 4.3 +/- 3.5 years). There were no late deaths. Two patients had recurrent coarctation, 1 after an end-to-end repair and the other because of incomplete arch enlargement after a side patch aortoplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Disruption of sutured pulmonary valve in Fontan operation.

Two patients who had undergone a Fontan operation presented late with considerable disruption of a sutured pulmonary valve. Both patients had increasing ascites, decreased exercise tolerance, atrial arrhythmias, high right atrial pressure, and a large ratio of pulmonary blood flow to systemic blood flow. At operation, the main pulmonary artery was closed either by suturing the anterior and posterior walls together immediately distal to the pulmonary valve or by reinforcing the resutured pulmonary valve with a polytetrafluoroethylene patch. Both patients had an uneventful postoperative course, with disappearance of the symptoms and return of sinus rhythm. Although it is tempting to simply suture the usually thickened pulmonary valve in the Fontan operation, approximation of the pulmonary artery walls or patch reinforcement is necessary to minimize disruption.

Wavelength dependency of the rate of iodine catalyzed photoisomerization of retinol and retinal.

In separate experiments, hydrocarbon solutions of the 11-cis isomers of retinol and retinal containing catalytic amounts of iodine were irradiated with monochromatic light. Changes in absorbance were followed spectroscopically for each wavelength of light and measured as a function of time. The curve obtained by plotting the change in absorbance (delta A) vs time (t) is a hyperbola, and thus the plot of 1/delta A vs 1/t forms a straight line. The half reaction time, t1/2, was extracted from this equation, giving a value for each wavelength of light. The parameter 1/t1/2 is adjusted to compensate for variation of light quanta from the xenon source, and it is plotted vs wavelength. A response spectrum is obtained that is a Gaussian. The lambda max is 510 nm for retinol and 519 nm for retinal. This shows that in the photoisomerization iodine is the absorbing species and not the carbocation, which absorbs at 589 nm.

Effects of hypovolemia on aortic baroreflex control of heart rate in humans.

INTRODUCTION: To test the hypothesis that hypovolemia can acutely increase the sensitivity of chronotropic baroreflex response, eight men (21-45 yr old) underwent measurements of heart rate response to aortic baroreceptor stimulation under normovolemic and hypovolemic conditions. METHODS: Hypovolemia was acutely induced by a bolus injection of 30 mg of furosemide. The sensitivity of the aortic-cardiac baroreflex was determined with a approximately 15 mmHg elevation in mean arterial pressure (MAP) induced by steady-state infusion of 30 to 97 micrograms.min-1 phenylephrine (PE) combined with approximately 13 mmHg lower body negative pressure (LBNP) to counteract central venous pressure elevations, and 17-19 mmHg neck pressure (NP) to offset increases in carotid sinus transmural pressure. The aortic-cardiac baroreflex gain was assessed by determining the ratio of the change in heart rate to the change in MAP (delta HR/delta MAP) between baseline and aortic baroreceptor isolated conditions (i.e., PE + LBNP + NP stage). RESULTS: When compared to normovolemia (3182 +/- 163 ml), furosemide-induced hypovolemia (2812 +/- 101 ml) resulted in an average 12% reduction in plasma volume (p = 0.05). Hypovolemia increased the average gain of the aortic-cardiac baroreflex by 68% (0.71 +/- 0.26 to 1.19 +/- 0.37 beats.min-1.mmHg-1; p = 0.0349) while it had no effect on the calculated response of the carotid-cardiac baroreflex. CONCLUSIONS: These results indicate that greater aortic baroreflex sensitivity observed in individuals who are physically untrained or have been exposed to microgravity may be explained by smaller vascular volume rather than differences in autonomic function associated with adaptations to lower aerobic capacity.

Altitude decompression sickness: hyperbaric therapy results in 528 cases.

We reviewed 528 cases of decompression sickness (DCS) resulting from altitude exposure (either aircraft or altitude chamber) during the period 1 January 1977 through 31 December 1986, and treated with hyperbaric therapy. Data collected include age, sex, date and place of origin, duty position, type of exposure, altitude, diagnosis, treatment, and result. Analysis of the data described maximum altitudes of exposure, time to onset of symptoms, diagnosis, and the treatment tables used. Significant results include an increased incidence of altitude DCS requiring hyperbaric therapy among females (relative risk for females is 4.3 times that of males), no significant difference in incidence rates between duty positions in the altitude chamber exposures reviewed, and confirmation of the efficacy of hyperbaric oxygen therapy.

Effects of hypovolemia and posture on responses to the Valsalva maneuver.

INTRODUCTION: We tested the hypotheses that hypovolemia would result in attenuated elevation in blood pressure, greater baroreflex-mediated tachycardia, and reduced capacity for vasoconstriction during a Valsalva maneuver (VM). METHODS: Heart rate (HR) and mean arterial pressure (MAP) were measured beat-by-beat before strain, during a 15-s VM strain at 30 mmHg expiratory pressure, and post-strain. Eight subjects performed three VM trials in each of three postures (supine, sitting, and standing) under two experimental conditions (normovolemic and hypovolemic). Hypovolemia was acutely induced by a bolus injection of 30 mg furosemide. Each experimental condition was conducted on a different day, separated by one week. delta MAP was used in analyses of phase I, late phase II (an indicator of vasoconstriction) and phase III of VM. The ratio delta HR/delta MAP, an index of nonspecific baroreflex control of HR, was used in analysis of early phase II and phase IV of the VM. RESULTS: Compared to normovolemia, hypovolemia resulted in 12% lower plasma volume (p = 0.0001). delta MAP for both phase I and phase III of the VM differed between postures (p = 0.0132 and p = 0.0003, respectively) and was lower in the hypovolemic condition than in the normovolemic condition for phase I in the standing posture (-5 mmHg, p = 0.0385). CONCLUSIONS: HR and blood pressure responses to alterations in intrathoracic pressure are affected by fluid redistribution (posture change), but not by circulating blood volume. Therefore, our results did not support our hypothesis that hypovolemia would result in attenuated elevation in blood pressure, greater baroreflex-mediated tachycardia, and reduced capacity for vasoconstriction during a Valsalva maneuver. However, moderate hypovolemia can be specifically predicted by the phase I response to a VM performed in the standing posture.

Text - background polarity affects performance irrespective of ambient illumination and colour contrast.

In a series of experiments, proofreading performance was consistently better with positive polarity (dark text on light background) than with negative polarity displays (light text on dark background). This positive polarity advantage was independent of ambient lighting (darkness vs. typical office illumination) and of chromaticity (black and white vs. blue and yellow). A final experiment showed that colour contrast (red text on green background) could not compensate for a lack of luminance contrast. Physiological measures of effort and strain (breathing rate, heart rate, heart rate variability and skin conductance level) and self-reported mood, fatigue, arousal, eyestrain, headache, muscle strain and back pain did not vary as a function of any of the independent variables, suggesting that participants worked equally hard in all experimental conditions, so that the interpretation of the primary performance measure was unlikely to be contaminated by a performance-effort trade-off.

Absorbable mesh splenorrhaphy for severe splenic injuries: functional studies in an animal model and an additional patient series.

Polyglycolic acid mesh has been introduced as a method of controlling hemorrhage in severely damaged spleens. This study examines the effect of splenic wrapping on the immune function of the spleen, and also on its ability to control splenic bleeding in trauma patients. Thirty purebred beagle dogs were divided into three groups and subjected to sham operation (Group 1), splenectomy (Group 2), and splenic wrap (Group 3). Immunologic studies showed no difference between the wrapped group (Group 3) and those with their spleens intact (Group 1) in the induction of specific antibody-producing lymphocytes in splenic tissue after the injection of attenuated Pneumococci. All splenic injuries treated at Cook County Hospital between January 1985 and May 1988 were retrospectively analyzed. Of 60 patients with splenic injuries, 14 underwent mesh splenorrhaphy without mortality or serious complications. This study demonstrates that the immune function of spleen is preserved following mesh splenorrhapy, and that this technique can be used in a clinical setting with safe and efficacious results.