Patient, family member, and clinician perspectives on advance care planning (ACP) in hematology and hematopoietic stem cell transplantation (HSCT)

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Background: Studies have found that ACP engagement remains low in patients undergoing HSCT in spite of the high risks of treatment-related morbidity and mortality. Methods: This qualitative study used Thorne’s Interpretive Description methodology. Participants were accrued from hematological malignancy outpatient clinics at a tertiary oncology center and underwent audio-recorded semi-structured interviews. Analysis involved meticulous review of interview transcripts. The constant comparative method was utilized; data collection occurred concurrently with analysis until saturation of themes was achieved. Results: The study involved 6 patients, 5 family members and 8 clinicians (physicians, nurses, social worker). Participants thought that ACP was both acceptable and important yet many had not engaged in ACP. Perceived barriers to ACP included: system-related barriers such as lack of process for ACP, lack of time and/or resources; patient-related factors such as lack of understanding of disease, prognosis and/or expectations of HSCT, lack of patient/family understanding of ACP, a desire to ‘focus on positives’; and disease/treatment-related factors such as unpredictability of the disease and treatment trajectories in hematology and HSCT. Potential facilitators identified by participants included: integrating ACP as part of routine HSCT care, involving the multidisciplinary team in ACP, and introducing ACP early and revisiting frequently. Conclusions: This study revealed various barriers and facilitators related to participation in ACP. We are using the results of this study to inform and tailor interventions on ACP at our center. Introducing ACP as part of standard care in HSCT and providing ongoing facilitation of ACP, including discussion of disease and treatment expectations at the outset, and when complications arise, may assist patients and families in recognizing how ACP fits into their care. Given the inherent unpredictability in this population, we suggest revisiting ACP frequently to optimize patient experience and ensure patients and family members are aware of other treatment options including supportive and palliative care.

Patient and healthcare perspectives on the importance and efficacy of addressing spiritual issues within an interdisciplinary bone marrow transplant clinic: a qualitative study

OBJECTIVES

The purpose of this study was to use a qualitative approach to better understand the importance and efficacy of addressing spiritual issues within an interdisciplinary bone marrow transplant clinic from the perspectives of patients and healthcare providers.

SETTING

Participants were recruited from the bone marrow transplant clinic of a large urban outpatient cancer care centre in western Canada.

PARTICIPANTS

Focus groups were conducted with patients (n=7) and healthcare providers (n=9) to explore the importance of addressing spiritual issues across the treatment trajectory and to identify factors associated with effectively addressing these needs.

RESULTS

Data were analysed using the qualitative approach of latent content analysis. Addressing spiritual issues was understood by patients and healthcare providers, as a core, yet under addressed, component of comprehensive care. Both sets of participants felt that addressing basic spiritual issues was the responsibility of all members of the interdisciplinary team, while recognising the need for specialised and embedded support from a spiritual care professional. While healthcare providers felt that the impact of the illness and treatment had a negative effect on patients' spiritual well-being, patients felt the opposite. Skills, challenges, key time points and clinical indicators associated with addressing spiritual issues were identified.

CONCLUSIONS

Despite a number of conceptual and clinical challenges associated with addressing spiritual issues patients and their healthcare providers emphasised the importance of an integrated approach whereby basic spiritual issues are addressed by members of the interdisciplinary team and by an embedded spiritual care professional, who in addition also provides specialised support. The identification of clinical issues associated with addressing spiritual needs provides healthcare providers with clinical guidance on how to better integrate this aspect of care into their clinical practice, while also identifying acute incidences when a more targeted and specialised approach may be of benefit.

Do patients think that dry powder inhalers can be used interchangeably?

As recognised in management guidelines, patients are the most important group of people in any prescribing decision. Despite their importance, few studies have asked what patients think about being switched between different inhalers. This paper reports two such studies, one involving interviews of a sample of patients and the other consisting of a quantitative survey of patients across five countries. In the qualitative study, four of the five patients interviewed reported that they would be confused, worried and unhappy about a switch in their dry powder inhaler and would revisit their physician to be shown how to use the inhaler or to ask for a new prescription for their old inhaler. In the quantitative survey of 499 patients with asthma, more than half (51%) were opposed to their current dry powder inhaler being replaced by a substitute device, with 83% reporting concerns. There was considerable concern about training in use of the new device and confusion about the need for change. Almost a quarter of patients (23%) would want training, and 23% of patients thought they would need information about the new inhaler. From limited information, it appears that patients would be concerned about switching of their existing dry powder inhaler for another, with the potential for confusion, need for additional consultations and need for training in the new device.

Best practice in the use of spirometry

This article examines spirometry as a method of detecting lung disease, particularly chronic obstructive pulmonary disease (COPD). Methods of producing an accurate assessment and identifying acceptable traces are outlined, and contraindications are discussed.

Implementing a discharge assessment tool in palliative home care

With an aging population and limited health care resources, reflection on end-of-life care is essential. While terminally ill cancer patients spend much of their last year in the home, the literature reveals that the majority of these patients would also prefer to die at home. Despite patients' and families' cited preference for home deaths, dying at home continues to be infrequent. In Edmonton's Capital Health Region (CHR) only 16% of cancer patients died at home in 1999. While many reasons for the low incidence of home death are cited, little data exists regarding discharges from the palliative home care program in the CHR. As such, it is difficult to assess where resources are needed in the community. The implementation of a discharge assessment tool for use in the Capital Health Palliative Home Care program may provide insight into potential correlates of home death. Not only providing information on individual patients, the inclusion of such data in the palliative home care database would allow for trends to be monitored over time.

Host recognition by the tobacco hornworm is mediated by a host plant compound

It is generally believed that animals make decisions about the selection of mates, kin or food on the basis of pre-constructed recognition templates. These templates can be innate or acquired through experience. An example of an acquired template is the feeding preference exhibited by larvae of the moth, Manduca sexta. Naive hatchlings will feed and grow successfully on many different plants or artificial diets, but once they have fed on a natural host they become specialist feeders. Here we show that the induced feeding preference of M. sexta involves the formation of a template to a steroidal glycoside, indioside D, that is present in solanaceous foliage. This compound is both necessary and sufficient to maintain the induced feeding preference. The induction of host plant specificity is at least partly due to a tuning of taste receptors to indioside D. The taste receptors of larvae fed on host plants show an enhanced response to indioside D as compared with other plant compounds tested.

The role of Ultrabithorax in the patterning of adult thoracic muscles in Drosophila melanogaster

Mutations in the homeotic gene, Ultrabithorax (Ubx), result in the transformation of the third thoracic (T3) segment into the second thoracic (T2) segment. Although it has been well established that these mutations have striking effects on adult epidermal structures in T3, the effect of these mutations on the adult musculature has been controversial. In this study, a series of Ubx regulatory mutations, anterobithorax, bithorax, postbithorax, and bithoraxoid, as well as combinations of these alleles were used to reevaluate the role of Ubx in the patterning of the T3 musculature. Homeotic indirect and direct flight muscles (IFMs and DFMs) were identified in the transformed T3 segment of all alleles and allelic combinations with the exception of postbithorax. We critically evaluated the pattern and amount of these muscles and found that while the amount and/or quality of homeotic IFMs increased, the amount of homeotic DFMs did not vary significantly as the severity of the ectodermal transformation increased. Because Ubx is not expressed in the adult mesoderm of T3, these results suggest that inductive cues play a major role in the patterning of adult thoracic muscles. We provide a model that illustrates the central role of inductive cues in generating the final adult muscle pattern in the thorax.

Imaginal pioneers prefigure the formation of adult thoracic muscles in Drosophila melanogaster

In insects, specialized mesodermal cells serve as templates to organize myoblasts into distinct muscle fibers during embryogenesis. In the grasshopper embryo, large mesodermal cells called muscle pioneers extend between the epidermal attachment points of future muscle fibers and serve as foci for myoblast fusion. In the Drosophila embryo, muscle founder cells serve a similar function, organizing large numbers of myoblasts into larval muscles. During the metamorphosis of Drosophila, nearly all larval muscles degenerate and are replaced by a set of de novo adult muscles. The extent to which specialized mesodermal cells homologous to the founders and pioneers of the insect embryo are involved in the development of adult-specific muscles has yet to be established. In the larval thorax, the majority of imaginal myoblasts are associated with the imaginal discs. We report here the identification of a morphologically distinct class of disc-associated myoblasts, which we call imaginal pioneers, that prefigures the formation of at least three adult-specific muscles, the tergal depressor of the trochanter and dorsoventral muscles I and II. Like the muscle pioneers of the grasshopper, the imaginal pioneers attach to the epidermis at sites where the future muscle insertions will arise and erect a scaffold for developing adult muscles. These findings suggest that a prior segregation of imaginal myoblasts into at least two populations, one of which may act as pioneers or founders, must occur during development.

Octopamine mimics the effects of parasitism on the foregut of the tobacco hornworm Manduca sexta

The parasitic braconid wasp Cotesia congregata lays its eggs inside the body of the larval stage of its host, the moth Manduca sexta. The Cotesia congregata larvae develop within the hemocoel of their host until their third instar, when they emerge and spin cocoons and pupate on the outer surface of the caterpillar. From this time until their death approximately 2 weeks later, the Manduca sexta larvae show striking behavioral changes that include dramatic declines in spontaneous activity and in the time spent feeding. Coincident with these behavioral changes, it is known that octopamine titers in the hemolymph of the host become elevated by approximately 6.5-fold. Octopamine is an important modulator of neural function and behavior in insects, so we examined hosts for neural correlates to the behavioral changes that occur at parasite emergence. We found that, in addition to the changes reported earlier, after parasite emergence (post-emergence), Manduca sexta larvae also showed marked deficits in their ability to ingest food because of a disruption in the function of the frontal ganglion that results in a significant slowing or the absence of peristaltic activity in the foregut. This effect could be produced in unparasitized fifth-instar larvae by application of blood from post-emergence parasitized larvae or of 10(−6)mol l(−1)d,l-octopamine (approximately the level in the hemolymph of post-emergence larvae). In contrast, blood from parasitized larvae before their parasites emerge or from unparasitized fifth-instar larvae typically had no effect on foregut activity. The effects of either post-emergence parasitized blood or 10(−6)mol l(−1) octopamine could be blocked by the octopamine antagonists phentolamine (at 10(−5)mol l(−1)) or mianserin (at 10(−7)mol l(−1)).

Homeotic gene expression in the wild-type and a homeotic mutant of the moth Manduca sexta

Antibodies were used to examine the expression patterns of Antennapedia (Antp), Ultrabithorax (Ubx), Ubx and abdominal-A combined (Ubx/abd-A), and Distalless (Dll) in the embryos of the moth Manduca sexta. We found that the spatial and temporal pattern of Antp expression in Manduca was correlated with the anterior migration of two patches of epithelium that include the anterior-most tracheal pits, and with the development of functional spiracles. Ubx expression showed an intricate pattern which suggests complex regulation during development. Throughout Manduca embryogenesis the expression of Ubx/Abd-A and Dll was similar to that reported for other insects. However, there was no apparent reduction in Ubx/Abd-A expression in the Manduca abdominal proleg primordia that expressed Dll. The expression of these four proteins was also examined in embryos of the Manduca homozygous homeotic mutant Octopod (Octo). The Octo mutation results in the transformation of A1 and A2 in the anterior direction, with homeotic legs appearing on A1 and occasionally A2. Our results suggest that in Octo animals there is a reduction in the level of Ubx protein expression throughout its domain. Based on homeotic gene expression in wild-type and mutant Manduca and in other insects, we discuss potential roles of homeotic genes in insect morphological evolution.