Effects of dignity therapy on psychological distress and wellbeing of palliative care patients and family caregivers - a randomized controlled study

BACKGROUND

This study extended the original Dignity Therapy (DT) intervention by including partners and family caregivers (FCs) of terminally-ill cancer patients with the overall aim of evaluating whether DT can mitigate distress in both patients nearing the end of life and their FCs.

METHODS

In this multicenter, randomized controlled trial (RCT), a total of 68 patients with life expectancy < 6 months and clinically-relevant stress levels (Hospital Anxiety Depression total score; HADStot ≥ 8) including their FCs were randomly assigned to DT, DT + (including their FCs), or standard palliative care (SPC) in a 1:1:1 ratio. Study participants were asked to complete a set of questionnaires pre- and post-intervention.

RESULTS

The coalesced group (DT and DT +) revealed a significant increase in patients' perceived quality of life (FACIT-Pal-14) following the intervention (mean difference 6.15, SD = 1.86, p < 0.01). We found a statistically significant group-by-time interaction effect: while the HADStot of patients in the intervention group remained stable over the pre-post period, the control group's HADStot increased (F = 4.33, df = 1, 82.9; p < 0.05), indicating a protective effect of DT. Most patients and their FCs found DT useful and would recommend it to other individuals in their situation.

CONCLUSIONS

The DT intervention has been well-received and shows the potential to increase HRQoL and prevent further mental health deterioration, illness burden and suffering in terminally-ill patients. The DT intervention holds the potential to serve as a valuable tool for facilitating end-of-life conversations among terminally-ill patients and their FCs. However, the implementation of DT within the framework of a RCT in a palliative care setting poses significant challenges. We suggest a slightly modified and less resource-intensive version of DT that is to provide the DT inventory to FCs of terminally-ill patients, empowering them to ask the questions that matter most to them over their loved one's final days.

TRIAL REGISTRATION

This study was registered with Clinical Trial Registry (ClinicalTrials.gov -Protocol Record NCT02646527; date of registration: 04/01/2016). The CONSORT 2010 guidelines were used for properly reporting how the randomized trial was conducted.

[In the Same Boat: How to Support Relatives of Patients with Dementia Using Diverse Interventions]

In the Same Boat: How to Support Relatives of Patients with Dementia Using Diverse Interventions Abstract. Caring for people with dementia has great psychological, physical, social, financial and spiritual effects on relatives. Support and counseling can contribute to an improved health of the relative, to the relationship with the dementia patient, as well as to better treatment (through shared decision-making/care planning) of the patient. This article reviews data from Switzerland and international studies.

Developing a measure to evaluate a positive youth development program for Native Hawaiians: the Hui Mālama o ke Kai rubrics of Hawaiian values

OBJECTIVE

This study introduces the rubrics of Native Hawaiian values developed to measure youth knowledge and understanding of indigenous values along with 8 other tools to evaluate Hui Mālama o ke Kai (HMK), a culturally relevant, positive youth development, after-school program in a Native Hawaiian community. Findings from our efforts to validate the rubrics tool, as an evaluation measure, using triangulation are presented.

METHODS

Evaluation tools were modified through community input and measured youth risk and protective factors, including knowledge and practice of Hawaiian values. Validity and reliability of the tools were tested by analyzing internal consistency, intraclass correlations, and triangulating data sources.

RESULTS

Corroboration of results from the different data sources indicated convergent validity of measures to evaluate youth understanding and practice of Hawaiian values.

CONCLUSIONS

This community-focused approach to evaluation demonstrates how multiple evaluation instruments may reliably evaluate a program.

[Pulse synchronous bruit, swollen eye, diplopia, exophthalmos, chemosis and diplopia three weeks after a head trauma]

Traumatic carotid-cavernous sinus fistulas represent an uncommon complication of a head trauma. The consequences of a delayed diagnosis are progressive ocular complications such as visual loss, extraocular muscle palsy, progressive proptosis, conjuctival chemosis, retinal vein occlusion and secondary glaucoma. Moreover, severe epistaxis, intracerebral and subarachnoidal hemorrhage may occur. We present a patient who developed a carotid-cavernous sinus fistula within three weeks after a craniocerebral injury. Despite initial exclusion of an arteriovenous fistula using duplex sonography, angiography later demonstrated the carotid-cavernous sinus fistula that was successfully occluded be means of catheter intervention. The patient's symptomatology consisting of pulse synchronous bruit, red, swollen and painful eye, diplopia, chemosis, pulsating exophthalmos, ocular hypertension and progressive visual loss allowed various differential diagnoses. Apart from inflammatory, mechanical, autoimmune, vascular and tumorous disorders, a traumatic cause was highly probable considering the patient's history of craniocerebral injury. A rapid elimination of such a fistula is necessary in order to prevent long-term damage. However it is important to consider the possible complications due to the intervention, in our case the risk of a hyperperfusion syndrome with a consecutive cerebral hemorrhage.

ISOLATION FROM NORMAL MICE OF A PNEUMOTROPIC VIRUS WHICH FORMS ELEMENTARY BODIES

1. A pneumotropic virus which forms elementary bodies has been isolated from apparently normal albino Swiss mice. 2. The antigenic relationship of this virus to those of meningopneumonitis, lymphogranuloma venereum, hamster pneumonia (7), and human pneumonitis (8) was established either by cross-immunity or complement fixation or both. 3. In spite of a relationship to other viruses, the virus could be differentiated from all the others studied by certain of its properties.

STUDIES ON THE CULTIVATION OF THE TYPHUS FEVER RICKETTSIA IN THE PRESENCE OF LIVE TISSUE

1. Rickettsia prowazeki can be cultivated for many generations in vitro, without diminution in numbers or virulence, in media similar to those described by Maitland, Rivers, and others for the cultivation of certain viruses. In all probability, such cultures can be maintained indefinitely. 2. It has been impossible, thus far, to cultivate the typhus rickettsia without employing living tissue.

[Blue discoloration of hands, numbness of feet, indolent cervical lymph node swelling in a 73-year-old man]

A 73-years old patient came to our outpatient clinic because of a blue discoloration of his hands. Furthermore there was a systemic inflammatory reaction, burning pain and numbness of his feet due to a polyneuropathy, and an indolent enlargement of the cervical lymph nodes. In 1996 and 2001 cervical lymph node resections were done because of localized angiofollicular lymphnode hyperplasia (Castleman's disease). The laboratory values confirmed a systemic inflammatory reaction, a hypothyreosis and a monoclonal gammopathy. A CT-scan showed enlarged cervical, intrathoracic and abdominal lymphnodes and a splenomegaly. So all the criterias for a POEMS syndrome (special form of multiple myeloma) were met with polyneuropathy, organomegaly, endocrinopathy, monoclonal protein and skin changes. The generalized lymphadenopathy corresponded histologically to the prior mentioned Castleman's disease. The patient responded well to systemic glucocorticoid treatment and today he is asymptomatic.

Physical activity staging distribution: Establishing a heuristic using multiple studies

The purpose of this study was to identify the population prevalence across the stages of change (SoC) for regular physical activity and to establish the prevalence of people at risk. With support from the National Institutes of Health, the American Heart Association, and the Robert Wood Johnson Foundation, nine Behavior Change Consortium studies with a common physical activity SoC measure agreed to collaborate and share data. The distribution pattern identified in these predominantly reactively recruited studies was Precontemplation (PC) = 5% (+/- 10), Contemplation (C) = 10% (+/- 10), Preparation (P) = 40% (+/- 10), Action = 10% (+/- 10), and Maintenance = 35% (+/- 10). With reactively recruited studies, it can be anticipated that there will be a higher percentage of the sample that is ready to change and a greater percentage of currently active people compared to random representative samples. The at-risk stage distribution (i.e., those not at criteria or PC, C, and P) was approximately 10% PC, 20% C, and 70% P in specific samples and approximately 20% PC, 10% C, and 70% P in the clinical samples. Knowing SoC heuristics can inform public health practitioners and policymakers about the population's motivation for physical activity, help track changes over time, and assist in the allocation of resources.

[Spontaneous dissection of visceral blood vesssels--a rare cause of epigastric pain]

A 51 year-old man presented with acute abdominal pain in our emergency room. The first examination revealed no pathological findings except coprostasis and after an enteroclysis the patient was sent home without any complaints. During a recent episode of abdominal pain a computer tomography was performed, showing dissection of the superior mesenteric and the celiac artery. Without any signs of mesenteric ischemia additional examinations like laboratory studies, x-rays, and abdominal ultrasound might be normal and therefore not helpful for diagnosis. In patients presenting with persistent abdominal pain and unspecific clinical and laboratory findings rare causes of abdominal symptoms should be considered. Despite the rarity of visceral artery dissection, awareness of this pathology is crucial because of its possible lifethreatening complications. Appropriate diagnostic imaging tests may avoid postmortem diagnosis by the pathologist.

[Eosinophilia in a family from Bosnia]

We describe reference to a family from Bosnia that the diagnosis of Trichinellosis can be difficult despite notice of travel-history and eosinophilia but lack of further epidemiological datas and due to the rarity of this zoonosis. Clinical pattern of trichinellosis are fever, headache, myalgia, periorbital oedema, less frequently diarrhea and abdominal pain. Dreaded complications are myocarditis and encephalitis. High eosinophilia and increased creatine phosphocinase activity are the most frequently observed laboratory features. The detection of specific circulating antibodies or the parasitological examination of a muscle biopsy will confirm the diagnosis. The medical treatment includes albendazol and steroid.

[Acute epigastric pain]

Epigastric pain is a frequent complaint in emergency patients and shows a wide spectrum of differential diagnostic possibilities. Dangerous causes with life threatening consequences have to be ruled out as soon as possible, including causes of extra abdominal organs (heart, great vesels). After checking for and adequate treatment of vital parameters an efficient management strategy should consider the acuteness of symptoms, as velocity of pain onset is often related to its seriousness (aneurysmatic rupture of great vessels, parenchymal damage or infarction). A rare cause of acute epigastric pain is bleeding or rupture of renal or hepatic cysts. Imaging techniques, such as ultrasound and computed tomography, are helpful in finding the correct diagnosis without loosing to much time. Therapy depends on aetiology and dignity of the lesion, often an invasive surgical intervention is the only possibility to confirm the correct diagnosis.

[Medical problems in migrants]

Medical problems in migrants are not only an abstract political problem but also a problem that concerns physicians in their daily practice. Beside somatic disorders that are more common in developing countries we often are confronted to problems due to psychosocial stress. Language difficulties, problems of cultural misunderstanding and a lack of successful concepts impair the physician-patient-relationship and hinder a satisfying solution. Missing economic resources influence the availability of efficient support. Despite all difficulties there are strategies that can help practitioners to deal with the subject without waiting for a social revolution.

Prevalence of Tropheryma whipplei DNA in patients with various gastrointestinal diseases and in healthy controls

BACKGROUND

Little is known about the epidemiology of Tropheryma whipplei and its prevalence in people without clinical signs of Whipple's disease.

PATIENTS AND METHODS

We screened 239 patients with various gastrointestinal diseases for T. whipplei DNA and compared them with 215 healthy controls in order to check whether T. whipplei might be a risk factor for common gastrointestinal problems or diseases. We detected the 16S rDNA of T. whipplei in salivary and stool samples using a specific seminested PCR.

RESULTS

The prevalence of T. whipplei DNA in patients and in controls was 4.2% (95% CI 2.0-7.6% ) and 7.0% (95% CI 4.0-11.3%), respectively. None of the different gastrointestinal diseases was associated with a higher rate of PCR-positive tests, except for the group of patients with reflux syndrome. Five out of 43 patients with reflux were found to be positive, with all five being positive in the salivary sample. This is in contrast to our findings in carriers without reflux with mainly positive stool samples (p < 0.01).

CONCLUSION

We conclude that the asymptomatic carrier state of T. whipplei indeed exists and that it is much more frequent than the rare Whipple's disease. The higher prevalence of T. whipplei DNA in the saliva of patients with reflux syndrome suggests that the stomach might be the habitat of the organism.

[Incidental finding: left sided cystic adrenal mass]

Because of the widespread use of imaging techniques the incidental diagnosis of an adrenal mass without clinical symptoms and pathologic laboratory values becomes more and more common. To avoid unnecessary therapeutic interventions an intensive evaluation should take place including blood and urine testing as well as radiologic examination. An accurate assessment is often helpful in making the diagnosis of a benign process to avoid an invasive procedure and to determine the frequency and intensity of further controls. Nevertheless, in some cases the invasive approach is necessary because of an unclear situation or because of influences caused by the patient. An advantage is the possibility of laparoscopic intervention because of the minimal morbidity and until now no reported mortality.

Early psychological reactions to life-threatening injuries

OBJECTIVE

To assess the prevalence of posttraumatic stress symptoms and coping patterns in severely injured accident victims; to study correlations between injury severity and psychosocial variables and the presence of posttraumatic stress symptoms; and to analyze intensive care unit (ICU) personnel's global clinical appraisals in relation to patient characteristics.

DESIGN

A study of critically ill accident victims assessed within one month of the trauma.

SETTING

ICU of the traumatology department at the University Hospital, Zurich.

PATIENTS

121 consecutive patients with accidental injuries (mean Injury Severity Score, 21.8; mean Glasgow Coma Scale score, 14.4) admitted to the ICU between January 1996 and June 1997, aged 18-68 yrs. Patients with severe head injuries, attempted suicides, and victims of physical assault were excluded.

MEASUREMENTS

Extensive clinical interview, Impact of Event Scale, Clinician-Administered Posttraumatic Stress Disorder Scale, social support, life events, biographical protective and risk factors, Sense of Coherence questionnaire, Freiburg Questionnaire of Coping with Illness.

RESULTS

13.7 (SD, 6.8) days after the accident, 5 patients (4.1 %) met all criteria for posttraumatic stress disorder with the exception of the time criterion. A further 24 patients (19.9%) had subsyndromal posttraumatic stress disorder. Posttraumatic psychiatric symptomatology did not correlate with objective injury criteria, but rather with pretrauma variables (female gender, biographical risk and protective factors, life events), the patients' subjective appraisal of the severity and threat of the accident, their general attitude toward life ("sense of coherence"), and their current coping strategies. Surgeons' and nurses' global clinical appraisals did not correlate with injury severity or with the patients' coping strategies.

CONCLUSIONS

Trauma surgeons and ICU personnel should pay special attention to the strains and stressors their patients have been exposed to when recording case histories and to the level of their patients' psychosocial adaptation before the trauma.