Advance care planning in the palliative phase of people with intellectual disabilities: analysis of medical files and interviews

BACKGROUND

Advance care planning (ACP) is a process in which professionals, patients and their relatives discuss wishes and options for future care. ACP in the palliative phase reduces the chance that decisions have to be taken suddenly and can therefore improve the quality of life and death. The primary aim of this study is to explore how ACP takes place in cases of people with intellectual disabilities (ID).

METHOD

Medical files were analysed, and interviews were held in six care organisations for people with mild to severe ID. The data concerned people with ID (n = 30), 15 in the palliative phase, identified using the 'surprise question', and 15 who had died after an identifiable period of illness. Additional pre-structured telephone interviews were conducted with their relatives (n = 30) and professionals (n = 33).

RESULTS

For half of the people with ID who had died, the first report in their file about palliative care (needs) was less than 1 month before their death. Professionals stated that ACP was started in response to the person's deteriorating health situation. A do-not-attempt-resuscitation order was recorded for nearly all people with ID (93%). A smaller group also had other agreements between professionals and relatives documented in their files, mainly about potentially life-sustaining treatments (43%) and/or hospitalisation admissions (47%). Relatives and professionals are satisfied with the mutual cooperation in ACP in the palliative phase. Cognitive and communication disabilities were most frequently mentioned by relatives and professionals as reasons for not involving people with ID in ACP.

CONCLUSIONS

Advance care planning in the palliative phase of people with ID focuses mainly on medical issues at the end of life. Specific challenges concern a proactive identification of changing needs, fear to initiate ACP discussions, documentation of ACP in medical files and the involvement of people with ID in ACP. It is recommended that relatives and professionals should be informed about the content of ACP and professionals should be trained in communicating in advance about wishes for future care.

Imagining the Future of the International Cancer Screening Network: Responding to Needs and Engagement in Cancer Screening Globally

Background: Over the past three decades, much evidence has been generated in high-income countries (HIC) for effective implementation of cervical, breast and colorectal cancer screening programs and their contribution to reducing mortality. However, translation of cancer screening programs to low- and middle-income countries (LMIC) continues to be a challenge. For 30 years, the US National Cancer Institute's International Cancer Screening Network (ICSN) has gathered cancer screening researchers, implementers and evaluators at the ICSN biennial scientific meeting, provided expert assistance and facilitated working groups that advance research on cancer screening, via standardization of definitions, metrics, and measures, and cross-national comparative studies. For many years, this group has been comprised largely of participants from HICs, with limited participation by individuals from LMICs. However, in recent years, cancer screening has been adopted in an increasing number of LMICs. There is now a critical need to understand how to translate cancer screening delivery, program implementation, documentation, and research to LMICs. Aim: To gather insights from ICSN participants on the translatability of cancer screening knowledge between high and low-resource settings to advance the field of cancer screening globally. Methods: In 2018, ICSN conducted an evaluation research study to assess the outcomes and impacts of the ICSN to date and inform future ICSN activities, including engagement of individuals working in LMICs. Data collection consisted of a survey to our listserv, which has 666 subscribers. Results: There were 266 network members who responded to the survey, including 244 advanced who completed the full survey. The majority (58.7%) have been working in the field of cancer screening for 15 or fewer years, although 27.8% have 20 or more years of experience. Most respondents work in government agencies (32.7%) and academic institutions (37.2%), and dedicate most of their time to conducting cancer screening research. ICSN members predominantly work in organized cancer screening programs (72.6%). In addition, 80.5% work primarily in HICs and 10.9% in upper middle-income countries. Of those who attended the 2017 ICSN biennial meeting (56.1%), 78.8% agreed that it enabled them to learn from cancer screening in higher resource settings while 66.4% agreed that it enabled them to learn from cancer screening in lower resource settings. Conclusion: With 30 years of experience facilitating the advancement of cancer screening research, implementation and evaluation in HICs, the ICSN has many lessons to offer to countries that are considering establishing cancer screening programs. Findings suggest the relevance of ICSN activities to advancing cancer screening in both HICs and LMICs. ICSN is currently engaged in and developing additional approaches to advance cancer screening in LMICs, including technical assistance, workshops, and regional meetings.

Interferon-free therapy of chronic hepatitis C with direct-acting antivirals does not change the short-term risk for de novo hepatocellular carcinoma in patients with liver cirrhosis

BACKGROUND

Hepatitis C virus (HCV) clearance with IFN-based therapies reduces the incidence of hepatocellular carcinoma (HCC). There has been some debate if IFN-free therapy with direct-acting antivirals alters the risk for HCC.

AIM

To investigate the HCC incidence in cirrhotic HCV patients who cleared HCV with direct-acting antivirals vs untreated controls.

METHODS

We prospectively monitored 373 patients with chronic hepatitis C who received IFN-free therapies with direct-acting antiviral after January 2014. A retrospective control cohort of untreated cirrhotic patients was recruited out of 3715 HCV patients who were followed at our centre between 2007 and 2013, with similar HCC screening protocols.

RESULTS

158 direct-acting antiviral-treated and 184 control patients with liver cirrhosis were included in this analysis. The groups did not differ in gender and genotype distribution, severity of liver disease and prevalence of diabetes mellitus. Patients were followed up for a median of 440 (range 91-908) and 592 (range 90-1000) days. HCCs developed in 6 and 14 patients during follow-up, resulting in an incidence of 2.90 vs 4.48 HCCs per 100 person-years. In the direct-acting antiviral-treated group, there was no new case of HCC later than 450 days after treatment initiation. In multivariate analysis, higher MELD-Scores and AFP-levels were independently associated with HCC development. Transplant-free patient survival was similar in both groups.

CONCLUSIONS

IFN-free direct-acting antiviral therapy of chronic hepatitis C does not alter the short-term risk for HCC in patients with liver cirrhosis. A reduced HCC incidence may become evident after more than 1.5 years of follow-up.

[Pedicled vascularized bone graft for scaphoid reconstruction after Zaidemberg]

BACKGROUND

Nonunion of the scaphoid as a result of proximal fractures, failed surgical reconstruction, and especially avascular fragment necrosis are possible indications of vascularized bone grafts. Various techniques of vascularized (pedicled and free) grafts have been described. Pedicled grafts from the direct vicinity of the wrist provide several benefits. Harvest-site morbidity is reduced and preserved graft perfusion, without the need for blood vessel anastomosis, may lead to an improved consolidation.

METHODS

A common pedicled vascularized bone graft for reconstruction of the scaphoid was first described by C. Zaidemberg and colleagues in 1991. We describe 49 consecutive patients, who underwent vascularized bone-grafting, pedicled on the 1.2 intercompartmental, supraretinacular artery in a modified technique based on Zaidemberg's description. The fixation of the bone graft was performed by Kirschner wires.

RESULTS

A consolidation was detected in 37 cases, and 9 cases showed a persistent nonunion (3 patients did not follow up). According to the classification of Herbert, 44 patients had a nonunion grade D2 or higher, of which 36 patients showed a bony consolidation (8 non-consolidated). Complications occurred in individual cases (1x intraoperative fracture of the radius, 4x transient irritations of the superficial branch of the radial nerve). A loss in the range of motion of the affected wrist was frequent. An indication for a pedicled graft was seen if the preoperative contrast-enhanced MRI showed an impaired perfusion of scaphoid fragments.

DISCUSSION

The more advanced the changes in MRI, the more frequently treatment failed. The vascularized bone graft from the dorsal distal radius described by C. Zaidemberg et al. is one of several ways to address a circulation-impaired nonunion of the scaphoid.

Artificial cloud test confirms volcanic ash detection using infrared spectral imaging

Airborne volcanic ash particles are a known hazard to aviation. Currently, there are no means available to detect ash in flight as the particles are too fine (radii < 30 μm) for on-board radar detection and, even in good visibility, ash clouds are difficult or impossible to detect by eye. The economic cost and societal impact of the April/May 2010 Icelandic eruption of Eyjafjallajökull generated renewed interest in finding ways to identify airborne volcanic ash in order to keep airspace open and avoid aircraft groundings. We have designed and built a bi-spectral, fast-sampling, uncooled infrared camera device (AVOID) to examine its ability to detect volcanic ash from commercial jet aircraft at distances of more than 50 km ahead. Here we report results of an experiment conducted over the Atlantic Ocean, off the coast of France, confirming the ability of the device to detect and quantify volcanic ash in an artificial ash cloud created by dispersal of volcanic ash from a second aircraft. A third aircraft was used to measure the ash in situ using optical particle counters. The cloud was composed of very fine ash (mean radii ~10 μm) collected from Iceland immediately after the Eyjafjallajökull eruption and had a vertical thickness of ~200 m, a width of ~2 km and length of between 2 and 12 km. Concentrations of ~200 μg m⁻³ were identified by AVOID at distances from ~20 km to ~70 km. For the first time, airborne remote detection of volcanic ash has been successfully demonstrated from a long-range flight test aircraft.

Oxaliplatin and 5-FU/folinic acid (modified FOLFOX6) with or without aflibercept in first-line treatment of patients with metastatic colorectal cancer: the AFFIRM study

BACKGROUND

The combination of aflibercept with FOLFIRI has been shown to significantly prolong overall survival in patients with metastatic colorectal cancer (mCRC) after progression on oxaliplatin-based therapy. This trial evaluated the addition of aflibercept to oxaliplatin-based first-line treatment of patients with mCRC.

PATIENTS AND METHODS

Patients with mCRC were randomized to receive first-line therapy with mFOLFOX6 plus aflibercept (4 mg/kg) or mFOLFOX6 alone. The primary end point of this phase II study was the progression-free survival (PFS) rate at 12 months in each arm. The analysis of efficacy between the arms was a pre-planned secondary analysis.

RESULTS

Of 236 randomized patients, 227 and 235 patients were evaluable for the primary efficacy analysis and safety, respectively. The probabilities of being progression-free at 12 months were 25.8% [95% confidence interval (CI) 17.2-34.4] for the aflibercept/mFOLFOX6 arm and 21.2% (95% CI 12.2-30.3) for the mFOLFOX6 arm. The median PFS was 8.48 months (95% CI 7.89-9.92) for the aflibercept/mFOLFOX6 arm and 8.77 months (95% CI 7.62-9.27) for the mFOLFOX6 arm; the hazard ratio of aflibercept/mFOLFOX6 versus mFOLFOX6 was 1.00 (95% CI 0.74-1.36). The response rates were 49.1% (95% CI 39.7-58.6) and 45.9% (95% CI 36.4-55.7) for patients treated with and without aflibercept, respectively. The most frequent treatment-emergent grade 3/4 adverse events (AEs) excluding laboratory abnormalities reported for aflibercept/mFOLFOX6 versus mFOLFOX6 were neuropathy (16.8% versus 17.2%) and diarrhea (13.4% versus 5.2%). Neutropenia grade 3/4 occurred in 36.1% versus 29.3%. The most common vascular endothelial growth factor inhibition class-effect grade 3/4 AEs for aflibercept/mFOLFOX6 versus mFOLFOX6 were hypertension (35.3% versus 1.7%), proteinuria (9.2% versus 0%), deep vein thrombosis (5.9% versus 0.9%) and pulmonary embolism (5.9% versus 5.2%).

CONCLUSION

No difference in PFS rate was observed between treatment groups. Adding aflibercept to first-line mFOLFOX6 did not increase efficacy but was associated with higher toxicity.

CLINICAL TRIAL NUMBER

NCT00851084, www.clinicaltrials.gov, EudraCT 2008-004178-41.