Radicalizing Hope.

The race against COVID-19 has been intense and painful and many of us are now looking for a way to move on. We may try to seize a degree of comfort and security by convincing ourselves that we are among the "fittest"-that is, among those who have managed to survive-who can now hope for a "new-normal" time, relatively unscathed. But this isn't what we should be hoping for. Our world, and ourselves, will never be free of COVID-19 or its insidious effects. COVID-19, like climate change, is a threat multiplier and the challenges it has raised are now indelibly engraved in our vulnerable, interconnected lives. Rather than vainly hoping for a return to an imaginary, erstwhile "normal" what we need is something more fundamental: a new version of hope that embraces a courage to learn what we need to do, to enable us to live a future to which we aspire. Perhaps counter-intuitively, we need to accept that the COVID-19 experience has already changed us deeply and hope that we can learn from this and from the future changes that the pandemic will give rise to. We need to radicalize our responses to the challenges, enabling ourselves to learn new lessons about old but increasingly pertinent topics, such as the realities of human fragility, and inter-connection.

Voluntary Assisted Dying/Euthanasia: Will This Have an Impact on Cancer Care in Future Years?

OPINION STATEMENT: In considering the impact of medically hastened death (MHD) on cancer care, a wide range of variables needs to be considered including demographic factors, diagnoses, local cultural factors, and the legislative frameworks in place. Here, we present a synthesis of recently available published literature and empirical data collected following legislative change to enable MHD in Victoria, Australia to explore in detail the potential impact of MHD on cancer care with a focus on patients/families and professional groups. Our findings reveal that for patients and families, both physical and existential distress frequently underlie MHD requests, with the latter less readily recognised by health professionals. The responses of those around the patient making the request may have a very significant impact on relationships within families and upon the nature of the subsequent bereavement. For palliative care, while differing views may remain, it appears that there has been some accommodation of MHD into or alongside practice over time. The recognition of a shared commitment to relief of suffering of palliative care and MHD appears a helpful means of establishing how these practices may co-exist. In cancer practice more broadly, as individual professionals reflect upon their own roles, new relationships and pathways of patient movement (or referral) must be established in response to patients' requests. Our findings also highlight many unanswered questions in understanding the impact of MHD, including that upon those dying who choose not to access MHD, First Nations peoples, the participating health professionals' longer term, and the relief of suffering itself. A systematic approach to the evaluation of MHD legislation must be adopted in order to understand its full impact. Only then could it be determined if the aspirations for such legislative change were being met.

'It's communication between people who are going through the same thing': experiences of informal interactions in hospital cancer treatment settings.

PURPOSE: In hospital settings, patients, visitors, and staff engage in many interactions outside formal clinical encounters. Whilst many of these may be inconsequential, others contribute significantly to how patients and their carers experience cancer and its treatment. This article aims to explore the experiences and significance of interactions that occur outside formal clinical encounters in hospital cancer treatment settings. METHODS: Semi-structured interviews were conducted with cancer patients, carers, and staff recruited from two hospital sites and cancer support groups. Hermeneutic phenomenology informed lines of questioning and data analysis. RESULTS: Thirty-one people participated in the study: 18 cancer patients, four carers, and nine staff members. The experiences of informal interactions were grouped into three themes: connecting, making sense, and enacting care. The participants described how these encounters allowed connection with others in the hospital spaces, facilitating a sense of belonging, normality, and self-worth. Through these interactions, individuals participated in making sense of their experiences, to better anticipate the decisions and challenges that might lie ahead. By connecting with other individuals, they cared for others and felt cared for themselves, and were able to learn from, teach, and support each other. CONCLUSIONS: Outside the confines of the clinical discourses participants negotiate terms of engagement, sharing of information, expertise, and their own personal stories that they may employ to contribute to the individuals around them. These interactions occur within a loose and evolving framework of social interactions, an 'informal community', in which cancer patients, carers, and staff members play active and meaningful roles.

A review of the utility of prognostic tools in predicting 6-month mortality in cancer patients, conducted in the context of voluntary assisted dying.

BACKGROUND: Eligibility to access the Victorian voluntary assisted dying (VAD) legislation requires that people have a prognosis of 6 months or less (or 12 months or less in the setting of a neurodegenerative diagnosis). Yet prognostic determination is frequently inaccurate and prompts clinician discomfort. Based on functional capacity and clinical and biochemical markers, prognostic tools have been developed to increase the accuracy of life expectancy predictions. AIMS: This review of prognostic tools explores their accuracy to determine 6-month mortality in adults when treated under palliative care with a primary diagnosis of cancer (the diagnosis of a large proportion of people who are requesting VAD). METHODS: A systematic search of the literature was performed on electronic databases Medline, Embase and Cinahl. RESULTS: Limitations of prognostication identified include the following: (i) prognostic tools still provide uncertain prognoses; (ii) prognostic tools have greater accuracy predicting shorter prognoses, such as weeks to months, rather than 6 months; and (iii) functionality was often weighted significantly when calculating prognoses. Challenges of prognostication identified include the following: (i) the area under the curve (a value that represents how well a model can distinguish between two outcomes) cannot be directly interpreted clinically and (ii) difficulties exist related to determining appropriate thresholds of accuracy in this context. CONCLUSIONS: Prognostication is a significant aspect of VAD, and the utility of the currently available prognostic tools appears limited but may prompt discussions about prognosis and alternative means (other than prognostic estimates) to identify those eligible for VAD.

Changing times in public health: The new wave of self-collection of invasive samples.

Testing in public health programs has long been recognised as beneficial but has often been experienced by community members as intrusive and paternalistic. Cervical screening has been seen as even more threatening by women who have experienced sexual violence or come from culturally and linguistically diverse communities. A simple and natural solution to these formidable barriers, increasingly recognised in recent years, has been presented by the advent of self-testing. This article recounts the struggle to encourage medical practitioners to accept patient self-testing. It emphasises the importance of scrutinising our own personal prejudices, listening to the community, and being open to novel strategies that ensure inclusiveness and respect for those whose interests we are seeking to serve.

Common Comorbidities that Alter Heart Failure Prognosis - Shaping New Thinking for Practice.

At least half of all heart failure (CHF) patients will have a comorbidity that could be undertreated, requires additional speciality input and/or polypharmacy. These patients are then at risk of iatrogenic and disease-related complications and readmissions if not closely supervised. Common comorbidities of relevance are cardiorenal and cardiometabolic syndromes (DM, obesity, OSA), chronic airways disease, elderly age, and accompanying pharmacotherapies. The structure of community practice often leaves primary, speciality, and allied health care in silos. For example, cardiology speciality training in Australia creates excellent sub-specialists to deliver diagnostic and therapeutic advances. A casualty of this process has been the gradual alienation of general cardiology toward general internal medical specialists and primary care practitioners. The consequences are largely noticed in community practice. The issue is compounded by suboptimal communication of information. This review explores these issues from a cardiology sub-speciality lens; firstly cross speciality areas that are important for cardiologists to maintain their skill, and finally, to obtain a brief overview of disease management and identify game-changing common denominators such as endothelial dysfunction and self-management.

Communal responsibility: a history of health collectives in Australia.

Healthcare encompasses multiple discourses to which health professionals, researchers, patients, carers and lay individuals contribute. Networks of patients and non-professionals often act collectively to build capacity, enhance access to resources, develop understanding and improve provision of care. This article explores the concept of health collectives and three notable examples that have had an enduring and profound impact in the Australian context.

Self-collected Pap smears may provide an acceptable and effective method of cervical cancer screening.

BACKGROUND AND AIMS: The role of the Papanicolou (Pap) smear in the early detection and prevention of cervical cancer is well established. However, many women fail to undertake the test because of embarrassment or other reasons. To address this problem, we evaluated the feasibility of implementing self-sampling of cervical cytology as an alternative to clinician-collected Pap smears and compared it with the gold standard of colposcopy in terms of specificity. MATERIALS AND METHODS: A prospective preliminary study of 40 women recruited from the colposcopy clinic of a tertiary referral hospital was undertaken. Participants were instructed in the technique of self-sampling and asked to collect their own Pap smears. Colposcopic examinations were performed and biopsies taken, if indicated. Clinician-collected Pap smears were performed 4 weeks later. Pairwise agreement was calculated between the outcomes of self-collected, colposcopic, and clinician-collected samples using the weighted κ statistic. RESULTS: Self-collected Pap smear had a high level of acceptability among the women, all of whom were able to collect adequate tissue. The agreement of self-collected Pap smears with colposcopic assessment was no worse than that of clinician-collected Pap smears (Cohen's κ statistic 0.54 [95% CI, 0.27-0.82]; cf 0.49 [0.2-0.78], respectively). The specificity of self-collected Pap smears was almost identical to that of clinician-collected samples (specificity: 86% vs 81%, respectively). Direct comparison between patient and clinician collected Pap smears showed fair agreement (κ statistic 0.38 [0.07-0.68]). There were no adverse events in either group. CONCLUSIONS: Self-collection of Pap smears is an effective and acceptable alternative to clinician-collected samples and may provide a strategy for improving compliance with cervical testing programs.

"NEVER REGARD YOURSELF AS ALREADY SO THOROUGHLY INFORMED": THE WITHDRAWAL OF ITS INVITATION TO RODNEY SYME TO ADDRESS ITS 2015 CONGRESS BY THE ROYAL AUSTRALASIAN COLLEGE OF PHYSICIANS.

In 1628, William Harvey presented his revolutionary theory of the circulation to ears at the Royal College of Physicians that had been deafened by the unquestionable authority of Galen's teachings, from one and a half millennia in the past. Harvey's theory was initially rejected, despite his faith in his colleagues being eager for truth and knowledge, and never regarding themselves as so well informed that they would not welcome "further information". Recently Rodney Syme, the retired Melbourne urologist who for a long time has agitated for the legalisation of assisted dying, and also challenged the authorities to apply the current law in response to his admitted assistance to a number of individuals, was invited to address the 2015 Congress of the Royal Australasian College of Physicians. At the eleventh hour, the invitation to speak was withdrawn. In this column, we trace the course of events leading to this withdrawal of the invitation, and describe some of the correspondence to and from the College in response to the withdrawal. We draw parallels between the experiences of Harvey and Syme, and point to lessons to be learnt from the recent episode of apparent unwillingness, on the part of an institution that seeks to present itself as outward-looking, progressive and socially aware, to fulfil this promise in the increasingly important area of the end-of-life.

Promises and ethical pitfalls of surgical innovation: the case of bariatric surgery.

The last two decades have seen remarkable advances in and acceptance of bariatric surgery. These advances include quality assurance, certification of surgeons and their institutions and the development of national bariatric registries. Yet, in spite of these advances, an urgent need to improve ethical standards in bariatric surgery remains. In particular, surgical innovation must be subjected to adequate scrutiny and sufficient safeguards. New procedures and the processes by which they are assessed should be subject to review and approval by the ethics committees operating under clearly defined guidelines. The public must be able to have confidence that the surgery itself, and the innovative practices that are introduced within it, are not subject to distortions associated with personal, wider professional, industry or institutional interests.

A case study approach to investigating end-of-life decision making in an acute health service.

AIM: To identify end-of-life (EOL) decision making processes for patients with non-cancer illnesses in a major metropolitan hospital. METHODS: A retrospective review using a case study framework of 47 randomly selected patient records over a 6-month period explored issues in EOL care planning. RESULTS: Reviewed charts represented 53% of total deaths in the study period. All patients (aged 66-99) had co-morbid conditions. In 64%, the first record of EOL discussions occurred in the last 24h of life. Four case groups were identified, ranging from a clear plan developed with patient/family involvement and fully implemented, to no plan with minimal patient/family involvement in decision making. Factors related to clearer EOL care planning according to expressed patient wishes included multiple previous admissions, shorter hospitalisations at EOL, living with a relative and involvement of family in decisions about care. CONCLUSION: This study has shown that the development and effective implementation of EOL plans is associated with the active involvement of both family members and health professionals. It also draws attention to the risks of delaying EOL discussions until late in the illness trajectory or later in life as well as pointing to challenges in acting on EOL developed outside the hospital environment.

An exploration of the dynamics and influences upon second medical opinion consultations in cancer care.

AIM: The aim of this study was to explore the dynamics within second medical opinion consultations in patients with cancer. METHODS: Semi-structured interviews were held with four oncologists and were subjected to a thematic analysis to define the broad issues. These formed the basis of a survey distributed to Australian medical oncologists. RESULTS: Overall 65 surveys were returned representing an overall response rate of 30% (10% and 63% electronic and hardcopy response rates, respectively). The dynamics in giving second medical opinions are influenced by the collegiate relationships of the doctors. Nearly two-thirds of oncologists believed that the first doctors' treatment and recommendations influenced the outcome of the second opinion, more than one-third believed the outcome was influenced by the relationship between the two doctors, and 41% believed the public nature of a second opinion was influential. In each case, these figures were more than double their assessments of patients' beliefs of these influences. Care was taken not to criticise the primary doctor. CONCLUSION: Second medical opinions provide an opportunity for oncologists to review medical care and engage in enhanced communication with patients who have additional needs. These consultations do not, however, occur in a vacuum but are influenced by the need to attend to relationships between the patient and their primary doctor and between the doctors themselves. The second medical opinion is embedded within a network of relationships and within the illness journey.

"The solution needs to be complex." Obese adults' attitudes about the effectiveness of individual and population based interventions for obesity.

BACKGROUND: Previous studies of public perceptions of obesity interventions have been quantitative and based on general population surveys. This study aims to explore the opinions and attitudes of obese individuals towards population and individual interventions for obesity in Australia. METHODS: Qualitative methods using in-depth semi-structured telephone interviews with a community sample of obese adults (Body Mass Index >or=30). Theoretical, purposive and strategic recruitment techniques were used to ensure a broad sample of obese individuals with different types of experiences with their obesity. Participants were asked about their attitudes towards three population based interventions (regulation, media campaigns, and public health initiatives) and three individual interventions (tailored fitness programs, commercial dieting, and gastric banding surgery), and the effectiveness of these interventions. RESULTS: One hundred and forty two individuals (19-75 years) were interviewed. Participants strongly supported non-commercial interventions that were focused on encouraging individuals to make healthy lifestyle changes (regulation, physical activity programs, and public health initiatives). There was less support for interventions perceived to be invasive or high risk (gastric band surgery), stigmatising (media campaigns), or commercially motivated and promoting weight loss techniques (commercial diets and gastric banding surgery). CONCLUSION: Obese adults support non-commercial, non-stigmatising interventions which are designed to improve lifestyles, rather than promote weight loss.

Laser acupuncture does not improve menopausal symptoms.

OBJECTIVE: Acupuncture is commonly used to treat menopausal symptoms and other gynecological conditions. Laser acupuncture, more accurately named "laser acupoint stimulation," has the advantages of being noninvasive, reproducible, and convenient. A few studies of conventional acupuncture have suggested a beneficial effect in treating menopausal symptoms. This study sought to investigate the effectiveness of laser acupoint stimulation in relieving symptoms associated with menopause. METHODS: A double-blind, randomized, placebo-controlled study was conducted in 40 women experiencing active symptoms of menopause. Outcome variables were numbers of diurnal and nocturnal flushes and symptom score, determined using a previously validated scale. A laser acupoint stimulation device was altered to produce identical flashing lights whether or not the laser was operating to allow for a placebo ("laser off") control. Participants received either active or placebo treatment on a fortnightly basis for 12 weeks. The acupoint selection in both groups was individualized to each participant, selected from a set of 10 acupoints. RESULTS: There were no significant differences between the active and placebo treatment groups in numbers of diurnal or nocturnal flushes or in nonflushing symptom scores. CONCLUSIONS: Laser acupoint stimulation chosen from a fixed set of acupoints is no more efficacious than manual stimulation with an inert laser probe in altering menopausal symptoms.

Second medical opinions: the views of oncology patients and their physicians.

INTRODUCTION: Second medical opinions (SMOs) are common in oncology practice, but the nature of these consultations has received relatively little attention. This study examines the views of patients with advanced cancer and their physicians of SMOs. METHOD: Parallel, concurrent surveys were developed for patients and physicians. The first was distributed to outpatients with advanced cancer-attending specialist clinics in an Australian quaternary hospital. The second survey, developed on the basis of results of exploratory interviews with medical oncologists, was distributed to medical oncologists in Australia. RESULTS: Seventeen of fifty two (33%) patients had sought a SMO, most commonly prompted by concerns around communication with their first doctor, the extreme and desperate nature of their medical condition and the need for reassurance. Most (94%) patients found the SMO helpful, with satisfaction related to improved communication and reassurance. Patients were concerned that seeking a second medical opinion may affect their relationship with their primary doctor. Most physicians (82%) reported seeing between one and five SMO per month, with patients being motivated by the need for additional information and reassurance. Physicians regarded SMO patients as having greater information needs (84%), greater psychosocial needs (58%) and requiring more of the physician's time and energy (77%) than other patients. CONCLUSION: SMOs are common in cancer care with most patients motivated by the need for improved communication, additional information and reassurance. Physicians identify patients who seek SMOs as having additional psychosocial needs compared with other oncology patients.

Patients' views on decision making in advanced cancer.

OBJECTIVE: To explore patients' understanding of decision making in the treatment of advanced cancer and to determine the factors they believe important to these processes in their care. METHODS: Surveys were distributed to consecutive outpatients with advanced malignancy attending a comprehensive cancer treatment center. RESULTS: Patients believed that the medical condition (94%), their doctors' experience (81%), and the medical literature (73%) are the most important factors for decisions made in their care. They also value their relationship with the doctor (63%) and their own (the patients') values (63%), and just over a third considered their family's values and the doctors' personality important. Most did not believe the doctors' values should influence decisions made. They were mindful of the uncertainty involved in decisions in the setting of advanced cancer. SIGNIFICANCE OF RESULTS: Overall, patients were satisfied with the decision-making processes and they understood and highly regarded the incorporation of factors, other than their medical condition, in their care.

Cardiovascular physiology of androgens and androgen testosterone therapy in postmenopausal women.

Women before menopause are at relatively lower risk of cardiovascular disease (CVD) compared with age-matched men and after menopause this gender advantage disappears. Androgen has been known to be an independent factor contributing to the higher male susceptibility to CVD, through adverse effects on lipids, blood pressure, and glucose metabolism. High androgen levels also contribute to CVD development in women with polycystic ovary syndrome as well as androgen abusing athletes and body builders. On the other hand, decline in androgen levels, as a result of ageing in men, is associated with hypertension, diabetes and atherosclerosis. Postmenopausal women, particularly those with oophorectomy are generally in low levels of sex hormones and androgen insufficiency is independently associated with the higher incidence of atherosclerosis in postmenopausal women. Androgen testosterone therapy (ATT) has been commonly used to improve well-being and libido in aging men with low androgen levels. The therapy has been demonstrated also to effectively reduce atherogenesis in these people. The use of ATT in postmenopausal women has increased in recent years and to date, however, the cardiovascular benefits of such therapy in these women remain uncertain. This review focuses on research regarding the impact of endogenous androgens and ATT on the cardiovascular physiology and CVD development in postmenopausal women.

A pharmaceutical preparation of Salvia miltiorrhiza protects cardiac myocytes from tumor necrosis factor-induced apoptosis and reduces angiotensin II-stimulated collagen synthesis in fibroblasts.

Salvia miltiorrhiza is a medicinal herb commonly used in traditional Chinese medicine for the prevention and treatment of cardiovascular disease. This study investigated the effects of Cardiotonic Pill (CP), a pharmaceutical preparation of Salvia miltiorrhiza, on cardiac myocytes and fibroblasts with respect to the viability, proliferation, and collagen synthesis in these cells under various conditions. A cardiac myocyte line, H9c2, and primarily cultured fibroblasts from rat hearts were incubated with CP over a broad concentration range (50-800 microg/ml) under normal cultures, conditions of ischemia (serum-free culture), and stimulation by angiotensin II (AII, 100 nM), hydrogen peroxide (H(2)O(2), 50-200 microM), or tumor necrosis factor alpha (TNFalpha, 40 ng/ml) for 24-48 h. Cell growth, apoptosis, DNA and collagen synthesis, and expression of relevant genes were assessed via cell number study, morphological examination, Annexin-V staining, flow-cytometry, [(3)H]-thymidine or [(3)H]-proline incorporation assay, and Western blotting analysis. It was found that (1) at therapeutic (50 microg/ml) and double therapeutic (100 microg/ml) concentrations, CP did not significantly affect normal DNA synthesis and cell growth in these cardiac cells, while at higher (over 4-fold therapeutic) concentrations (200-800 microg/ml), CP decreased DNA synthesis and cell growth and increased cell death; (2) CP treatment (50 microg/ml) significantly inhibited TNFalpha-induced apoptosis in myocytes, with 12.3+/-1.46% cells being apoptosis in CP treatment group and 37.0+/-7.34% in the control (p<0.01), and simultaneously, expression of activated (phosphorylated) Akt protein was increased by about 2 folds in the CP-treated cells; and (3) in cultured fibroblasts, CP significantly reduced AII-induced collagen synthesis in a concentration-dependent manner (by approximately 50% and approximately 90% reduction of AII-induced collagen synthesis at 50 and 100 microg/ml, respectively). Thus, Salvia miltiorrhiza preparation CP is physiologically active on cardiac cells. The actions by CP to reduce apoptotic damage in myocytes and collagen synthesis in fibroblasts may help to preserve the heart function and reduce heart failure risk. The actions by CP to inhibit DNA synthesis and cell growth, which occurred at over therapeutic doses, may weaken the ability of heart repair. Further studies are needed to identify the chemical compounds in this herbal product that are responsible for these observed physiological effects.

Effects of four medicinal herbs on human vascular endothelial cells in culture.

BACKGROUND: Danshen (DS, Salvia miltiorrhiza), Shanchi (SQ, Panax notoginseng), Shanzai (SZ, Hawthorn) and Heshouwu (HSW, Polygonum multiflorum Thunb) are four medicinal herbs commonly used in traditional Chinese medicine and previously shown to have activity that may contribute to cardiovascular protection. This study aims to investigate effects of these herbs on vascular endothelial cells with respect to cell viability and expression of cellular adhesion molecules under inflammatory conditions. METHODS: Herbal extracts were prepared by an established industrial manufacturing process. Human umbilical vein endothelial cells (HUVEC) were incubated with the herbal extract under normal or serum-free culture and tumor necrosis factor (TNF) alpha stimulation. Cell apoptosis, apoptosis-associated gene expression, expression of cellular adhesion molecules, DNA synthesis, and growth were assessed via morphological examination, Annexin-V staining, Western blotting analysis, Flow-Cytometry, [(3)H]-thymidine incorporation assay, and cell number study. RESULTS: SZ and HSW significantly inhibited apoptosis in HUVEC undergoing serum deprivation and TNFalpha stimulation, accompanied by down-regulation of caspase-3 gene expression. DS and SQ significantly attenuated TNFalpha-induced expression of adhesion molecule VCAM-1 and also ICAM-1 by DS in the cells. All four herbs at therapeutic concentrations (100 microg/mL) inhibited DNA synthesis (10-42% decrease in [(3)H]-thymidine incorporation rates) and growth (5-10% decrease in cell numbers) in HUVEC under normal cultures. CONCLUSION: DS, SQ, SZ and HSW are physiologically active on human vascular endothelial cells. The actions by HSW and SZ to reduce apoptosis and DS and SQ to inhibit adhesion molecule expression may help protect endothelial function and inhibit atherogenesis, while their actions to inhibit DNA synthesis and cell growth may weaken the ability of endothelial repair. Further studies are needed to identify the chemical compounds responsible to these physiological effects by these herbs.