Factors Contributing to Non-Concordance Between End-of-Life Care and Advance Care Planning.

CONTEXT: Despite making do-not-resuscitate or comfort care decisions during advance care planning, terminally ill patients sometimes receive life-sustaining treatments as they approach end of life. OBJECTIVES: To examine factors contributing to nonconcordance between end-of-life care and advance care planning. METHODS: In this longitudinal retrospective cohort study, terminally ill patients with a life expectancy shorter than six months, who had previously expressed a preference for do-not-resuscitate or comfort care, were followed up after palliative shared care intervention. An instrument with eight items contributing to non-concordant care, developed through literature review and experts' consensus, was employed. An expert panel reviewed electronic medical records to determine factors associated with non-concordant care for each patient. Statistical analysis, including descriptive statistics and the chi-square test, examines demographic characteristics, and associations. RESULTS: Among the enrolled 7871 patients, 97 (1.2%) received non-concordant care. The most prevalent factor was "families being too distressed about the patient's deteriorating condition and therefore being unable to let go" (84.5%) followed by "limited understanding of medical interventions among patients and surrogates" (38.1%), and "lack of patient participation in the decision-making process" (25.8%). CONCLUSIONS: This study reveals that factors related to relational autonomy, emotional support, and health literacy may contribute to non-concordance between advance care planning and end-of-life care. In the future, developing an advance care planning model emphasizes respecting relational autonomy, providing emotional support, and enhancing health literacy could help patients receiving a goal concordant and holistic end-of-life care.

Double Nutri (Liposomal Encapsulation) Enhances Bioavailability of Vitamin C and Extends Its Half-Life in Plasma.

Vitamin C is an important antioxidant in the human body that plays a role in many body functions. Liposomal encapsulation is a technology commonly used in food processing and medicine. This study determines whether Double Nutri (liposomal encapsulation) increases the absorption rate for vitamin C supplementation. Subjects enrolled in this study took vitamin C without liposome; then, 14 d washout was given with liposomal process A vitamin C. After 14 d washout, the subjects took liposomal process B vitamin C (Double Nutri) was given. After taking the test sample, the vitamin C concentration in venous blood was measured from the baseline (0 h), 0.5, 1, 2, 3, 4, and 8 h. Eleven healthy subjects were recruited for three tests. The vitamin C concentration for liposomal process B vitamin C (Double Nutri) group is higher (7.26±3.52, p<0.01) than that for the liposomal process A vitamin C group (6.41±3.80, p<0.05) and for vitamin C without liposome (2.21±4.07). This shows that Double Nutri has better bioavailability and can last up in the body to 8 hours. In addition, this study shows that Double Nutri increases the half-life of vitamin C in plasma and has higher bioavailability.

Mindfulness-based cognitive therapy on bereavement grief: Alterations of resting-state network connectivity associate with changes of anxiety and mindfulness.

Bereavement, the experience of losing a loved one, is one of the most catastrophic but inevitable events in life. It causes grief and intense depression-like sadness. Recent studies have revealed the effectiveness and proficiency of mindfulness-based cognitive therapy (MBCT) in emotional regulation among bereavement populations. MBCT improves the well-being of the bereaved by enhancing cognitive performances. Regarding the neural correlates of bereavement grief, previous studies focused on the alleviation of emotion-cognition interferences at specific brain regions. Here, we hypothesized that the bereavement grief fundamentally triggers global alterations in the resting-state brain networks and part of the internetwork connectivity could be reformed after MBCT intervention. We recruited 19 bereaved individuals who participated the 8-week MBCT program. We evaluated (a) the large-scale changes in brain connectivity affected by the MBCT program; as well as (b) the association between connectivity changes and self-rated questionnaire. First, after MBCT, the bereaved individuals showed the reduction of the internetwork connectivity in the salience, default-mode and fronto-parietal networks in the resting state but not under emotional arousal, implying the alleviated attention to spontaneous mind wandering after MBCT. Second, the alterations of functional connectivity between subcortical (e.g., caudate) and cortical networks (e.g., cingulo-opercular/sensorimotor) were associated with the changes of the mindfulness scale, the anxiety and the emotion regulation ability. In summary, MBCT could enhance spontaneous emotion regulation among the bereaved individuals through the internetwork reorganizations in the resting state.

Mindfulness Improves Emotion Regulation and Executive Control on Bereaved Individuals: An fMRI Study.

The grief of bereavement is recognized as a severe psychosocial stressor that can trigger a variety of mental and physical disorders, and the long-lasting unresolved grief has a detrimental effect on brain functionality. Literature has documented mindfulness-based cognitive therapy (MBCT) as an efficient treatment for improving well-being, specifically related to the mood and cognition, in a variety of populations. However, little attention has been devoted to neural mechanisms with regard to bereaved individuals' cognition after MBCT intervention. In this study, we recruited 23 bereaved participants who lost a significant relative within 6 months to 4 years to attend 8-week MBCT course. We used self-reporting questionnaires to measure emotion regulation and functional magnetic resonance imaging (fMRI) with the numerical Stroop task to evaluate the MBCT effect on executive control among the bereaved participants. The self-reported questionnaires showed improvements on mindfulness and reductions in grief, difficulties in emotion regulation, anxiety, and depression after the MBCT intervention. The fMRI analysis demonstrated two scenarios: (1) the activity of the fronto-parietal network slightly declined accompanied with significant improvements in the reaction time of incongruent trials; (2) the activities in the posterior cingulate cortex and thalamus were positively associated with the Texas Revised Inventory of Grief, implying emotional interferences on cognitive functions. Results indicated that MBCT facilitated the executive control function by alleviating the emotional interferences over the cognitive functions and suggested that the 8-week MBCT intervention significantly improved both executive control and emotion regulation in bereaved individuals.

The relationship between pain management and psychospiritual distress in patients with advanced cancer following admission to a palliative care unit.

BACKGROUND: Although many cross-sectional studies have demonstrated the association between cancer pain and psychospiritual distress, the time-dependent relationship has not been fully explored. For that reason, this study aims to investigate the time-dependent relationship between psychospiritual distress and cancer pain management in advanced cancer patients. METHODS: This is a prospective observational study. Two hundred thirty-seven advanced cancer patients were recruited from a palliative care unit in Taiwan. Demographic and clinical data were retrieved at admission. Pain and psychospiritual distress (i.e.: anxiety, depression, anger, level of family and social support, fear of death) were assessed upon admission and one week later, by using a "Symptom Reporting Form". Patients were divided into two groups according to the pain status one week post-admission (improved versus not improved groups). RESULTS: One hundred sixty-three (68.8 %) patients were assigned to the improved group, and 74 (31.2 %) patients were assigned to the not improved group. There were no differences in the psychospiritual variables between groups upon admission. In overall patients, all psychospiritual variables improved one week post-admission, but the improvement of depression and family/social support in the not improved group was not significant. Consistent with this, for depression scores, there was a statistically significant pain group x time interaction effect detected, meaning that the pain group effect on depression scores was dependent on time. CONCLUSIONS: We demonstrated a time-dependent relationship between depression and pain management in advanced cancer patients. Our results suggest that poor pain management may be associated with intractable depression. The inclusion of interventions that effectively improve psychospiritual distress may contribute to pain management strategies for advanced cancer patients.

The protective effect of eupafolin against TNF-α-induced lung inflammation via the reduction of intercellular cell adhesion molecule-1 expression.

ETHNOPHARMACOLOGICAL RELEVANCE: Eupafolin, a major bioactive compound found in Phyla nodiflora, has the anti-inflammatory property. Upregulation of cell adhesion molecules in the lung airway epithelium is associated with the epithelium-leukocyte interaction and plays a critical role in the pathogenesis of lung airway inflammatory disorders. To investigate the effects of eupafolin on tumor necrosis factor-α (TNF-α)-induced intercellular cell adhesion molecule-1 (ICAM-1) expression in A549 human lung airway epithelial cells and the underlying mechanisms. MATERIALS AND METHODS: The effect of eupafolin on ICAM-1 expression in A549 cells were examined by Western blotting and immunofluorescent staining. The mice were injected intraperitoneally with or without eupafolin and then were left untreated or were injected intratracheally with TNF-α. To detect the effect of eupafolin on ICAM-1 expression, the lung tissues were also examined by Western blotting and immunohistochemical staining. RESULTS: Eupafolin pretreatment reduced the TNF-α-induced ICAM-1 expression and also the ERK1/2, JNK, p38, and AKT/PI3K phosphorylation. However, the increase in ICAM-1 expression with TNF-α treatment was unaffected by p38 and PI3K inhibitors. Eupafolin decreased the TNF-α-induced NF-κB p65 activation and its nuclear translocation. Furthermore, eupafolin reduced ICAM-1 expression in the lung tissues of TNF-α-treated mice. CONCLUSIONS: Eupafolin exerts its anti-inflammatory activity by suppressing the TNF-α-induced ICAM-1 expression and subsequent monocyte adhesion via AKT/ERK1/2/JNK phosphorylation and nuclear translocation of NF-κB p65. These results suggest that eupafolin may represent a novel therapeutic agent targeting epithelial activation in lung inflammation.

Magnolol reduced TNF-α-induced vascular cell adhesion molecule-1 expression in endothelial cells via JNK/p38 and NF-κB signaling pathways.

Expression of cell adhesion molecules by the endothelium and the attachment of leukocytes to these cells play major roles in inflammation and cardiovascular disorders. Magnolol, a major active component of Magnolia officinalis, has antioxidative and anti-inflammatory properties. In the present study, the effects of magnolol on the expression of vascular cell adhesion molecule-1 (VCAM-1) in human aortic endothelial cells (HAECs) and the related mechanisms were investigated. TNF-α induced VCAM-1 protein expression and mRNA stability were significantly decreased in HAECs pre-treated with magnolol. Magnolol significantly reduced the phosphorylation of ERK, JNK, and p38 in TNF-α-treated HAECs. The decrease in VCAM-1 expression in response to TNF-α treatment was affected by JNK and p38 inhibitors, not by an ERK inhibitor. Magnolol also attenuates NF-κB activation and the translocation of HuR (an RNA binding protein) in TNF-α-stimulated HAECs. The VCAM-1 expression was weaker in the aortas of TNF-α-treated apo-E deficient mice with magnolol treatment. These data demonstrate that magnolol inhibits TNF-α-induced JNK/p38 phosphorylation, HuR translocation, NF-κB activation, and thereby suppresses VCAM-1 expression resulting in reduced leukocyte adhesion. Taken together, these results suggest that magnolol has an anti-inflammatory property and may play an important role in the prevention of atherosclerosis and inflammatory responses.

Ganoderma lucidum polysaccharides prevent platelet-derived growth factor-stimulated smooth muscle cell proliferation in vitro and neointimal hyperplasia in the endothelial-denuded artery in vivo.

Ganoderma lucidum is used in traditional Chinese medicine to prevent or treat a variety of diseases, including cardiovascular disorders. We previously demonstrated that a glucan-containing extract of Reishi polysaccharides (EORP) has the potent anti-inflammatory action of reducing ICAM-1 expression in lipopolysaccharide (LPS)-treated human aortic smooth muscle cells (HASMCs) and LPS-treated mice. In the present study, we examined whether EORP inhibited platelet-derived growth factor-BB (PDGF)-stimulated HASMC proliferation and the mechanism involved. EORP dose-dependently reduced cell numbers and DNA synthesis of PDGF-treated HASMCs in vitro. EORP also arrested cell cycle progression in the G0/G1 phase, and this was associated with decreased expression of cyclin D1, cyclin E, CDK2, CDK4, and p21(Cip1) and upregulation of the cyclin-dependent kinase inhibitor p27(Kip1). The anti-proliferative effect of EORP was partly mediated by downregulation of PDGF-induced JNK phosphorylation. In in vivo studies, the femoral artery of C57BL/6 mice was endothelial-denuded and the mice were fed a diet containing 100 mg/kg/day of EORP. On day 14, both cell proliferation (proliferating cell nuclear antigen-positive cells) in the neointima and the neointima/media area ratio (0.67 ± 0.03 vs. 1.46 ± 0.30) were significantly reduced. Our data show that EORP interferes with the mitogenic activation of JNK, preventing entry of HASMCs into the cell cycle in vitro and reducing cell proliferation in the neointima and decreasing the neointimal area in vivo. Thus, EORP may represent a safe and effective novel approach to the prevention and treatment of vascular proliferative diseases.

Effectiveness of Taiwanese traditional herbal diet for pain management in terminal cancer patients.

In addition to modern medicinal therapy, many cancer patients in Taiwan are treated regularly with herbal medicines or prescribed a traditional herbal diet. In this paper, the effect of a Taiwanese traditional herbal diet (TTHD) on pain in terminal cancer patients was investigated. A total of 2,466 patients diagnosed with a variety of cancers were included. The most common patient-reported symptoms included troublesome pain (79.2%), weakness (69.0%), anorexia (46.4%), fever (36.5%), dyspnea (31.1%), and leg edema (30.9%). The 2,466 terminal cancer patients included in the study were randomly divided into three groups. The TTHD group (n=1044; 42.3%) were given the TTHD consisting of analgesic herbs (paeony root: licorice root=1:1) and a Taiwanese tonic vegetable soup (Lilii bulbus, Nelumbo seed, and Jujube fruit). The remaining patients were divided into a reference group, given the regular hospital diet, (n=909, 36.9%) and a control group, given the Taiwanese tonic vegetable soup without analgesic herbs, (n=513, 20.8%). All patients maintained their assigned diets for one week. A verbal numerical scale was used to assess pain. Results revealed that the patients given TTHD reported enhanced pain relief (p<0.05) compared to the reference and control groups. We found that TTHD could alleviate the pain among terminal cancer patients thereby supporting the supposition that Eastern and Western medicines can be effectively co-administered to enhance terminal patient's quality of life. Further research is warranted.

Fear of death and good death among the young and elderly with terminal cancers in Taiwan.

Fear of death is a common characteristic among palliative care patients. We might think that the elderly display a higher degree of acceptance of the inevitability and less fear in the face of death. This study was aimed at investigating the relationship between the death fear level and the good-death scale in two age groups. The study was conducted in 224 patients with terminal cancers admitted to the Palliative Care Unit in National Taiwan University Hospital during the period of January 1 through October 31, 2001. The mean age was 62.13 +/- 15.47 years. The duration of admission in the elderly group was shorter than that of the younger group (P < 0.05). The severity of death fear decreased gradually in both groups after being admitted to the hospice (P < 0.05). However, the elderly (> or = 65 years of age) displayed higher levels of death fear than the younger group at two days before death (P < 0.05). A significant negative correlation was observed between the degree of death fear and the total good death score in both groups at two days before death (P < 0.05). The comprehensive care in the palliative care unit might relate to the relief of the death fear of terminal cancer patients. There is a need for psychological and spiritual care in elderly patients.