End-of-life decisions and advance directives in palliative care: a cross-cultural survey of patients and health-care professionals

In order to explore possible differences in the scope of end-of-life decisions and attitudes toward advance directives (AD) in palliative care, we conducted a survey of 159 patients in palliative care institutions and 93 health-care professionals experienced in palliative care in the United States, Germany, and Japan. Giving an AD in this clinical setting was considered important by patients and professionals. The prevalence of a formal written AD was 79% in the United States, 18% in Germany, and 9% in Japan. In Japan, there was a high prevalence of entrusting all decisions to the family (known as omakase). More than 80% of the patients had negative feelings toward their future decisions in the United States and Germany, in contrast to only 45% in Japan. Although favored by the professionals, there were no specific instruments for obtaining ADs. In Germany and Japan, some patients had given an informal AD. As a pilot content validity step, survey results were used to derive a checklist for content and procedural aspects in end-of-life decision-making. This checklist may provide the basis for developing an instrument to guide physicians, especially non-palliative care specialists, in communication with their patients and their families in this difficult clinical situation.

Dangers of delay of initiation of either thrombolysis or primary angioplasty in acute myocardial infarction with increasing use of primary angioplasty

We observed treatment delays and suboptimal outcomes when beginning to treat patients with acute myocardial infarction (AMI) with primary angioplasty. Of the 37 patients treated during a 12-month period, 12 (32%) required either emergency bypass surgery or died. Delayed time intervals to balloon reperfusion (mean 134 minutes) probably contributed to these adverse outcomes, with hemodynamic instability requiring pressors or intra-aortic balloon pumping in 15 patients, 12 (75%) before the first balloon inflation. Eleven of the 12 patients with significant adverse outcomes required such intervention. As angioplasty use increased, time intervals to thrombolysis in those not treated with angioplasty increased from an average of 29 minutes (53% treated less than the national standard of 30 minutes) to 39 minutes (32% treated <30 minutes, p <0.001). During the last 2 months of the study period, the time intervals had increased to 48 minutes (14% treated <30 minutes, p <0.0001). There was no change in thrombolytic time intervals at a local community hospital that did not offer primary angioplasty. Emergency Department physician confusion about the best therapy (angioplasty or thrombolysis) was documented in the medical records in 42% of cases (53 of 127). Confusion regarding therapy of AMI led to unacceptable delays in the administration of thrombolytic agents and probably contributed to the adverse outcomes in patients receiving primary angioplasty.

Organization and patients' perception of palliative care: a crosscultural comparison

The hospice model of care for patients with advanced diseases exists in almost all industrialized countries. To date, there have been no international or crosscultural comparisons of the organization and patient outcomes associated with hospice services in different parts of the world. This survey evaluated 159 patients in the USA, Germany and Japan. There were differences between countries in the time of first contact, who recommended palliative care first, the underlying diagnoses, the location of patients, and how consent for hospice care was obtained. Across all countries, there were similar levels of comfort and satisfaction with care. We conclude that the hospice philosophy addresses the basic needs of dying patients which are independent of cultural background, but may be adapted to very different cultures.

Evidence from Earthquake Data for a Partially Molten Crustal Layer in Southern Tibet

Earthquake data collected by the INDEPTH-II Passive-Source Experiment show that there is a substantial south to north variation in the velocity structure of the crust beneath southern Tibet. North of the Zangbo suture, beneath the southern Lhasa block, a midcrustal low-velocity zone is revealed by inversion of receiver functions, Rayleigh-wave phase velocities, and modeling of the radial component of teleseismic P-waveforms. Conversely, to the south beneath the Tethyan Himalaya, no low-velocity zone was observed. The presence of the midcrustal low-velocity zone in the north implies that a partially molten layer is in the middle crust beneath the northern Yadong-Gulu rift and possibly much of southern Tibet.

Aggregate/community-centered undergraduate community health nursing clinical experience

Debate continues about the appropriateness of clinical experiences targeting aggregates in undergraduate community health nursing education. This paper describes a practical model to teach, through experience, the concepts of aggregate/community-centered practice at the baccalaureate level. As a voluntary alternative to the usual community assessment paper, groups of students worked in partnership with community groups to define health needs and to address one need. Sequential student groups focused the assessment and implemented a plan. The required time for each project varied. One project is described to illustrate the model. While independent community-centered practice is not expected of the B.S.N. graduate, the model described here develops comprehension of the concepts and process of such practice.

Guidelines for developing a new standard in hospice care

Hospice care has been overlooked by many in the medical community. This is partly due to the nature of medical training; it could be overcome by the development of industry guidelines by which to measure quality of care.

Marchiafava-Bignami disease. Premortem diagnosis of an acute case utilizing magnetic resonance imaging

Marchiafava-Bignami disease is a rare demyelinating disease involving the corpus callosum and other central white matter tracts. In the patient described here, the disease produced extensive demyelination of the corpus callosum and deep cerebral white matter. This widespread demyelination, confirmed pathologically, was associated with a fulminant fatal course. The magnetic resonance imaging appearance is quite suggestive of Marchiafava-Bignami disease and plays an important role in the premortem diagnosis.

Age-related chemosensitivity of stem cells from human malignant brain tumours

After radiation therapy and chemotherapy for malignant glioma, patients aged 50 or under survive longer than patients over 50. Data from Brain Tumor Study Group trials show that, without treatment, these age groups have similar survival; therefore unperturbed tumour growth does not account for the difference. Sixteen consecutive patients with malignant glioma were studied, half of whom were less than or equal to 50 years of age; none had been treated before initial surgery, and all were subsequently treated with radiation and chemotherapeutic agents (in all but two patients, with nitrosoureas). Median survival of those aged greater than 50 was less than or equal to 50 years was 54 + weeks whereas that of those aged greater than 50 was 37 weeks. The longer survival for younger patients could not be attributed to tumour type, size, or location, pretreatment Karnofsky status, or mode of treatment. In-vitro sensitivity testing of clonogenic cells obtained from biopsy specimens showed that tumour cells from seven of eight patients aged less than or equal to 50 years were sensitive to 1,3-bis (2-chloroethyl)-1-nitrosourea (greater than 40% cell kill at clinically achievable concentrations) compared with only one patient with sensitive cells out of eight older patients. Patient age was inversely correlated with in-vitro cell kill, and patients with sensitive cells were significantly younger than those with resistant cells. Therefore influence of age on survival after treatment of malignant gliomas is probably due to inherent differences in the sensitivity of clonogenic cells to radiation and/or chemotherapeutic agents.

Potentials and possible pitfalls of human stem cell analysis

A clonogenic cell assay for malignant brain tumors that permits the evaluation of tumor cell sensitivity to BCNU and that correlates with patient response to BCNU has been developed. The potential for a stem cell analysis of human tumors has been demonstrated by studies of the reasons for clinical drug failure, tumor heterogeneity, and age-response relationships. The basic requirements of a stem cell assay include the ability to dissociate representative single cells from solid tumors, to optimize culture conditions, and to characterize the growth of colonies. Exposure of cells to a drug in vitro must be comparable to the in situ situation; possible significant differences between short-term and "continuous" treatment methods are emphasized. Also discussed are criteria for in vitro sensitivity of cells, problems inherent in the "early" evaluation of cultures (at the cell "cluster" stage), and the effects of system errors, which if overcome should lead to the development of analytic methods with a maximum sensitivity and predictive value.

Studies on an oncofetal antigen, POA

This paper describes the purification and partial characteristics of a putative oncofetal antigen, POA, which appears to be associated with the pancreas. POA is a glycoprotein of molecular weight between 800,000 and 900,000 daltons. It is found in fetal pancreas and pancreas cancer tissue, but not in normal adult pancreas. It is clearly different from carcinoembryonic antigen, other known tumor associated antigens, acute phase reactants and normal serum proteins. A quantitative rocket immunoelectrophoresis assay was developed for POA. Its specificity was monitored routinely by double immunodiffusion against known fetal and adult standards. The assay was performed on sera from over 700 patients. The results demonstrate that POA is found in the sera of most individuals. However, by far the highest absolute levels and the highest frequency of elevated levels was found in sera of patients with carcinoma of the pancreas. Elevated levels of POA were also found in the serum of a proportion of patients with carcinomas of the lung, stomach, colon, biliary tract, and breast and in a few other individuals with benign conditions. The spectrum of patients who have elevated levels of POA in their serum is quite different from that found with CEA or other known tumor markers.

Acute monocytic leukemia. Cytologic, histologic, cytochemical, ultrastructural, and cytogenetic observations

A case of acute monocytic leukemia (AMoL) studied by cytologic, histologic, cytochemical, ultrastructural, and cytogenetic technics is reported. The immature monocytes were characterized by strong fluoride-sensitive nonspecific esterase activity. Nuclear irregularity, prominent nucleoli, erythrophagocytosis, and pinocytosis were observed on transmission electron microscopy, whereas broad-based ruffles, similar to those found on normal monocytes, were identified with scanning electron microscopy. Cytogenetic analysis showed an 8/9 translocation and four or five identical 8p- marker chromosomes in most bone marrow cells.

Human cord blood lymphocytes. Ultrastructural and immunologic surface marker characteristics; a comparison with B- and T-cell lymphomas

The ultrastructural and surface marker characteristics of human cord blood lymphocytes were studied. These properties were compared with those in cells of patients in the leukemic phase of both malignant lymphoma, poorly differentiated lymphocytic type, and mycosis fungoides. Nuclear folding in cord blood lymphocytes was similar to that seen in lymphocytes of patients with malignant lymphoma, poorly differentiated lymphocytic type and mycosis fungoides. Surface marker characteristics of cord blood lymphocytes included increased percentages of surface IgD on cells bearing surface immunoglobulins and decreased percentages of E-rosette-forming cells. The hypothesis that both malignant lymphoma, poorly differentiated lymphocytic type and mycosis fungoides represent an arrest in the normal lymphocyte maturation sequence is discussed.

The Sézary syndrome cell: surface ultrastructural characteristics

Peripheral blood mononuclear cells from a patient with Sézary syndrome which lacked E-rosette-forming ability and surface immunoglobulins, and which displayed a markedly depressed response to a variety of mitogens, were studied by scanning electron microscopy (SEM) and transmission electron microscopy (TEM) on 3 occasions. The first peripheral blood sample (smooth) differed significantly from two later samples (moderate numbers of microvilli) when surface characteristics were examined by SEM; these differences were confirmed by TEM. The Sézary syndrome cells in this patient may be related to a T lymphocyte which has lost certain surface markers and mitogen response characteristics through a process of de-differentiation.