[Cardiac sarcoidosis revealed by recurrent ventricular tachycardia]. / Tachycardie ventriculaire récidivante révélant une sarcoïdose cardiaque.

Sarcoidosis is an inflammatory disease whose diagnosis is suggested by clinical and paraclinical signs and confirmed by histological evidence showing granulomatosis without caseous necrosis. The clinical presentation is sometimes misleading and the diagnosis difficult to confirm. We report here the case of a young woman with cardiac sarcoidosis of difficult diagnosis, revealed by a myocardial infarction with normal coronary angiography and recurrent ventricular tachycardia. Multimodal imaging, combined with left ventricular endomyocardial biopsies guided by electrophysiological analysis and endocavitary mapping, finally confirmed the diagnosis, and allowed effective medical treatment.

Factors Influencing Anti-Xa Assays: A Multicenter Prospective Study in Critically Ill and Noncritically Ill Patients Receiving Unfractionated Heparin.

BACKGROUND: The presence of dextran sulfate (DS) in reagents and the type of blood collection tube (citrate/citrated-theophylline-adenosine-dipyridamole [CTAD]) can lead to discrepancies between unfractionated heparin (UFH) anti-Xa levels. OBJECTIVES: To evaluate the extent of the effect (1) of different reagents containing or not containing DS and (2) of the blood collection tubes, on UFH anti-Xa levels, in various clinical situations (NCT04700670). METHODS: We prospectively included patients from eight centers: group (G)1, cardiopulmonary bypass (CPB) after heparin neutralization (n = 39); G2, cardiothoracic intensive care unit (ICU) after CPB (n = 35); G3, medical ICU (n = 53); G4, other medical inpatients (n = 38). Blood was collected into citrated and CTAD tubes. Chromogenic anti-Xa assays were centrally performed, using seven reagent/analyzer combinations including two without DS. The association between anti-Xa levels and covariates was tested using a linear mixed-effects model. RESULTS: We analyzed 4,546 anti-Xa values from 165 patients. Median anti-Xa levels were systematically higher with reagents containing DS, whatever the patient group, with the greatest effect observed in G1 (0.32 vs. 0.05 IU/mL). Anti-Xa levels were slightly higher in CTAD than in citrate samples, irrespective of the assay. The model showed: (1) a significant dextran-patient group interaction (p < 0.0001), the effect of DS on anti-Xa levels varying from 30.9% in G4 to 296% in G1, and (2) a significant effect of CTAD, varying between patient groups (p = 0.0302). CONCLUSION: The variability of anti-Xa levels with a great overestimation of the values, using a reagent containing DS, can lead to different treatment decisions, especially after heparin neutralization by protamine. Clinical consequences of these differences remain to be demonstrated.

Characteristics and Prognosis of Patients With Fibromuscular Dysplasia in a Population of Spontaneous Coronary Artery Dissections (from the French Registry of Spontaneous Coronary Artery Dissections "DISCO").

Spontaneous coronary artery dissection (SCAD) and fibromuscular dysplasia (FMD) are pathologies that appear to be closely related. This study compares the characteristics of the FMD population to the non-FMD population in a SCAD cohort. It thus assesses the involvement of the FMD phenotype in a SCAD population. From the data of the French DISCO registry, we included patients with a diagnosis of SCAD and in whom a search for FMD was performed. We collected the following characteristics of this population: the clinical and angiographic presentation, the data concerning the management, and the events occurring during the follow-up. In the 373 SCADs confirmed in the DISCO registry, we obtained imaging data for 340 of them. FMD was found in 45% of cases. The mean age was higher in the FMD group, 53.2 ± 8.8 years, versus 50.1 ± 11 years in the non-FMD group. High blood pressure and postmenopausal status were significantly higher in the FMD group. Clinical presentation, angiographic data, and management were comparable. The major adverse cardiac event rate and recurrence rate were not different between the 2 groups after 1 year of follow-up. In conclusion, we confirmed a 45% prevalence of FMD in the SCAD population. The median age was higher in the FMD group, suggesting that FMD may develop over time. The rate of major adverse cardiac events and recurrence were similar in the FMD group versus the non-FMD group after 1 year of follow-up.

Complementary pre-screening strategies to uncover hidden prodromal and mild Alzheimer's disease: Results from the MOPEAD project.

INTRODUCTION: The Models of Patient Engagement for Alzheimer's Disease (MOPEAD) project was conceived to explore innovative complementary strategies to uncover hidden prodromal and mild Alzheimer's disease (AD) dementia cases and to raise awareness both in the general public and among health professionals about the importance of early diagnosis. METHODS: Four different strategies or RUNs were used: (a) a web-based (WB) prescreening tool, (2) an open house initiative (OHI), (3) a primary care-based protocol for early detection of cognitive decline (PC), and (4) a tertiary care-based pre-screening at diabetologist clinics (DC). RESULTS: A total of 1129 patients at high risk of having prodromal AD or dementia were identified of 2847 pre-screened individuals (39.7%). The corresponding proportion for the different initiatives were 36.8% (WB), 35.6% (OHI), 44.4% (PC), and 58.3% (DC). CONCLUSION: These four complementary pre-screening strategies were useful for identifying individuals at high risk of having prodromal or mild AD.

Prevention of dementia using mobile phone applications (PRODEMOS): protocol for an international randomised controlled trial.

INTRODUCTION: Profiles of high risk for future dementia are well understood and are likely to concern mostly those in low-income and middle-income countries and people at greater disadvantage in high-income countries. Approximately 30%-40% of dementia cases have been estimated to be attributed to modifiable risk factors, including hypertension, smoking and sedentary lifestyle. Tailored interventions targeting these risk factors can potentially prevent or delay the onset of dementia. Mobile health (mHealth) improves accessibility of such prevention strategies in hard-to-reach populations while at the same time tailoring such approaches. In the current study, we will investigate the effectiveness and implementation of a coach-supported mHealth intervention, targeting dementia risk factors, to reduce dementia risk. METHODS AND ANALYSIS: The prevention of dementia using mobile phone applications (PRODEMOS) randomised controlled trial will follow an effectiveness-implementation hybrid design, taking place in the UK and China. People are eligible if they are 55-75 years old, of low socioeconomic status (UK) or from the general population (China); have ≥2 dementia risk factors; and own a smartphone. 2400 participants will be randomised to either a coach-supported, interactive mHealth platform, facilitating self-management of dementia risk factors, or a static control platform. The intervention and follow-up period will be 18 months. The primary effectiveness outcome is change in the previously validated Cardiovascular Risk Factors, Ageing and Incidence of Dementia dementia risk score. The main secondary outcomes include improvement of individual risk factors and cost-effectiveness. Implementation outcomes include acceptability, adoption, feasibility and sustainability of the intervention. ETHICS AND DISSEMINATION: The PRODEMOS trial is sponsored in the UK by the University of Cambridge and is granted ethical approval by the London-Brighton and Sussex Research Ethics Committee (reference: 20/LO/01440). In China, the trial is approved by the medical ethics committees of Capital Medical University, Beijing Tiantan Hospital, Beijing Geriatric Hospital, Chinese People's Liberation Army General Hospital, Taishan Medical University and Xuanwu Hospital. Results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: ISRCTN15986016.

Blunting periprocedural myocardial necrosis: Rationale and design of the randomized ALPHEUS study.

BACKGROUND: Clopidogrel associated with aspirin is the recommended treatment for patients undergoing elective percutaneous coronary intervention (PCI). Although severe PCI-related events are rare, evidence suggests that PCI-related myocardial infarction and myocardial injury are frequent complications that can impact the clinical prognosis of the patients. Antiplatelet therapy with a potent P2Y12 receptor inhibitor such as ticagrelor may reduce periprocedural ischemic complications while maintaining a similar safety profile as compared with conventional dual antiplatelet therapy by aspirin and clopidogrel in this setting. METHODS: Assessment of Loading with the P2Y12 inhibitor ticagrelor or clopidogrel to Halt ischemic Events in patients Undergoing elective coronary Stenting (ALPHEUS) (NCT02617290) is an international, multicenter, randomized, parallel-group, open-label study in patients with stable coronary artery disease who are planned for an elective PCI. In total, 1,900 patients will be randomized before a planned PCI to a loading dose of ticagrelor 180 mg or a loading dose of clopidogrel (300 or 600 mg) in addition to aspirin. Patients will then receive a dual antiplatelet therapy with aspirin and ticagrelor 90 mg twice daily or clopidogrel 75 mg once daily for 30 days. The primary ischemic end point is PCI-related myocardial infarction (myocardial infarction type 4a or 4b) or major myocardial injury within 48 hours (or at hospital discharge if earlier) after elective PCI/stent. Safety will be evaluated by major bleeding events (Bleeding Academic Research Consortium type 3 or 5) at 48 hours (or discharge if it occurs earlier). CONCLUSION: ALPHEUS is the first properly sized trial comparing ticagrelor to clopidogrel in the setting of elective PCI and is especially designed to show a reduction in periprocedural events, a surrogate end point for mortality.

The MOPEAD project: Advancing patient engagement for the detection of "hidden" undiagnosed cases of Alzheimer's disease in the community.

In most, if not all health systems, dementia is underdiagnosed, and when diagnosis occurs, it is typically at a relatively late stage in the disease process despite mounting evidence showing that a timely diagnosis would result in numerous benefits for patients, families, and society. Moving toward earlier diagnoses in Alzheimer's disease (AD) requires a conscientious and collective effort to implement a global strategy addressing the multiple causes hindering patient engagement at different levels of society. This article describes the design of the Models of Patient Engagement for Alzheimer's Disease project, an ongoing EU-funded public-private multinational initiative that will compare four innovative patient engagement strategies across five European countries regarding their ability to identify individuals with prodromal AD and mild AD dementia, which are "hidden" in their communities and traditionally not found in the typical memory clinic setting. The strategies include an online AD citizen science platform, an open house initiative at the memory clinics, and patient engagement at primary care and diabetologist clinics.

Time-Course Reduction in Patient Exposure to Radiation From Coronary Interventional Procedures: The Greater Paris Area Percutaneous Coronary Intervention Registry.

BACKGROUND: The frequency of complex percutaneous coronary interventions (PCIs) has increased in the last few years, with a growing concern on the radiation dose received by the patients. Multicenter data from large unselected populations on patients' radiation doses during coronary angiography (CA) and PCI and temporal trends are lacking. This study sought to evaluate the temporal trends in patients' exposure to radiation from CA and PCI. METHODS AND RESULTS: Data were taken from the CARDIO-ARSIF registry that prospectively collects data on all CAs and PCIs performed in the 36 catheterization laboratories in the Greater Paris Area, the most populated regions in France with about 12 million inhabitants. Kerma area product and Fluoroscopy time from 152 684 consecutive CAs and 103 177 PCIs performed between 2009 and 2013 were analyzed. A continuous trend for a decrease in median [interquartile range] Kerma area product was observed, from 33 [19-55] Gy cm2 in 2009 to 27 [16-44] Gy cm2 in 2013 for CA (P<0.0001), and from 73 [41-125] to 55 [31-91] Gy cm2 for PCI (P<0.0001). Time-course differences in Kerma area product remained highly significant after adjustment on Fluoroscopy time, PCI procedure complexity, change of x-ray equipment, and other patient- and procedure-related covariates. CONCLUSIONS: In a large patient population, a steady temporal decrease in patient radiation exposure during CA and PCI was noted between 2009 and 2013. Kerma area product reduction was consistent in all types of procedure and was independent of patient-related factors and PCI procedure complexity.

Radial versus femoral access for coronary angiography and intervention is associated with lower patient radiation exposure in high-radial-volume centres: Insights from the RAY'ACT-1 study.

BACKGROUND: Literature suggests that radial access is associated with higher radiation doses than femoral access. AIMS: To compare patient radiation exposure during coronary angiography (CA) and percutaneous coronary intervention (PCI) with radial versus femoral access. METHODS: RAY'ACT is a nationwide, multicentre, French survey evaluating patient radiation in interventional cardiology. Variables of patient exposure from 21,675 CAs and 17,109 PCIs performed at 44 centres during 2010 were analysed retrospectively. RESULTS: Radial access was used in 71% of CAs and 69% of PCIs. Although median fluoroscopy times were longer for radial versus femoral access (CA, 3.8 vs 3.5minutes [P<0.001]; PCI, 10.4 vs 10.1minutes [P=0.001]), the Kerma-area product (KAP) was lower with radial access (CA, 26.8 vs 28.1Gy·cm2; PCI, 55.6 vs 59.4Gy·cm2; both P=0.001). Differences in KAP remained significant in the multivariable analysis (P<0.01), and in a propensity score-matched analysis (P=0.01). A significant interaction was found between KAP and the percentage of procedures with radial access by centre (P<0.001). KAP was higher by radial versus femoral access in low-radial-volume centres, and lower in high-radial-volume centres. Radiation protection techniques, such as the use of low frame rates (7.5 frame/s), were used more frequently in high-radial-volume radial centres. CONCLUSIONS: In this multicentre study, radial access was associated with lower radiation doses to patient than femoral access in high-radial-volume centres. Provided that radioprotection methods are implemented, radial access could be associated with lower patient radiation exposure.

Assessment of global longitudinal strain at low-dose anthracycline-based chemotherapy, for the prediction of subsequent cardiotoxicity.

AIMS: We sought to assess whether global longitudinal strain (GLS) measured early during treatment with anthracyclines (at a cumulative dose of 150 mg/m2) can predict subsequent alterations in left ventricular ejection fraction. METHODS AND RESULTS: Eighty-six patients with Hodgkin's disease, non-Hodgkin's lymphoma, or acute leukaemia and receiving anthracyclines were prospectively included. Patients underwent complete echocardiography on four occasions: baseline (V1); after reaching a cumulative dose of 150 mg/m2 (V2); end of treatment (V3); and 1 year follow-up (V4). Six patients developed cardiotoxicity, defined as a decrease in left ventricular ejection fraction of >10 percentage points, to a value <53%, at V4. GLS measured at V1 and V2 was significantly lower in the cardiotoxicity group vs. the controls (P = 0.042 and P = 0.01, respectively). Compared with GLS at V1, GLS obtained at V2 provided incremental predictive information and appeared to be the strongest predictor of cardiotoxicity (area under the receiver-operating-characteristic curve, 0.82). At a threshold of -17.45% for GLS measured at V2, the sensitivity and specificity of detecting cardiotoxicity were 67% (95% confidence interval 33-100) and 97% (95% confidence interval 94-100), respectively. CONCLUSION: GLS greater than -17.45%, obtained after 150 mg/m2 of anthracycline therapy, is an independent predictor of future anthracycline-induced cardiotoxicity. These findings should encourage physicians to perform echocardiography earlier during treatment with anthracyclines.

Radiation Doses to Patients in Interventional Coronary Procedures-Estimation of Updated National Reference Levels by Dose Audit.

The objective of this study was to estimate the French national updated reference levels (RLs) for coronary angiography (CA) and percutaneous coronary intervention (PCI) by a dose audit from a large data set of unselected procedures and in standard-sized patients. Kerma-area product (PKA), air kerma at interventional point (Ka,r), fluoroscopy time (FT), and the number of registered frames (NFs) and runs (NRs) were collected from 51 229 CAs and 42 222 PCIs performed over a 12-month period at 61 French hospitals. RLs estimated by the 75th percentile in CAs and PCIs performed in unselected patients were 36 and 78 Gy.cm² for PKA, 498 and 1285 mGy for Ka,r, 6 and 15 min for FT, and 566 and 960 for NF, respectively. These values were consistent with the RLs calculated in standard-sized patients. The large difference in dose between sexes leads us to propose specific RLs in males and females. The results suggest a trend for a time-course reduction in RLs for interventional coronary procedures.

Patient exposure to X-rays during coronary angiography and percutaneous transluminal coronary intervention: results of a multicenter national survey.

OBJECTIVES: To evaluate practices for the protection from radiation of patients during coronary angiography (CA) and percutaneous coronary intervention (PCI), and to update reference values for the main radiation dose parameters. BACKGROUND: Few multicenter data from large populations exist on radiation doses to patients during CA and PCI. METHODS: RAY'ACT is a multicenter, nationwide French survey, with retrospective analysis of radiation parameters routinely registered in professional software from 33,937 CAs and 27,826 PCIs performed at 44 centers from January 1, through December 31, 2010. RESULTS: Kerma-area product (KAP) was registered in 91.7% (44/48) of centers and in 91.5% of procedures for CA (median, 27.2 Gy·cm(2) , interquartile range [IQR], 15.5-45.2) and 91.1% for PCI (median, 56.8 Gy·cm(2) , IQR, 32.8-94.6). Fluoroscopy time was registered in 87.5% (42/48) of centers and in 83.1% of procedures (median, 3.7 min, IQR, 2.3-6.3 for CA; 10.3 min, 6.7-16.2 for PCI). Variability across centers was high. Old equipment and routine left ventriculography were more common and number of registered frames and frame rate were higher in centers delivering high doses. The radial route was associated with lower doses than the femoral route (median KAP 26.8 Gy·cm(2) [15.1-44.25] vs. 28.1 [16.4-46.9] for CA, respectively; and 55.6 Gy·cm(2) [32.2-92.1] vs. 59.4 [24.6-99.9] for PCI, respectively; P < 0.01). CONCLUSIONS: This survey showed a very high rate of compliance with dose registration during CA and PCI in French nonacademic hospitals. Updated diagnostic reference values are established for the main dose parameters (KAP, 45 Gy·cm(2) for CA, 95 Gy·cm(2) for PCI).

Strategies used by respiratory nurses to stimulate self-management in patients with COPD.

AIMS AND OBJECTIVES: To gain an insight into strategies, adopted by Dutch respiratory nurses during clinic sessions, to improve self-management of patients with chronic obstructive pulmonary disease. BACKGROUND: Chronic obstructive pulmonary disease is highly prevalent and a significant cause of morbidity and mortality, impacting on quality of life and healthcare expenditure. Health promotion is therefore an important consideration. By applying specific strategies, respiratory nurses can play a major role in the promotion of self-management. Research has shown that respiratory nurses, who run clinics, have insufficient knowledge of evidence-based strategies that can be adopted to promote self-management among chronic obstructive pulmonary disease patients. It appears that respiratory nurses adopt their own strategies during clinic sessions. DESIGN: A qualitative research study was carried out using Grounded Theory method. METHODS: Data were collected during open interviews conducted by an external researcher with a nursing background. The interviews were analysed through coding after which categories were developed. RESULTS: Fourteen respiratory nurses were interviewed. The results show that respiratory nurses emphasise quitting smoking during the consult. Attention is also paid to inhalation medication and techniques. Other self-management strategies that respiratory nurses use are: application of specific interviewing techniques, referring to other healthcare professionals and providing tools for coping with the illness in everyday life. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: The main emphasis during the clinic session is directed at quitting smoking. Other self-management strategies such as providing information regarding nutrition and exercise, instilling confidence and becoming an equal discussion partner, gain less attention. During the clinic session, respiratory nurses should also focus on these self-management strategies in addition to quitting smoking. Further research should be directed at self-management strategies used by respiratory nurses in relation to different characteristics of patients. In this way, a more patient-oriented form of consultation could be developed for chronic obstructive pulmonary disease patients.

Reduction of radiation delivered to patients undergoing invasive coronary procedures. Effect of a programme for dose reduction based on radiation-protection training.

BACKGROUND: Exposure of patients to radiation from invasive cardiac procedures is high and may be deleterious. AIMS: To assess the effectiveness of a dose-reduction programme based on radiation-protection training, according to the recommendations of the Euratom Council, the International Commission on Radiological Protection and the French Society of Cardiology. METHODS: In this single-centre survey, dose-area product (DAP, Gy.cm(2)), fluoroscopy time (minutes) and number of runs were evaluated in 3285 consecutive procedures (2077 coronary angiographies [CAs], 1208 percutaneous coronary interventions [PCIs]), performed one year before (2005) and two years after (2006 to 2007) implementation of a programme for radiation dose-reduction. The programme included a 2-day training course in radiological protection for all medical and paramedical staff and recommendations for routine use of low fluoroscopic and acquisition pulse rates (6.25 and 12.5 i/s, respectively), large field size (23cm), maximal collimation and optimal X-ray tube/patient/detector distances. Routine left ventriculography was discouraged. The radial approach was used in>80% of the procedures. RESULTS: Compared with 2005, a significant 50% reduction in DAP was observed in 2006 and 2007 during CA (median [interquartile range] 53 Gy.cm(2) [33-84] vs 26 [16-43] and 21 [14-32], respectively; p<0.0001) and PCI (125 Gy.cm(2) [78-184] vs 49 [31-79] and 44 [27-66], respectively; p<0.0001). Fluoroscopy time and number of runs did not vary significantly in 2006, and decreased slightly in 2007, likely due to an important reduction in rate of left ventriculographies (from 32 to 4%). Inter-operator variability in DAP was reduced. CONCLUSION: Training in radiation protection for interventional cardiologists and use of simple and cost-free dose-reduction techniques were associated with a 50% reduction in radiation exposure to patients undergoing invasive cardiac procedures, without any loss of diagnostic information.

Relatives' perspective on the terminally ill patients who died after euthanasia or physician-assisted suicide: a retrospective cross-sectional interview study in the Netherlands.

This study used retrospective interviews with 87 relatives to describe the experiences of patients who died by euthanasia or physician-assisted suicide (EAS) in the Netherlands. Most of the patients suffered from cancer (85%). The relatives were most often a partner (63%) or a child (28%) of the patient. Before explicitly requesting EAS most patients (79%) had spoken about their wishes concerning medical end-of-life decisions to be made at a later date. Hopeless suffering, loss of dignity, and no prospect of recovery were the most prevalent reasons for explicitly requesting EAS. According to the relative, in 92% of patients EAS had contributed favourably to the quality of the end of life, mainly by preventing or ending suffering.

Physicians' opinions on palliative care and euthanasia in the Netherlands.

BACKGROUND: In recent decades significant developments in end-of-life care have taken place in The Netherlands. There has been more attention for palliative care and alongside the practice of euthanasia has been regulated. OBJECTIVE: The aim of this paper is to describe the opinions of physicians with regard to the relationship between palliative care and euthanasia, and determinants of these opinions. DESIGN: Cross-sectional. SETTING/SUBJECTS: Representative samples of physicians (n = 410), relatives of patients who died after euthanasia and physician-assisted suicide (EAS; n = 87), and members of the Euthanasia Review Committees (ERCs; n = 35). MEASUREMENTS: Structured interviews with physicians and relatives of patients, and a written questionnaire for the members of the ERCs. RESULTS: Approximately half of the physicians disagreed and one third agreed with statements describing the quality of palliative care in The Netherlands as suboptimal and describing the expertise of physicians with regard to palliative care as insufficient. Almost two thirds of the physicians disagreed with the suggestion that adequate treatment of pain and terminal care make euthanasia redundant. Having a religious belief, being a nursing home physician or a clinical specialist, never having performed euthanasia, and not wanting to perform euthanasia were related to the belief that adequate treatment of pain and terminal care could make euthanasia redundant. CONCLUSION: The study results indicate that most physicians in The Netherlands are not convinced that palliative care can always alleviate all suffering at the end of life and believe that euthanasia could be appropriate in some cases.

Requests to forgo potentially life-prolonging treatment and to hasten death in terminally ill cancer patients: a prospective study.

This study investigates the background and evolution of requests to forgo treatment and hasten death in terminally ill cancer patients. Physicians participating in a nationwide study on end-of-life decision making were asked whether they were treating a terminally ill cancer patient whose life expectancy was longer than 1 week but no longer than 3 months and who they would continue to treat until the patient's death. Of the 120 physicians who had a patient who met the inclusion criteria, 85 (70.8%) completed a questionnaire each month until the patient's death. The questionnaire provided information on the patient's symptoms, concerns, and requests involving end-of-life decisions. Most patients suffered from cancer of the gastrointestinal tract or the respiratory system, and 66% died within 2 months of the initial interview. The prevalence of requests involving end-of-life decisions increased during the last 3 months of a patient's life. The evolution of a request was especially related to an increase in the number of severe symptoms and concerns. Requests to forgo treatment were related to general weakness, whereas loss of dignity was a major reason for requests to hasten death. Physical suffering alone appeared to lead to less drastic requests than suffering blended by concerns and psychological problems leading to requests for hastened death. The results emphasize the importance of gaining insight into the patients' suffering to provide meaningful assistance.

Symptoms, treatment and "dying peacefully" in terminally ill cancer patients: a prospective study.

GOALS: The aims of this study were to describe the symptoms, their treatment during the final months of life of terminally ill cancer patients and to assess characteristics of the dying process. PATIENTS AND METHODS: We used a prospective study design. From a representative sample of physicians who participated in a study of end-of-life decision making, we asked whether they were treating a patient with cancer whose treatment was no longer aimed at cure, whose life expectancy was probably longer than 1 week but no longer than 3 months and who would probably continue to be treated by the same physician until their death; 85 physicians completed a monthly questionnaire until patients' deaths. RESULTS: Patients were confronted with an increasing amount of symptoms during the final months of their life. Fatigue, loss of appetite, dependency and feeling unwell were the most prevalent symptoms. Physical symptoms were more often treated than psychosocial symptoms. The number of medical disciplines involved in the patient's care decreased in the period before death, but the number of informal caregivers increased; 73% of patients died peacefully. A peaceful death was impeded by feelings of anxiety and loneliness but promoted by the involvement of children in their patients' care. CONCLUSION: The results give insight into the nature of suffering and factors related to the dying process of terminally ill cancer patients. Attention to psychosocial well-being and to the need to be with loved ones appears to be essential for patients' quality of life.