Strengthening primary health care teams with palliative care leaders: protocol for a cluster randomized clinical trial.

BACKGROUND: The objective of the Balearic Islands Palliative Care (PC) Program is to improve the quality of PC through a shared model consisting of primary health care professionals, home-based PC teams, and PC units in hospitals. According to the World Health Organization (WHO), patients with advanced cancer and other terminal diseases benefit from early identification and proactive PC. We will evaluate the effectiveness of an intervention in which a PC leader is established in the primary health care center, and assess the effect of this intervention on the early identification of patients in need of PC, the efficient use of health care services, and direct health care costs. METHODS: Design: A two-arm cluster randomized clinical trial of 30 Primary Health Care Centers (PHCC) in Mallorca (Spain), in which each center was randomized to an intervention arm or a usual care arm. We expect that the number of patients identified as suitable for PC (including non-oncological PC) is at least 5% greater in the intervention arm. SAMPLE SIZE: A total of 4640 deceased patients. Outcomes will be assessed by a blinded external review of the electronic records. INTERVENTIONS: General practitioners (GPs) and nurse leaders in PC for each PHCC will be appointed. These leaders will help promote PC training of colleagues, improve symptom management and psychological support of patients, and evaluate the complexity of individual cases so that these cases receive assistance from PC home-based teams. MEASUREMENTS: Early identification (>90 days before death), evaluation of case complexity, level of case complexity (with referral to a home-based PC team), use and cost of hospital and primary care services, and quality of life during the last month of life (≥2 emergency room visits, ≥2 hospital admissions, ≥14 days of hospitalization). DISCUSION: PC leaders in primary care teams will improve the early identification of patients eligible for PC. This initiative could improve the quality of end-of-life care and utilization of hospital resources. TRIAL REGISTRATION: ISRCTN Registry identifier: ISRCTN92479122 . Retrospectively registered on 28 February 2017.

Prognostic understanding, quality of life and mood in patients undergoing hematopoietic stem cell transplantation.

Little is known about how patients undergoing hematopoietic stem cell transplantation (HCT) and their family caregivers (FC) perceive their prognosis. We examined prognostic understanding in patients undergoing HCT and their FC and its relationship with quality of life (QOL) and mood. We conducted a longitudinal study of patients (and FC) hospitalized for HCT. We used a questionnaire to measure participants' prognostic understanding and asked the oncologists to estimate patients' prognosis prior to HCT. We assessed QOL and mood weekly and evaluated the relationship between prognostic understanding, and QOL and mood using multivariable linear mixed models. We enrolled 90 patients undergoing (autologous (n=30), myeloablative (n=30) or reduced intensity allogeneic (n=30)) HCT. About 88.9% of patients and 87.1% of FC reported it is 'extremely' or 'very' important to know about prognosis. However, 77.6% of patients and 71.7% of FC reported a discordance and more optimistic prognostic perception compared to the oncologist (P<0.0001). Patients with a concordant prognostic understanding with their oncologists reported worse QOL (ß=-9.4, P=0.01) and greater depression at baseline (ß=1.7, P=0.02) and over time ((ß=1.2, P<0.0001). Therefore, Interventions are needed to improve prognostic understanding, while providing patients with adequate psychological support.

Intrauterine light delivery for photodynamic therapy of the human endometrium.

Photodynamic therapy is currently being evaluated as a minimally invasive procedure for endometrial ablation not requiring anaesthesia. Light penetration depths at 630, 660 and 690 nm and the optimal configuration of intrauterine light-diffusing fibres were determined in 14 human uteri to assist in the design of a light intrauterine device. Post-menopausal ex-vivo uteri showed a significantly lower light penetration depth than pre-menopausal uteri. With a single central diffusing fibre inserted, the fluence rate measured in the uterine wall at the most remote point of the cavity decreased to 1.1 +/- 0.4% of that measured at closest proximity, whereas it decreased to only 40.0 +/- 9.0% with three fibres. Distension of the uterine cavity with 2 ml of an optically clear fluid increased the fluence rate at the fundus between the fibres at a depth of 2 mm by a factor of 4. We conclude that in normal-sized pre-menopausal uterine cavities, three diffusing fibres will deliver an optical dose above the photodynamic threshold level at a depth of 4 mm, even in the most remote areas, in < 30 min without causing thermal damage. For distorted and elongated cavities, either slight distension of the cavity or the insertion of a fourth diffusing fibre is required.

Alterations in transmitral flow dynamics in patients with early mitral valve closure and aortic regurgitation.

Ten patients with severe aortic regurgitation (AR) and early diastolic mitral closure demonstrated by M-mode echocardiography (group I) were compared to 10 age-matched patients with severe AR and normal timing of mitral closure to quantify the accompanying alterations in transmitral flow dynamics assessed by pulsed Doppler echocardiography. Transmitral filling period expressed as a fraction of the time available for diastolic filling was significantly shortened in group I patients relative to group II patients (0.50 +/- 0.10 vs 1.04 +/- 0.09, p < 0.001) because early mitral closure truncated transmitral filling and obliterated the atrial contribution to left ventricular filling. The rapid diastolic filling period normalized for the time available for diastolic filling was also shortened for group I patients relative to group II patients (0.49 +/- 0.11 vs 0.64 +/- 0.19; p < 0.05). Early mitral closure in group I patients was functionally incomplete because 9 of the 10 patients had diastolic mitral regurgitation, which was not detected in any patients in group II (p < 0.001). Thus the group I patients with early mitral closure and severe aortic regurgitation had truncated transmitral inflow and diastolic mitral regurgitation. These patients had higher pulmonary capillary wedge pressures (32 +/- 6 vs 11 +/- 9 mm Hg; p < 0.001) and more severe functional limitation (p < 0.001) than group II patients.