Palliative management of malignant bowel obstruction in terminally ill patient.

Mr. P was a 57-year-old man who presented with symptoms of bowel obstruction in the setting of a known metastatic pancreatic cancer. Diagnosis of malignant bowel obstruction was made clinically and radiologically and he was treated conservatively (non-operatively)with octreotide, metoclopromide and dexamethasone, which provided good control over symptoms and allowed him to have quality time with family until he died few weeks later with liver failure. Bowel obstruction in patients with abdominal malignancy requires careful assessment. The patient and family should always be involved in decision making. The ultimate goals of palliative care (symptom management, quality of life and dignity of death) should never be forgotten during decision making for any patient.

A pilot randomised controlled trial comparing a health-related lifestyle self-management intervention with standard cardiac rehabilitation following an acute cardiac event: Implications for a larger clinical trial.

PURPOSE: This pilot study was to assess the feasibility of the health-related lifestyle self-management (HeLM) intervention as a strategy to decrease cardiovascular risk following acute coronary syndrome. METHODS: Participants in this randomised controlled trial were recruited from a tertiary teaching hospital in metropolitan Sydney Australia. The multifaceted HeLM intervention, using the principles of the transtheoretical model, involved the use of bibliotherapy, a structured evidence-based approach to cardiovascular risk reduction, a communication strategy with general practitioners, three supportive telephone calls to participants and provision of behavioural prompts and a health record diary. Differences in behavioural and clinical outcomes between the HeLM intervention group (n=29) and the standard cardiac rehabilitation group (n=22) were assessed. RESULTS: A total of 125 participants screened were eligible for participation in the study. Fifty-one participants, mean age 57 years (+/-8.78) were randomised. At the 8-week follow-up, participants in the HeLM intervention group had a reduced systolic blood pressure compared to the standard care group (120.3 S.D.: 16.3 vs. 126.4 S.D.: 14.6). There were no significant differences in diastolic blood pressure and cholesterol levels between the two groups. Participants in both the intervention and control group had a reduction in waist circumference although when compared to baseline values, women in the HeLM intervention group had a greater reduction compared to those receiving standard care. Patients reported high levels of satisfaction with this intervention. CONCLUSIONS: Findings support the feasibility of implementing the health-related lifestyle self-management intervention for risk factor modification in patients with acute coronary syndrome. An adequately powered randomised controlled trial is required to test the impact of the intervention on cardiovascular risk reduction.

Active life expectancy of older people in Mexico.

BACKGROUND: Social and economic development together with demographic changes and health interventions have resulted in an increase in life expectancy and a rapidly ageing population in Mexico. Whether people will live longer active and independent lives is still, however, unknown. We will address this question, providing the first estimates of active life expectancy by age, sex and local regional area in Mexico. METHODS: Active life expectancy was calculated using the Sullivan method with abridged life tables. Information on the older Mexican population covered by the Mexican Institute of Social Security (IMSS) and the number of deaths for the same group in the year 2000 was obtained from the Office for Health Statistics and Information at IMSS in Mexico. Information on ability to perform basic activities of daily living was obtained from the National Survey on Ageing carried out in IMSS during 1998-99. RESULTS: For males and females combined, active life expectancy decreased from 26.9 years at 60 years to 5.7 years at 85 years. Women's life expectancy exceeded that of men but women lived more years dependent. Similarly, older people in geographical areas with longer life expectancy spent a lower proportion of remaining life active. CONCLUSION: The success in increasing life expectancy above average in some groups of older people covered by IMSS has been accompanied by increments in the proportion of remaining years dependent upon others for help in basic self-care activities.

Alcohol withdrawal as an underrated cause of agitated delirium and terminal restlessness in patients with advanced malignancy.

A significant number of patients with terminal cancer experience terminal restlessness or an agitated delirium in the final days of life. Multifactorial etiologies may contribute to agitation and restlessness for any one patient; alcohol withdrawal may be underrated as a contributing factor. The symptoms and signs of alcohol withdrawal--autonomic dysfunction, tremor, anxiety, sleep disturbances, insomnia, and abnormal vital signs--may continue for 6 to 12 months after the cessation of alcohol. We report four patients with terminal restlessness in whom we believe alcohol withdrawal to be a significant causal factor and a fifth patient who subsequently benefited from our team's increased awareness of this clinical problem. Formal assessment of alcohol withdrawal may be of more value in the palliative setting than using the currently accepted assessment instruments. Many of the medications utilized for the treatment of agitated delirium and terminal restlessness in the palliative care setting are effective therapies for alcohol withdrawal.