Medical education and law: withholding/withdrawing treatment from adults without capacity

BACKGROUND

Law is increasingly involved in clinical practice, particularly at the end of life, but undergraduate and postgraduate education in this area remains unsystematic. We hypothesised that attitudes to and knowledge of the law governing withholding/withdrawing life-sustaining treatment from adults without capacity (the WWLST law) would vary and demonstrate deficiencies among medical specialists.

AIMS

We investigated perspectives, knowledge and training of medical specialists in the three largest (populations and medical workforces) Australian states, concerning the WWLST law.

METHODS

Following expert legal review, specialist focus groups, pre-testing and piloting in each state, seven specialties involved with end-of-life care were surveyed, with a variety of statistical analyses applied to the responses.

RESULTS

Respondents supported the need to know and follow the law. There were mixed views about its helpfulness in medical decision-making. Over half the respondents conceded poor knowledge of the law; this was mirrored by critical gaps in knowledge that varied by specialty. There were relatively low but increasing rates of education from the undergraduate to continuing professional development (CPD) stages. Mean knowledge score did not vary significantly according to undergraduate or immediate postgraduate training, but CPD training, particularly if recent, resulted in greater knowledge. Case-based workshops were the preferred CPD instruction method.

CONCLUSIONS

Teaching of current and evolving law should be strengthened across all stages of medical education. This should improve understanding of the role of law, ameliorate ambivalence towards the law and contribute to more informed deliberation about end-of-life issues with patients and families.

Abstract OT2-01-10: A phase 1 study of RAD1901, a novel, orally available, selective estrogen receptor degrader, for the treatment of ER positive advanced breast cancer

The current NCCN treatment guidelines for ER+ breast cancer involves the use of approved agents such as fulvestrant, tamoxifen and aromatase inhibitors that either inhibit estrogen production or block estrogen receptor binding. While the initial treatment regimens with these selective estrogen receptor modulators (SERMs) and selective estrogen receptor degraders (SERDs) is often successful, many women eventually relapse with more aggressive forms of endocrine-resistant disease. To begin to overcome some of the challenges associated with current therapies including exposure limitations and intramuscular administration, we have developed RAD1901, a novel, non-steroidal, orally available SERD. Preclinical studies with RAD1901 have demonstrated potent dose dependent ER degradation consistent with a SERD mechanism of action, as well as potent inhibition of proliferation in vitro in breast cancer cell lines. RAD1901 also demonstrated significant anti-tumor efficacy in vivo, and notably single agent regressions in both MCF7 and a primary patient derived xenograft models harboring an ESR1 mutations.

A phase 1 monotherapy study conducted in healthy postmenopausal female volunteers evaluated forty four subjects treated once daily with RAD1901 with doses ranging from 200 mg/day up to 1000 mg/day for 7 days. All dose levels were generally well tolerated and pharmacokinetic analysis demonstrated plasma exposures consistent with preclinical efficacy in ER+ breast cancer models. Furthermore, 18F-estradiol positron emission tomography (FES-PET) was also performed at baseline and after 7 days of RAD1901 treatment, to evaluate estrogen receptor engagement. Standardized uptake values (SUV) pre- and post-treatment with RAD1901 demonstrated complete attenuation of FES-PET signal in ER+ tissues such as the uterus from the 200 mg/day dose level. Taken together, these results provide strong preclinical and clinical rationale for the development of RAD1901 as a potent and selective oral SERD for the treatment of hormone driven and hormone resistant ER + metastatic breast cancers.

RAD1901-005 is a Phase 1 study currently enrolling ER+ advanced metastatic breast cancer patients. The study consists of two parts: a monotherapy dose escalation followed by a safety expansion at the maximum tolerated dose (MTD). The dose escalation will follow a standard 3+3 design with once daily dosing to establish, safety, tolerability, and PK. Once the MTD for RAD1901 has been established, the safety expansion will further evaluate the safety, tolerability, biomarkers and preliminary efficacy at the recommended phase 2 dose (RP2D) following a continuous once daily schedule. Key inclusion criteria include post-menopausal women aged 18 years or older, with advanced ER positive, HER2 negative breast cancer, who have received ≤ 2 prior chemotherapy regimens in the metastatic setting and > 6 months of prior endocrine therapy. Patient enrollment started in early 2015, and is currently ongoing.

ClinicalTrials.gov identifier: NCT02338349.

Citation Format: Harb W, Garner F, McDermott J, Zimmerman T, Williams G, Hattersley G, Purandare D. A phase 1 study of RAD1901, a novel, orally available, selective estrogen receptor degrader, for the treatment of ER positive advanced breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr OT2-01-10.

Stifling magnesium corrosion via a novel anodic coating

The use of light-weight magnesium (Mg) alloys as engineering materials has been hampered in part due to their poor corrosion performance. An effective novel sacrificial coating is presented herein.

Differential outcome of the IDEFICS intervention in overweight versus non-overweight children: did we achieve 'primary' or 'secondary' prevention?

BACKGROUND

The aim of this study was to explore whether the IDEFICS intervention had a differential effect on 11,041 children's weight trajectories depending on their baseline body mass index status.

METHODS

Two subgroups of children are considered in the present analysis: those who were overweight or obese prior to the intervention and those who were neither overweight nor obese.

RESULTS

Among children in all eight countries who did not have prevalent overweight or obesity (OWOB) at baseline, 2 years later, there was no significant difference between intervention and control groups in risk of having developed OWOB. However, we observed a strong regional heterogeneity, which could be attributed to the presence of one distinctly outlying country, Belgium, where the intervention group had increased risk for becoming overweight. In contrast, among the sample of children with prevalent OWOB at baseline, we observed a significantly greater probability of normalized weight status after 2 years. In other words, a protective effect against persistent OWOB was observed in children in intervention regions compared with controls, which corresponded to an adjusted odds ratio of 0.76 (95% confidence interval: 0.58, 0.98).

DISCUSSION

This analysis thus provided evidence of a differential effect of the IDEFICS intervention, in which children with overweight may have benefited without having been specifically targeted. However, no overall primary preventive effect could be observed in children without initial overweight or obesity.

Parents' evaluation of the IDEFICS intervention: an analysis focussing on socio-economic factors, child's weight status and intervention exposure

INTRODUCTION

From April 2008 to August 2010 the Identification and prevention of Dietary- and lifestyle-induced health EFfects In Children and infantS (IDEFICS) intervention aimed to encourage healthier diets, higher physical activity levels and lower stress levels among European children and their families. While the intervention was intended to improve children's health, we also wished to assess whether there were unwelcome aspects or negative side-effects. Therefore all parents of children who participated in the IDEFICS intervention were asked for their views on different aspects of the intervention.

METHODS

A total of 10,016 parents of children who participated in the IDEFICS survey and who were involved in the intervention were invited to complete a questionnaire on positive and negative impacts of the intervention. Responses to each of the statements were coded on a four point Likert-type scale. Demographic data were collected as part of the baseline (T0 ) and first follow-up (T1 ) surveys; intervention exposure data was also collected in the T1 follow-up survey. Anthropometric data was collected in the same surveys, and child's weight status was assessed according to Cole and Lobstein. After initial review of the univariate statistics multilevel logistic regression was conducted to analyse the influence of socio-economic factors, child's weight status and intervention exposure on parental responses.

RESULTS

In total 4,997 responses were received. Approval rates were high, and few parents reported negative effects. Parents who reported higher levels of exposure to the intervention were more likely to approve of it and were also no more likely to notice negative aspects. Less-educated and lower income parents were more likely to report that the intervention would make a lasting positive difference, but also more likely to report that the intervention had had negative effects. Parents of overweight and obese children were more likely to report negative effects - above all, that 'the intervention had made their child feel as if he/she was "fat" or "overweight." '

CONCLUSION

While the results represent a broad endorsement of the IDEFICS intervention, they also suggest the importance of vigilance concerning the psychological effects of obesity interventions on overweight and obese children.

The IDEFICS intervention: what can we learn for public policy?

INTRODUCTION

As considered in the rest of this volume, the effects of the IDEFICS intervention on obesity rates were not encouraging. This paper considers how far findings from the IDEFICS study and similar intervention studies are relevant to the policy process and political decision-making.

METHODS

The paper offers theoretical and policy-level arguments concerning the evaluation of evidence and its implications for policymaking. The paper is divided into three parts. The first considers problems in the nature and applicability of evidence gained from school- and community-level obesity interventions. The second part considers whether such interventions present a model that policymakers could implement. The third part considers how we should think about policy measures given the limited evidence we can obtain and the many different goals that public policy must take account of.

RESULTS

The paper argues that (1) there are clear reasons why we are not obtaining good evidence for effective school- and community-level interventions; (2) public policy is not in a good position to mandate larger-scale, long-term versions of these interventions; and (3) there are serious problems in obtaining 'evidence' for most public policy options, but this should not deter us from pursuing options that tackle systemic problems and have a good likelihood of delivering benefits on several dimensions.

CONCLUSIONS

Research on school- and community-level obesity interventions has not produced much evidence that is directly relevant to policymaking. Instead, it shows how difficult it is to affect obesity rates without changing wider social and economic factors. Public policy should focus on these.

Vulnerability within families headed by teen and young adult mothers investigated by child welfare services in Canada

INTRODUCTION

Young mothers' families are at increased risk of child maltreatment and other poor health and social outcomes.

METHODS

Chi-square analyses of pooled child welfare services data from the Canadian Incidence Study of Reported Child Abuse and Neglect (CIS-2003; CIS-2008) were used to compare 284 teen mothers (18 years or younger) and 800 young mothers (19-21 years) and their families with 5752 families where the mother was 22 years or older.

RESULTS

Twenty-six percent of young mothers were 18 years or younger. Most (68% of teen-mother families and 57% of families with a young adult mother) received social assistance as their main source of income compared with 36% of families with a mother aged 22 years or older. Teen and young adult mothers were more likely than those aged 22 or older to have childhood histories of out-of-home care (31% and 23% vs. 10%) and were more likely to have risk factors such as alcohol abuse (25% and 23% vs. 18%) and few social supports (46% and 41% vs. 37%). Secondary caregivers in families with young mothers also had more risk factors. Teen and young adult mother families were more likely to have their child placed out-of-home during the investigation (29% and 27% vs. 17%). All were equally likely to be victims of domestic violence and to have mental health issues.

CONCLUSION

Within this sample of high-risk families, young mothers' families were more at risk than comparison families. Mothers' youth may be a useful criterion to identify families for targeted interventions.

Critical care nursing organizations and activities: a fourth worldwide review

AIM

To examine the activities and concerns of critical care nurses and professional critical care nursing organizations around the world and to identify expectations held of nursing leaders and policy makers to help address their concerns.

BACKGROUND

This study is the fourth worldwide review of its type. Previous surveys were undertaken in 2001, 2005 and 2009.

METHODS

An online descriptive survey was emailed to 88 potential participants from countries with critical care nursing organizations or known critical care nursing leaders. Responses were downloaded into Survey Monkey™ (Version 22) and analysed by geographical region and income level.

RESULTS

Fifty-nine respondents from 58 countries completed the questionnaire, of whom 43 had critical care nursing organizations established in their countries and 29 were members of the World Federation of Critical Care Nurses. The services provided by the organizations to be of most value were national conferences, website, professional representation, and practice standards and guidelines. Professional policies had been developed by some organizations on workforce, education and practice, while almost half provided their members with either a newsletter or journal. Collectively, the most important issues for critical care nurses were working conditions, provision of formal practice guidelines and competencies, staffing levels and access to quality education programmes.

CONCLUSIONS

Important issues continue to challenge the specialty of critical care nursing as new developments, priorities, clinical issues and other global events and influences impact critical care nursing worldwide.

IMPLICATIONS FOR NURSING AND HEALTH POLICY

This study will help guide nursing leaders and policy makers to address the needs of critical care nurses and their patients. Collaborative approaches between the specialty, nursing leaders and health policy advisors will assist to inform appropriate change in areas recommended for further action.

An examination of John Fewster's role in the discovery of smallpox vaccination

Edward Jenner is recognised today as the father of vaccination but, as this paper explores, he was not the only Gloucestershire doctor to be linked to this discovery. John Fewster, a local surgeon and apothecary, is also said to have experimented with vaccination, many years before Jenner. This claim is made in a letter addressed to John Coakley Lettsom, written by John Player, a Quaker farmer. Player describes in detail Fewster's realisation that cowpox could be used to protect against smallpox. This letter is frequently cited but has not previously been subjected to critical analysis. We have identified several inconsistencies, including conflicting dates and a possible ulterior motive in that Player's son was to marry Fewster's daughter. We think it unlikely that Player, a devout Quaker, would have consciously fabricated evidence, but argue that the discrepancies in his account undermine the assumption that Fewster carried out vaccination experiments prior to Jenner. We also explore the assertion that Fewster presented a paper in 1765 on the subject of cowpox and its protective effect over smallpox. We conclude that, although there is no doubt that Fewster did pre-empt Jenner's discovery of vaccination, he did not realise the significance or importance of this momentous medical advance.

NVP-QBE170: an inhaled blocker of the epithelial sodium channel with a reduced potential to induce hyperkalaemia

BACKGROUND AND PURPOSE

Inhaled amiloride, a blocker of the epithelial sodium channel (ENaC), enhances mucociliary clearance (MCC) in cystic fibrosis (CF) patients. However, the dose of amiloride is limited by the mechanism-based side effect of hyperkalaemia resulting from renal ENaC blockade. Inhaled ENaC blockers with a reduced potential to induce hyperkalaemia provide a therapeutic strategy to improve mucosal hydration and MCC in the lungs of CF patients. The present study describes the preclinical profile of a novel ENaC blocker, NVP-QBE170, designed for inhaled delivery, with a reduced potential to induce hyperkalaemia.

EXPERIMENTAL APPROACH

The in vitro potency and duration of action of NVP-QBE170 were compared with amiloride and a newer ENaC blocker, P552-02, in primary human bronchial epithelial cells (HBECs) by short-circuit current. In vivo efficacy and safety were assessed in guinea pig (tracheal potential difference/hyperkalaemia), rat (hyperkalaemia) and sheep (MCC).

KEY RESULTS

In vitro, NVP-QBE170 potently inhibited ENaC function in HBEC and showed a longer duration of action to comparator molecules. In vivo, intratracheal (i.t.) instillation of NVP-QBE170 attenuated ENaC activity in the guinea pig airways with greater potency and duration of action than that of amiloride without inducing hyperkalaemia in either guinea pig or rat. Dry powder inhalation of NVP-QBE170 by conscious sheep increased MCC and was better than inhaled hypertonic saline in terms of efficacy and duration of action.

CONCLUSIONS AND IMPLICATIONS

NVP-QBE170 highlights the potential for inhaled ENaC blockers to exhibit efficacy in the airways with a reduced risk of hyperkalaemia, relative to existing compounds.

Leveraging everyday technology for people living with dementia: a case study

Purpose

– The purpose of this paper is to present the self-described “journey” of a person with dementia (Brian; author 3) in his re-learning of old technologies and learning of new ones and the impact this had on his life.

Design/methodology/approach

– This is a single case study detailing the participant's experiences collaborating with a researcher to co-create methods of facilitating this learning process, which he documented in the form of an online blog and diary entries. These were analysed using NVivo to reveal the key themes.

Findings

– Brian was able to relearn previously used technologies and learn two new ones. This lead to an overarching theme of positive outlook on life supported by person-centredness, identity and technology, which challenged negative perceptions about dementia.

Research limitations/implications

– The paper provides an example of how learning and technology improved the life of one person with dementia. By sharing the approach the authors hope to encourage others to embrace the challenge of designing and developing innovative solutions for people with a dementia diagnosis by leveraging both current mainstream technology and creating novel bespoke interventions for dementia.

Originality/value

– The personal perspective of a person with dementia and his experiences of (re-) learning provide a unique insight into the impact of technology on his life.