A multi-site study on the impact of an advance care planning workshop on attitudes, beliefs and behavioural intentions over a 6-month period.

BACKGROUND: This study evaluated the impact of the adapted version of the Respecting Choices® The Living Matters Advance Care Planning (ACP) facilitator training programme on trainees' attitudes on facilitation 6 months post-training. SETTING AND PARTICIPANTS: Two hundred and twenty-one healthcare professionals consisting of doctors, nurses, medical social workers from different training venues in Singapore participated in the first phase of the study (pre- and post) of which 107 participated in the second phase 6 months later (follow-up). METHODS: Participants self-rated their attitudes, beliefs and behavioural intentions through surveys at three time points in an evaluation design that utilised repeated measures one-way ANOVA (pre-, post-, follow-up). Between-group differences were also examined using independent t-test. RESULTS: At follow-up, mean scores increased significantly in understanding, confidence, and competence. Changes in effect sizes were large. Although trainees continued to think that ACP is emotionally draining for facilitators, more than before, facilitation experience was considered pleasant for themselves with the positive change significant and moderate in effect size. Those who had experience completing/initiating ACP significantly held more positive views than those who did not. CONCLUSIONS: The ACP facilitator training programme had lasting effects on enhancing the understanding, competence, and confidence of trainees. Importantly, findings showed that experience in actual facilitation within 6 months after training was important and giving trainees opportunities to facilitate is recommended.

Adolescent BMI trajectories with clusters of physical activity and sedentary behaviour: an exploratory analysis.

OBJECTIVE: The purpose of this study is to identify distinct body mass index (BMI) trajectories associated with weight classification, and to examine demographic characteristics and clusters of obesogenic behaviours in adolescents with these trajectories. METHODS: Data were extracted from the National Institute of Child Health and Human Development Study of Early Child Care and Youth Development (n = 1,006, Grades 5-8). The independent variables were physical activity (accelerometer and child report), sports participation, television/video watching time and recreational computer use. The dependent variable was raw BMI. Growth mixture modelling, mixture modelling and independent t-test analyses were used. RESULTS: Two distinct BMI trajectories were identified - one with the mean BMI within the Overweight-Obese classification (≥85th percentile) and the other within the healthy weight classification (5th- 84th percentile). Two clusters of physical and sedentary behaviours were identified in adolescents with the Overweight-Obese BMI trajectory. These clusters differed in the type of sedentary behaviour (computer vs. television/video). Three clusters were identified in adolescents with the Healthy Weight BMI trajectory. These clusters differed in levels of physical activity and types of sedentary behaviour. CONCLUSION: This study contributes to the understanding of multi-dimensional obesogenic behavioural patterns and highlights the importance of understanding types of sedentary behaviour in adolescents.

Human polyomavirus BKV transcriptionally activates DNA methyltransferase 1 through the pRb/E2F pathway.

Many DNA tumor virus oncogenes are capable of activating and highjacking the host cell's DNA replication machinery for its own reproduction purposes through targeting and inactivation of the retinoblastoma pocket protein family. Pocket proteins function to regulate cell cycle progression and DNA synthesis through inhibitory interactions with the E2F transcription factors. The interaction of viral oncogenes with the pocket proteins is crucial for their transforming activity. We recently demonstrated that the DNA methyltransferase 1 (DNMT1) gene is an E2F target gene that is transcriptionally activated in cells lacking the retinoblastoma gene (Rb-/-). Overexpression of DNMT1 is implicated in tumor suppressor gene hypermethylation which is associated with tumorigenesis. Given that viral oncogenes potently stimulate E2F activity, we hypothesized that viral infection might activate DNMT1 and thereby promote transformation. Herein, we demonstrate that DNMT1 is strongly activated by the human polyomavirus BKV large T antigen (TAg) and adenovirus E1a. Viral oncogene mutants incapable of binding the pocket proteins are ineffective at activating DNMT1 compared to their wild-type counterparts. Additionally, mutation of the E2F sites within the DNMT1 promoters dramatically abrogates transcriptional activation. These data suggest that viral induction of DNMT1 through modulation of the pRB/E2F pathway may be involved in viral transformation.

Symptoms and care of dying elderly patients in an acute hospital.

INTRODUCTION: We aimed to study the symptoms and the care of elderly patients dying in an acute hospital in Singapore. METHODS: Over a one year period, we retrospectively studied all patients admitted to the Department of Geriatric Medicine and all other patients aged more than 75 years old who were admitted and died during the same admission to all other units in an acute hospital. There were 189 such patients. Demographical data, information on the patients' background and prevailing medical problems, symptoms, intervention and treatment methods were obtained from the patients' medical records and analysed. RESULTS: The patients were frail and old. 17 percent had bedsores and 20 percent had limb contractures noted at the point of admission. 20 percent had known terminal disease. 88 percent of the deaths were expected and 12 percent unexpected. In spite of the deaths being anticipated, 25 percent of them were subjected to cardiopulmonary resuscitation and 17 percent were intubated at the point of collapse. The majority (81 percent) of relatives of the 160 patients whose deaths were anticipated and had family had no acceptance problems. 52 (31 percent) of the 167 expected deaths had input from palliative care. These patients were more dependent, (p-value equals 0.018; odds ratio [OR] = 2.5; 95 percent confidence interval [CI] 1.2-5.2), less likely to undergo resuscitation (p-value is less than 0.001; OR = 0.16; 95 percent CI, 0.06-0.44), and were more likely to be on treatment for their symptoms (p-value is equal to 0.001; OR = 7.7; 95 percent CI, 2.1-28.8). CONCLUSION: The common symptoms experienced by the elderly at the end of life are difficulty with breathing, fever, pain and respiratory secretions. A number of patients were not on any treatment for these problems though the proportion is less where there is palliative input.

Treatment of recurrent aspiration pneumonia in end-stage dementia: preferences and choices of a group of elderly nursing home residents.

BACKGROUND: Clinicians are often faced with the dilemma of how best to manage patients with advanced dementia who present to the hospital with repeated episodes of aspiration pneumonia. Rarely, if at all, are the opinions of the group that is most likely to be directly affected, that is the older nursing home resident, sought. This study seeks to fill that gap. AIMS: To study the choices and preferences of a group of elderly nursing home residents in the treatment of recurrent aspiration pneumonia on a background of severe disability from end-stage dementia. METHODS: A descriptive cross-sectional interview study using a hypothetical scenario carried out in six nursing homes within eastern Sydney, from June to August 2000. Views and attitudes towards hospitalization, antibiotic use, tube feeding and other treatment measures, given a situation of recurrent aspiration pneumonia and end-stage dementia, were obtained. RESULTS: Fifty-two elderly nursing home residents who were cognitively intact and not depressed were interviewed. Most of the subjects would prefer further hospital admissions (61.5%, P<0.1) and would choose to have antibiotic treatment (73.1%, P<0.001). Slightly more than half would not agree to artificial ventilation. Sixty-nine percent of the respondents would not agree to feeding via a nasogastric tube (P<0.05) and 71% would not agree to a feeding gastrostomy (P<0.001). Most would agree to a modified diet (75%, P<0.0001) and to continue oral feeding despite the attendant risk of re-aspiration (59.6%, P<0.01). CONCLUSIONS: The participants generally preferred to be treated in a hospital setting given the scenario. Most disagreed with the use of artificial feeding.

A palliative care approach to end-stage neurodegenerative conditions.

INTRODUCTION: Neurodegenerative conditions, such as Alzheimer's disease, Parkinson's disease and motor neurone disease, are progressive and incurable conditions that ultimately lead to a state of total functional incapacitation and death. These conditions are "terminal" and, therefore, should be managed with a palliative care approach. This article highlights some of the issues in caring for patients with end-stage neurodegenerative conditions from a palliative perspective. METHODS: This review is based on evidence from pre-existing medical literature on the above subject and the authors' personal experiences and observations. CONCLUSION: Patients with end-stage neurodegenerative conditions have needs similar to that of advanced cancer patients. Therefore, the principles and practice of palliative care should be applied to such patients. This may also mean that palliative care training should be undertaken in nursing homes, where a large number of such patients are located.

Increased stromal expression of murine urokinase plasminogen activator in a human breast cancer xenograft model following treatment with the matrix metalloprotease inhibitor, batimastat.

The matrix metalloprotease (MMP) family of enzymes and the urokinase plasminogen activator (uPA) pathway have both been implicated in tumor invasion and metastasis and in poor prognosis of cancer. We have previously shown that treatment with batimastat, a synthetic MMP inhibitor, leads to significant retardation but not regression of tumor growth in a human breast cancer xenograft model. In addition, batimastat treatment did not inhibit local tumor invasion, nor did it encourage stromal encapsulation of the tumor, suggesting the additional involvement of non-MMP proteolytic mechanisms. To investigate the presence of an alternative extracellular matrix protease whose activity is known to be important in breast cancer, but which is not inhibited by batimastat, expression of murine and human uPA were examined by in situ hybridization and ELISA. No differences were observed between untreated and batimastat-treated tumors regarding human uPA mRNA and protein. In contrast, murine uPA mRNA expression was increased at the tumor-stromal junction in batimastat-treated tumors in comparison with the control tumors. In agreement with these results, batimastat treatment was shown to significantly induce murine uPA protein content in the tumors. Inoculating MDA435/LCC-6 cells into immunodeficient, uPA-deficient mice resulted in tumor growth retardation as compared to tumor growth in littermate wild-type controls, while addition of batimastat treatment to uPA-/- mice did not result in further growth inhibition. The increased expression of stromal uPA may represent a cellular response to MMP inhibition and may demonstrate a new level of plasticity in the malignant progression of the disease. These results may have important implications for the clinical applications of MMP inhibitors, as well as for development of other anti-invasion drugs.

Role for the adenovirus IVa2 protein in packaging of viral DNA.

Although it has been demonstrated that the adenovirus IVa2 protein binds to the packaging domains on the viral chromosome and interacts with the viral L1 52/55-kDa protein, which is required for viral DNA packaging, there has been no direct evidence demonstrating that the IVa2 protein is involved in DNA packaging. To understand in greater detail the DNA packaging mechanisms of adenovirus, we have asked whether DNA packaging is serotype or subgroup specific. We found that Ad7 (subgroup B), Ad12 (subgroup A), and Ad17 (subgroup D) cannot complement the defect of an Ad5 (subgroup C) mutant, pm8001, which does not package its DNA due to a mutation in the L1 52/55-kDa gene. This indicates that the DNA packaging systems of different serotypes cannot interact productively with Ad5 DNA. Based on this, a chimeric virus containing the Ad7 genome except for the inverted terminal repeats and packaging sequence from Ad5 was constructed. This chimeric virus replicates its DNA and synthesizes Ad7 proteins, but it cannot package its DNA in 293 cells or 293 cells expressing the Ad5 L1 52/55-kDa protein. However, this chimeric virus packages its DNA in 293 cells expressing the Ad5 IVa2 protein. These results indicate that the IVa2 protein plays a role in viral DNA packaging and that its function is serotype specific. Since this chimeric virus cannot package its own DNA, but produces all the components for packaging Ad7 DNA, it may be a more suitable helper virus for the growth of Ad7 gutted vectors for gene transfer.

Specialist community palliative care services--a survey of general practitioners' experience in Eastern Sydney.

The role of the general practitioner (GP) in providing palliative care in the community is of increasing importance. Concomitantly, there is more interaction between the palliative care support services and the GP. Even when there is input from the palliative care support services, there can be barriers that impede effective delivery of palliative care by the GP. These include poor communication between the GP and the supporting team, inaccessibility of the service and inadequate after-hours coverage. We carried out a postal survey to assess what experiences and perceptions GPs working within the Eastern Sydney Area had of our palliative care support service. The response was generally favourable, with most GPs finding the level of communication, accessibility, usefulness of advice given and degree of follow-up visits by the service to be adequate. However, an important number felt that we tended to over-hospitalise our patients.

The prediction and prevention of intrapartum fetal asphyxia in term pregnancies.

OBJECTIVE: This study was undertaken to examine the roles of clinical risk scoring, electronic fetal heart rate monitoring, and fetal blood gas and acid-base assessment in the prediction and prevention of intrapartum fetal asphyxia in term pregnancies. STUDY DESIGN: The outcomes of 166 term pregnancies with biochemically confirmed fetal asphyxia (umbilical artery base deficit at delivery, >12 mmol/L) were examined. This population included 83 pregnancies delivered abdominally matched with 83 pregnancies delivered vaginally. Antepartum and intrapartum clinical risk factors and neonatal complications were documented. Fetal assessments included fetal heart rate patterns in the fetal heart rate record and fetal capillary blood gas and acid-base assessments. Fetal asphyxia was classified as mild, moderate, or severe on the basis of umbilical artery base deficit (cutoff >12 mmol/L) and neonatal encephalopathy and other organ system complications. RESULTS: Fetal asphyxial exposures were as follows: mild, 140; moderate, 22; and severe, 4. Intervention and delivery during the first or second stage of labor occurred in 98 of the 166 pregnancies. Predictive fetal heart rate patterns were the primary indication leading to intervention and delivery during the first or second stage of labor. Clinical risk factors when present were secondary indications in the clinical decision to intervene. Fetal blood gas and acid-base assessment was a useful supplementary test in 41 pregnancies. Intervention and delivery may have prevented the progression of mild asphyxia in 78 pregnancies and may have modified the degree of moderate or severe asphyxia in 20 pregnancies. CONCLUSION: Although fetal heart rate patterns will not discriminate all asphyxial exposures, continuous fetal heart rate monitoring supplemented by fetal blood gas and acid-base assessment can be a useful fetal assessment paradigm for intrapartum fetal asphyxia. Such an assessment paradigm will not prevent all cases of moderate or severe fetal asphyxia. However, prediction and diagnosis with intervention and delivery during the first or second stage of labor could prevent the progression of mild asphyxia to moderate or severe asphyxia in some cases.

Maturation of fetal heart rate and body movement in 24-33-week-old fetuses threatening to deliver prematurely.

Maturation of spontaneous cardiac and body movement behavior from 24 to 33 weeks gestational age was characterized prospectively in 168 high-risk fetuses threatening to deliver prematurely. Forty-eight, low-risk fetuses delivering as healthy full-term infants served as a comparison group. Fetuses were classified on the basis of gestational age at time of testing and newborn outcome following delivery (high-risk: premature compromised, premature healthy, term healthy infant; low-risk term healthy). In the high-risk group, the average fetal heart rate was greater and decreased over gestation from 148 to 140 bpm, regardless of outcome. In the low-risk group, it decreased from 145 to 138 bpm. In high- and low-risk groups, the average number of heart rate accelerations greater than or = 15 bpm increased over gestation from 2-3 to 8 while the average number of maternally perceived movements decreased. It was concluded that maturational changes in spontaneous fetal heart rate and maternally perceived body movements in fetuses threatening to deliver prematurely parallel those of low-risk fetuses.

Administrative records management and archival program: the Kingston experience.

Administrative records management and archival programs are important to the administration of health care institutions and to the historian of health care. The development of an administrative records management and archival program at the Kingston General Hospital is outlined in this report. This program has been possible because of the endorsement of the President and Board of Directors, the appointment of a hospital archivist, and an agreement to maintain the archives in Queen's University Archives. The Records of the Kingston General Hospital Archives reflect the dramatic transformation from a charitable institution of the mid-19th century to a tertiary care centre. Much of the history of health care in Canada will be lost unless similar initiatives to ensure the preservation of primary records of Canadian health care institutions are undertaken.

End-of-life issues--preferences and choices of a group of elderly Chinese subjects attending a day care centre in Singapore.

INTRODUCTION: This was an exploratory study that was intended to provide a descriptive analysis of the choices and preferences of a group of elderly Chinese subjects attending a day care centre in Singapore with regard to end-of-life issues. MATERIALS AND METHODS: A semi-structured one-to-one interview was conducted to collect data from the subjects. Qualitative techniques were used to analyse the data. RESULTS: Forty-three subjects were interviewed. The median age was 71 years. There were more women than men (58.1% vs. 41.9%). The predominant religion was Buddhism/Taoism. 83.7% and 76.7% of the subjects preferred to be told of the diagnosis and prognosis of a terminal illness, respectively. The person most preferred to reveal the diagnosis was the attending doctor (60.5%). About 83.7% of the subjects have never heard of the Advanced Medical Directive Act, while 37.2% agreed that making an advanced directive would be necessary. Twenty-three (53.5%) would choose the doctor, while 15 (34.9%) would choose a family member as a surrogate decision-maker. Twenty-two (51.2%) thought that euthanasia should be allowed, while 15 (34.9%) disagreed. With regard to supportive measures at the end of life, 67.4% wanted cardiopulmonary resuscitation, 62.8% wanted artificial ventilation, 55.8% wanted nasogastric feeding, 65.1% wanted intravenous hydration and 41.9% wanted renal dialysis. CONCLUSION: There is a need for closer communication between older persons and their carers with regard to end-of-life care. The attending doctor appears to have an important role in this respect.

A pitfall to avoid when starting a patient on transdermal fentanyl.

BACKGROUND: A woman with advanced carcinoma of the ovary developed fentanyl toxicity while being changed from oral morphine to transdermal fentanyl. OBJECTIVE: To explain the reason for the toxicity and ways to avoid it. DISCUSSION: The transdermal fentanyl patch is proving to be a safe, well tolerated and effective treatment modality in the control of cancer pain, but care has to be exercised when using this drug, especially at the time of initiation, as the consequences may be disastrous for the patient.

Is euthanasia compatible with palliative care?

There has been a gradual shift in the attitude of the medical community as well as the lay public towards greater acceptance of euthanasia as an option for care of the terminally ill and dying. There have also been calls by certain groups to actually legalize voluntary euthanasia and physician-assisted suicide for patients who meet certain conditions, some of which are as follows: that the patient be of a sound mind, suffering from an incurable or terminal illness, experiencing unbearable suffering and uncontrollable pain. The rationale for legalizing euthanasia is based on the principle of the patient's right of self-determination and the duty of doctors to relieve pain and suffering at all times. A few within the medical community quickly saw certain similarities in terms of goals and aims between euthanasia and palliative care and, thus, proposed that euthanasia be an option or choice for difficult palliative care cases. Some even went as far as to suggest that euthanasia and palliative care be part of the continuum of care for terminally ill patients. When palliative medicine fails to fully control pain and suffering for the patient, euthanasia can be the logical next step in the continuum of care. This article seeks to discuss why the rationale for legalizing euthanasia is flawed, why euthanasia goes against the fundamental principles of Medicine in general and why it is incompatible with the practice of palliative medicine.

Ethnicity, obstructive sleep apnoea and ischaemic heart disease.

We studied the relationship between different ethnic groups, obstructive sleep apnoea (OSA) and ischaemic heart disease. Four hundred and thirty-two inpatients from the medical wards were interviewed. Limited overnight sleep studies were done in 129 of those who had habitual snoring, daytime sleepiness based on an Epworth sleepiness scale of 8 or more, or a large neck size of 40 cm or more. There were 315 Chinese (72.9%), 67 Malays (15.5%), 43 Indians (10%) and 3 from other races (1.4%). The prevalence of OSA was 19.7%, 30% and 12% among the Chinese, Malays and Indians, respectively. The prevalence ratio for OSA was 1.52 in Malays using Chinese patients as the baseline (P = 0.07). The median neck circumference was 37 cm in both racial groups. The median body mass index was 22.7 kg/m2 in Chinese compared to 23.6 kg/m2 in Malays. The median apnoea-hypopnoea index was 22.7, 19.0 and 26.9 events/hour among the Chinese, Malays and Indians, respectively. OSA was independently associated with the prevalence of IHD (adjusted prevalence ratio 1.68; 95% CI: 1.15, 2.46; P = 0.009). The prevalence of ischaemic heart disease (IHD) was 31%, 24% and 28% in Chinese, Malays and Indians, respectively. The prevalence ratio for IHD in Malays compared to Chinese was 0.77. After adjusting for OSA, there was an even greater reduction in the risk of IHD (adjusted prevalence ratio 0.70). This suggests that OSA is a confounder in the relationship between race and ischaemic heart disease.

Maturation of body and breathing movements in 24-33 week-old fetuses threatening to deliver prematurely.

Maturation of spontaneous fetal body and breathing movements of 24- to 33-week-old fetuses in 168 pregnancies threatening to deliver prematurely were examined on the basis of newborn outcome (premature compromised, premature healthy, term healthy). Maturation of fetuses in 60 low-risk pregnancies delivering as healthy full-term infants served as a normative comparison group. Each fetus was observed for 30 min; the amount of body and breathing movements were noted and an estimation of amniotic fluid volume was made. The pattern of behavioural maturation was similar for all outcome groups; with advancing gestation there was a decrease in body movements and an increase in breathing movements. Both reduced activity levels and advanced behaviours were observed in the high-risk outcome groups. The high-risk fetuses had reduced levels of body movements which increased with better outcome and, an earlier onset of increased amounts of breathing, occurring at 30 weeks in contrast to 33 weeks for the comparison group. In the presence of ruptured membranes, those high-risk fetuses who were born prematurely had less breathing compared to those who delivered at term. Similar maturation patterns among high- and low-risk outcome groups suggests normal/typical functional development in the high-risk fetal groups. The observed differential behaviours were associated with prematurity and most likely associated with events leading to premature labour.

Predictive value of electronic fetal monitoring for intrapartum fetal asphyxia with metabolic acidosis.

OBJECTIVE: To determine the predictive value of each fetal heart rate (FHR) variable and of patterns of FHR variables for fetal asphyxia during labor. METHODS: This matched case-control study included an asphyxia group of 71 term infants with umbilical artery base deficit greater than 16 mmol/L and a control group of 71 term infants with umbilical artery base deficit less than 8 mmol/L. Each FHR record available for the 4 hours before delivery was scored in 10-minute cycles for each FHR variable. Selected patterns of important FHR variables were examined during the last hour before delivery for their predictive value for fetal asphyxia. RESULTS: The FHR variables associated with fetal asphyxia included absent and minimal baseline variability and late and prolonged decelerations. Fetal heart rate patterns with absent baseline variability were the most specific but identified only 17% of the asphyxia group. The sensitivity of this test increased to 93% with the addition of less specific patterns. The estimated positive predictive value ranged from 18.1% to 2.6%, and the negative predictive value ranged from 98.3% to 99.5%. CONCLUSION: A narrow 1-hour window of FHR patterns including minimal baseline variability and late or prolonged decelerations will predict fetal asphyxial exposure before decompensation and newborn morbidity. Thus, with careful interpretation, predictive FHR patterns can be a useful screening test for fetal asphyxia. However, supplementary tests are required to confirm the diagnosis and to identify the large number of false-positive patterns to avoid unnecessary intervention.