Discussing preferred place of death with patients: staff experiences in a UK specialist palliative care setting.

BACKGROUND: National end-of-life care policies propose that health professionals regularly discuss matters such as preferred place of death (PPD) with patients. AIM: To explore clinician experiences of discussing PPD with palliative care patients. METHOD: Six clinicians from a Scottish hospice each participated in a semi-structured interview. Interview data was analysed using interpretative phenomenological analysis. RESULTS: Four themes were integral to the participants' accounts: the importance of discussing preferences at the end of life (staff recognise the value of discussing patients' final wishes), identifying how and when to discuss PPD (discussions are tailored to the individual), reflecting on the emotional aspects of discussing PPD (discussing PPD is challenging but rewarding), and a journey from expectations to experience (discussing PPD becomes easier with time). CONCLUSION: Although potentially difficult, the participants believed that advance care planning is important and beneficial. With time, they had developed communication strategies enabling them to discuss PPD in an effective, patient-centred way.

Comparison of the developmental tests Bayley-III and Bayley-II in 7-month-old infants born preterm.

The study aims on comparing Bayley Scales of infant development third (Bayley-III) and Bayley second (Bayley-II) edition with special focus on patterns in the first year of life. Fifty-five premature infants (43 with low birth weight/LBW >1,499 g and 12 with very/extremely low birth weight/VLBW/ELBW <1,500 g) aged 7 months (corrected for prematurity) were assessed with the complete Bayley-III. From this assessment, Bayley-II results were retrospectively estimated. Bayley-III results were compared to the expected mean with one-sample t-tests. The mean scores of both editions were compared with the aid of paired-sample t-tests. Pearson correlations between subscales and editions were analysed. The Bayley-III cognitive score of the study group was significantly higher than the expected mean of the standardization sample. VLBW/ELBW had significantly lower motor scores than LBW in both editions. When compared to estimated Bayley-II scores, all relevant Bayley-III scores were significantly higher (all p < .01) with highest difference (ten points) between the motor scales of both editions. There were significant correlations not only between Bayley-III cognitive and language scales but also between language and motor scales. Given the strong association between motor and cognitive behaviour in early infancy, this age-specific pattern is heightening the risk of failure to identify infants at risk for both cognitive and motor delay. Therefore, assessment of infants should comprise all subscales. Since Bayley-III probably overestimates especially motor performance in young infants, when interpreting Bayley-III scores in this age, comparison groups are highly recommended until further validation of normative data are outstanding.

Necessary and sufficient role for T helper cells to prevent fungal dissemination in allergic lung disease.

Mucosal immune responses to fungal infection range from T helper type 2 (Th2) cell-directed allergic inflammation to Th1-predominant neutrophilic inflammation, but the mechanisms directing these divergent mucosal immune outcomes and the role of T cells in host defense against mucosal fungal infections are not known. Here we examined the mouse mucosal immune responses to 12 filamentous environmental fungal species over a broad range of exposure doses and determined the requirement of T cells for host defense. For all tested fungi, low-grade conidium exposures induced Th2- and eosinophil-predominant allergic lung disease, whereas higher exposures led to rapid conversion to neutrophil- and Th1 cell-predominant inflammation, a phenomenon we term immune phenotype switching. All fungal exposure doses were further linked to the secretion of interleukin-17A (IL-17A). Fungal infections with Curvularia lunata and Aspergillus fumigatus were typically confined to the airway during allergic inflammation but became locally invasive and disseminated to the brain at higher conidium challenge doses, in association with predominant Th1 responses. Fungal dissemination occurred at relatively low challenge doses with the conidia of Aspergillus fumigatus administered to recombinase activating gene 1 (Rag-1)-deficient mice, which lack B and T cells, but B cell-deficient µMT mice and T helper cell-reconstituted Rag-1-deficient mice were comparable to wild-type mice in preventing fungal dissemination. Our findings demonstrate that Th2 cell-predominant allergic responses followed by immune phenotype switching and fungal dissemination are highly predictable outcomes with progressive fungal infectious burdens and that T helper cell responses are protective against lethal fungal dissemination.

Circadian rhythms in myocardial metabolism and contractile function: influence of workload and oleate.

Multiple extracardiac stimuli, such as workload and circulating nutrients (e.g., fatty acids), known to influence myocardial metabolism and contractile function exhibit marked circadian rhythms. The aim of the present study was to investigate whether the rat heart exhibits circadian rhythms in its responsiveness to changes in workload and/or fatty acid (oleate) availability. Thus, hearts were isolated from male Wistar rats (housed during a 12:12-h light-dark cycle: lights on at 9 AM) at 9 AM, 3 PM, 9 PM, and 3 AM and perfused in the working mode ex vivo with 5 mM glucose plus either 0.4 or 0.8 mM oleate. Following 20-min perfusion at normal workload (i.e., 100 cm H(2)O afterload), hearts were challenged with increased workload (140 cm H(2)O afterload plus 1 microM epinephrine). In the presence of 0.4 mM oleate, myocardial metabolism exhibited a marked circadian rhythm, with decreased rates of glucose oxidation, increased rates of lactate release, decreased glycogenolysis capacity, and increased channeling of oleate into nonoxidative pathways during the light phase. Rat hearts also exhibited a modest circadian rhythm in responsiveness to the workload challenge when perfused in the presence of 0.4 mM oleate, with increased myocardial oxygen consumption at the dark-to-light phase transition. However, rat hearts perfused in the presence of 0.8 mM oleate exhibited a markedly blunted contractile function response to the workload challenge during the light phase. In conclusion, these studies expose marked circadian rhythmicities in myocardial oxidative and nonoxidative metabolism as well as responsiveness of the rat heart to changes in workload and fatty acid availability.