"It's More Difficult…": Clinicians' Experience Providing Palliative Care to Adolescents and Young Adults Diagnosed With Advanced Cancer

PURPOSE

Adolescents and young adults (AYAs; age 15-39 years) with advanced cancer are a population in whom quality of life is uniquely affected because of their stage of life. However, training focused on palliative care for AYAs is not routinely provided for health care providers (HCPs) in oncology. This study aims to explore the experiences of HCPs involved in introducing and providing palliative care caring for AYAs with advanced cancer and their families to understand the unique challenges HCPs experience.

METHODS

Using a qualitative descriptive design, semistructured interviews were conducted with medical and radiation oncologists, palliative care physicians, psychiatrists, and advanced practice nurses involved in caring for AYAs diagnosed with advanced cancer (N = 19). Interviews were transcribed verbatim and analyzed using thematic analysis in combination with constant comparative analysis and theoretical sampling.

RESULTS

There were 19 participants, 9 men and 10 women, with a median age of 45 years (range, 24-67 years). Six were palliative care physicians, 5 medical oncologists, 4 nurse practitioners, and 2 each radiation oncologists and psychiatrists. Overall, participants perceived the provision of palliative care for AYAs to be more difficult compared with older adults. Four themes emerged: (1) challenges helping AYAs/families to engage in and accept palliative care, (2) uncertainty regarding how to involve the family, (3) HCP sense of tragedy, and (4) HCP sense of emotional proximity.

CONCLUSION

Findings from this study support the development of dedicated training for HCPs involved in palliative care for AYA.

Comparison of health care-related social media and Internet usage between patients treated with curative and palliative intent

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Background: Cancer patients (pts) are increasingly searching online for information and support. Online resource usage and preferences may differ between patients treated with curative versus palliative intent. Methods: Cancer pts completed a cross-sectional survey at Princess Margaret Cancer Centre, assessing their usage and perceptions of social media and the internet with regards to their cancer. Associations between patients’ responses and treatment intent were evaluated univariably (t-tests, chi-squared tests) and multivariably (linear/logistic regression). Results: In a univariable analysis comparing 65 palliative pts (PALL) and 222 curative pts, PALL were more likely to be older (p < 0.001) and less likely to be currently employed or a student (p < 0.001); they were less likely to use the internet (91% vs. 97%, p = 0.03), social media (68% vs. 87%, p < 0.001), and used social media less frequently than curative patients (66% vs. 83%, p = 0.01). PALL were less likely to be interested in an online personal health record (62% vs 76%, p = 0.04) and more likely to indicate that they would not use online information (17% vs. 7%, p = 0.02), compared to curative pts. PALL were more likely to be unfamiliar with social media (20% vs. 7%, p = 0.01), to not know how to use social media (21% vs. 7%, p < 0.001), and to have difficulty finding information (14% vs. 5%, p = 0.03). However, no significant differences by intent were identified after adjustment in a multivariable analysis controlling for age. Conclusions: After the age differences between both groups were adjusted for, there were no significant differences in patients’ online activity nor their perceptions of the trustworthiness, utility, and role of social media, and the Internet. These similarities suggest that online resources for PALL can be developed simultaneously with curative pts.

A closer look on the coordination of soft nitrogen-donor ligands to Cm(iii): SO3-Ph-BTBP

The combination of theory, VSBS and TRLFS revealed new insights into the coordination structure of [Cm(SO₃-Ph-BTBP)₂]⁵⁻.

A review of the demonstration of innovative solvent extraction processes for the recovery of trivalent minor actinides from PUREX raffinate

The selective partitioning (P) of long-lived minor actinides fromhighly active waste solutions and their transmutation (T) to short-lived or stable isotopes by nuclear reactions will reduce the long-term hazard of the high-level waste and significantly shorten the time needed to ensure their safe confinement in a repository. The present paper summarizes the on-going research activities at Forschungszentrum Jülich (FZJ), Karlsruher Institut für Technologie (KIT) and Institute for Transuranium Elements (ITU) in the field of actinide partitioning using innovative solvent extraction processes. European research over the last few decades, i.e. in the NEWPART, PARTNEW and EUROPART programmes, has resulted in the development of multi-cycle processes for minor actinide partitioning. These multi-cycle processes are based on the co-separation of trivalent actinides and lanthanides (e.g. by the DIAMEX process), followed by the subsequent actinide(III)/lanthanide(III) group separation in the SANEX process. The current direction of research for the development of innovative processes within the recent European ACSEPT project is discussed additionally.

This paper is focused on the development of flow-sheets for recovery of americium and curium from highly active waste solutions. The flow-sheets are verified by demonstration processes, in centrifugal contactors, using synthetic or genuine fuel solutions. The feasibility of the processes is also discussed.

Dexrazoxane prevents doxorubicin-induced long-term cardiotoxicity and protects myocardial mitochondria from genetic and functional lesions in rats

BACKGROUND AND PURPOSE

Doxorubicin causes a chronic cardiomyopathy in which reactive oxygen species (ROS) accumulate over time and are associated with genetic and functional lesions of mitochondria. Dexrazoxane is a cardioprotective iron chelator that interferes with ROS production. We aim to analyze the effects of dexrazoxane on mitochondria in the prevention of doxorubicin-induced chronic myocardial lesions.

EXPERIMENTAL APPROACH

Wistar rats (11 weeks of age) were injected with intravenous doxorubicin (0.8 mg kg(-1) weekly for 7 weeks) with or without simultaneous dexrazoxane (8 mg kg(-1)). Animals were killed at 48 weeks. Cardiomyopathy was scored clinically and histologically and cardiac mitochondria were analyzed.

KEY RESULTS

Compared to control rats receiving saline, rats treated with doxorubicin alone developed a clinical, macroscopic, histological and ultrastructural cardiomyopathy with low cytochrome c-oxidase (COX) activity (26% of controls). The expression of the mtDNA-encoded COX II subunit was reduced (64% of controls). Myocardia exhibited a high production of ROS (malondialdehyde 338% and superoxide 787% of controls). Mitochondria were depleted of mitochondrial DNA (mtDNA copy number 46% of controls) and contained elevated levels of mtDNA deletions. Dexrazoxane co-administration prevented all these effects of doxorubicin on mitochondria, except that hearts co-exposed to doxorubicin and dexrazoxane had a slightly lower mtDNA content (81% of controls) and mtDNA deletions at low frequency.

CONCLUSIONS AND IMPLICATIONS

Dexrazoxane prevented doxorubicin induced late-onset cardiomyopathy and also protected the cardiac mitochondria from acquired ultrastructural, genetic and functional damage.

Pathogenesis of HIV-1 infection within bone marrow cells

Mononuclear phagocytic cells and CD4+ T lymphocytes represent the major targets for infection by HIV-1 in vivo. The most severe pathogenic features associated with HIV-1 infection can be attributed to malfunction or premature death of these cells that are of hematopoietic origin. Patients with acquired immunodeficiency syndrome (AIDS), suffer from many hematologic disorders, particularly those persons with long-term infection of HIV-1. These disorders include anemia, lymphocytopenia, thrombocytopenia and neutropenia. The mechanisms that lead to the induction of these disorders are multi-factorial. However, sufficient evidence has accumulated which suggests that HIV-1 infection of cells within the microenvironment of the bone marrow can lead to the induction of hematopoietic deficits. Most studies indicate that marrow-derived hematopoietic stem cells cannot be infected by HIV-1 until they undergo modest differentiation in order to express the appropriate receptors to enable virus entry and subsequent replication. Some cells within the mixed environment of the marrow stroma appear to support HIV-1 replication however. These cells include marrow microvascular endothelial cells, sometimes referred to as blanket cells, stromal fibroblasts, as well as mononuclear phagocytes. Our recent experiments suggest that the HIV-1 accessory protein, Vpr, plays some role in the activation of marrow-derived mononuclear phagocytes which appears to result in premature phagocytosis of non-adherent marrow cells present in the in vitro cultures. This phenomenon could account, in part, for the induction of cytopenias that are typical of individuals infected by HIV-1.

A novel Vpr peptide interactor fused to integrase (IN) restores integration activity to IN-defective HIV-1 virions

A novel approach to complement human immunodeficiency virus type I (HIV-1) integrase (IN)-defective virions has been identified. The approach involves fusion of a 23-amino-acid stretch to the N-terminus of wild-type IN and coexpression of this chimera with the IN-defective proviral template in virus producing cells. The 23-amino-acid peptide represents a Vpr "interactor," referred to as the the WxxF or WF domain, which apparently leads to docking of the domain along with the fusion partner onto HIV-1 Vpr, thus permitting virion incorporation of the chimeric protein when expressed, in trans, with other viral products. Transfection of the WF-IN expression plasmid along with HIV-1 viral clones that produce Vpr, but bear an IN mutation, results in the release of a proportion of viral particles that are competent for integration. The extent of complementation was assessed using the MAGI cell assay, where integration of viral DNA results in the eventual appearance of easily visible multinucleated blue syncytia. The efficiency of dWF-IN (double copy of WF domain) complementation is not improved markedly by incorporation of a HIV-1 protease cleavage site (PR) between the dWF domain and IN (dWF-PR-IN), unlike that observed with Vpr fusions to IN. Furthermore, the ability of Vpr-PR-IN and dWF-PR-IN to complement IN-defective proviral clones, both of which bear an intervening protease cleavage site, appear comparable. Western blotting analyses using virions isolated through sucrose cushions demonstrate clearly the incorporation of the dWF-IN fusion protein into Vpr containing HIV-1 particles but not in Vpr-deficient virions. Additional Western blotting analyses indicate that all Vpr-IN and dWF-IN chimeras, with or without a PR site, are packaged into virions. The efficiency of virion incorporation of Vpr-IN and dWF-IN chimeras appears approximately comparable by Western blotting analysis. The ability of dWF-IN to complement IN-defective proviruses with efficiency similar to that of Vpr-PR-IN and dWF-PR-IN indicates that dWF-IN retains the full complement of functions necessary for integration of proviral DNA and is likely due to the benign nature of this small domain at the amino-terminus of IN.

Effect of delayed treatment with recombinant human granulocyte colony-stimulating factor on survival and plasma cytokine levels in a non-neutropenic porcine model of Pseudomonas aeruginosa sepsis

BACKGROUND

Neutrophils are of great importance for the host's defense against invading organisms. Granulocyte colony-stimulating factor (G-CSF) has been used to augment both the neutrophil number and function, and its prophylactic administration has proved beneficial in animal models of sepsis. However, pretreatment with G-CSF is not practical under clinical conditions. We therefore investigated the effect of recombinant human (rh)G-CSF, administered only after infection, on the survival rate as well as the hemodynamic and cytokine response of the animals.

METHODS

Chronically catheterized conscious pigs were challenged with Pseudomonas aeruginosa (8 x 10(7) colony-forming units kg(-1) x h(-1) for 120 h (control group, n = 10). Animals in the G-CSF group (n = 7) also received rhG-CSF (5 microg kg(-1) x day(-1)), the first dose being given 3 h after beginning bacterial infusion.

RESULTS

The mortality rate was 50% (5/10) and 29% (2/7) in the control and G-CSF groups, respectively (p = NS, control vs. G-CSF group). Fever, severe pulmonary hypertension, and a hyperdynamic response were recorded in all of the animals. In spite of a prompt and significant recovery from the initial leukopenia (p < .05 vs. control group), the animals of the G-CSF group showed no significant differences in the parameters investigated from those of the controls. Compared with the survivors, the interleukin-1 receptor antagonist was markedly elevated in all nonsurvivors after 6 h of sepsis (p < .05).

CONCLUSIONS

These data suggest that treatment with rhG-CSF after the onset of bacterial sepsis might not significantly improve the chances of survival for non-neutropenic patients.

Eccentric and posteccentric contractile behaviour of skeletal muscle: a comparative study in frog single fibres and in humans

Eccentric and posteccentric force behaviour in human skeletal muscle and in isolated frog muscle fibres was studied by imposing stretch-and-hold loading conditions during contractions with maximal voluntary effort or under tetanic stimulation in the isolated preparations. The investigations on human muscle were made on the forearm flexors of a group of kayak racers (n = 16; age: 17-22 years) and of schoolgirls (n = 15; age: 17-18 years) with both groups participating in a strength-training programme over 4 (kayak racers) or 3 (girls) months. Half of the training regime consisted of eccentric elements. In the isolated muscle fibres, it could be shown that in the posteccentric hold phase the enhanced force decayed exponentially to the original isometric value with a mean time-constant of 0.35 s (10 degrees C) and of 0.23 (20 degrees C). In the forearm flexor of human subjects similar results were obtained not only qualitatively but even quantitatively (time constant of posteccentric force decay: 0.25-0.37 s). Strength training in both groups did not lead to an enhancement in maximal isometric force alone [mean increase in force 17 (SD 10)%], a well-known and generally accepted fact, but also to a parallel shift in eccentric [21 (SD 10)%] and posteccentric force level. The close similarity between the findings in isolated muscle fibres and in human muscle in situ suggests that the eccentric and posteccentric behaviour must be primarily ascribed to the contractile properties of the muscle fibres themselves. A three-element muscle model with variable visco-elastic properties would appear to be most suitable for simulating the experimental findings.