Fighting cancer in the information age: the role of Internet

Cancer is a major health problem worldwide which is likely to assume alarming proportions in the next two decades. Communication and information have increasingly been considered important in helping people to cope with cancer. The arrival of Internet offers the opportunity to fundamentally reinvent medicine and health care delivery. Medical professionals can now use the Internet for continuing medical education, access latest medical information, for fast confirmation of diagnosis, exchange opinion on treatment strategies and in palliative care. Internet can provide cost-effective and timely ways to deliver a complex mix of interesting and high-quality information and expertise to cancer patients. Patients can also independently search the Internet to know about their illness and treatment options. However, of concern is the quality of information that is available in the 'Net'. Some Internet sites may contain erroneous information on cancer and can pose serious problems. There are also many good sites, which provide quality information on cancer for medical professionals, researchers and patients. This article focuses on how the Internet will aid us in fight against cancer.     

Advances, challenges, and limitations in serum-proteome-based cancer diagnosis

Recent advances in medicine have dramatically reduced the incidence and mortality of many cardiovascular, infectious, and certain neoplastic diseases; the overall mortality for most malignant solid tumors remains high. The poor prognosis in these cancers is due, in part, to the absence of adequate early screening tests, leading to delays in diagnosis. Three strategies have been applied to fight cancer: analysis of the molecular mechanisms involved in its pathogenesis and progression, improvement of early diagnosis, and the development of novel treatment strategies. There have been major advances in our understanding of cancer biology and pathogenesis and in the development of new (targeted) treatment modalities. However, insufficient progress has been made with respect to improving the methods for the early diagnosis and screening of many cancers. Therefore, cancer is often diagnosed at advanced stages, delaying timely treatment and leading to poor prognosis. Proteome analysis has recently been used for the identification of biomarkers or biomarker patterns that may allow for the early diagnosis of cancer. This tool is of special interest, since it allows for the identification of tumor-derived secretory products in serum or other body fluids. In addition, it may be used to detect reduced levels or loss of proteins in the serum of cancer patients that are present in noncancer individuals. These changes in the serum proteome may result from cancer-specific metabolic or immunological alterations, which are, at least partly, independent of tumor size or mass, thereby facilitating early discovery.     

Pancreatic acinar cell: its role in acute pancreatitis

The pancreatic acinar cell is the functional unit of the exocrine pancreas. It synthesizes, stores, and secretes digestive enzymes. Under normal physiological conditions, digestive enzymes are activated only once they have reached the duodenum. Premature activation of these enzymes within pancreatic acinar cells leads to the onset of acute pancreatitis; it is the major clinical disorder associated with pancreatic acinar cells. Although there have been major advances in our understanding of the pathogenesis of this disease in recent years, available treatment options are still limited to traditional nonspecific and palliative interventions. Novel therapeutic strategies have been suggested based on ongoing research in the physiology and pathophysiology of the disease; these include the administration of systemic antibiotics, antioxidants, cytokine antagonists, and more recently, inhibition of the renin-angiotensin system. Notwithstanding this promising development, most of these potential therapies are still in an experimental stage or clinical trial. Further investigation is needed to prove the efficacy of these novel treatment modalities.     

Appropriate,timely, and rational treatment of type 2 diabetes mellitus: Meeting the challenges of primary care

Diabetes now affects >24 million people in the United States. As the prevalence of diabetes continues to increase, long-term complications of diabetes have emerged as major health care issues. Although much focus has been placed on diabetes, it is important to note that prediabetes, the intermediate state of type 2 diabetes mellitus (DM), is not benign. The progression to type 2 DM for patients with impaired glucose tolerance (IGT) is 6% to 10% per year; for persons with both impaired fasting glucose and IGT, the cumulative incidence of diabetes in 6 years may be as high as 60%. Given the significant clinical and financial impact of both conditions, it is vital that clinicians initiate treatment of diabetes and prediabetes early and aggressively. Despite advances in diabetes treatment, many health care providers do not initiate or intensify therapy appropriately during patient visits, which contributes to poor diabetes control. Although management of blood pressure and lipid levels can be complex, glycemic control is often problematic for patients and their clinicians. Thus, clinicians must learn to use the various pharmacologic and nonpharmacologic strategies effectively to achieve glucose targets in their patients with type 2 DM. Patients with prediabetes should be managed with a combination of lifestyle intervention and appropriately timed pharmacotherapy. Pancreatic β-cell preservation should be a primary metabolic target.     

Acute burn care

LEARNING OBJECTIVES: After studying this article and accompanying Supplemental Digital Content, the participant should be able to: 1. Explain current burn-prevention strategies and criteria for referral to a burn center. 2. Summarize the current advances made in the critical care of acute burn patients. 3. Outline the recent developments in burn depth assessment and burn wound dressing technology. 4. Describe the common psychosocial aspects of postburn rehabilitation. SUMMARY: Burn patients require interdisciplinary care in which the plastic surgeon plays a prominent role. Appropriate referral, assessment, treatment, and posttreatment supports are essential to achieving favorable outcomes following burn injury. The authors reviewed the current literature on epidemiology, prevention, referral criteria, critical care, wound assessment, wound dressings, and psychosocial aspects of burn injury. Recent advances in burn care are highlighted and have been made possible through ongoing collaborative epidemiologic, clinical, and basic biomedical research. A systematic interdisciplinary approach to the evaluation and treatment of acute burn injuries is pivotal to providing patients with the greatest chance of functional recovery. Plastic surgeons treating burn patients must remain current in a wide variety of areas, ranging from critical care to psychosocial rehabilitation.     

Leveraging Metabolomics to Assess the Next Generation of Temozolomide-based Therapeutic Approaches for Glioblastomas

Glioblastoma multiforme (GBM) is the most common adult primary tumor of the central nervous system. The current standard of care for glioblastoma patients involves a combination of surgery, radiotherapy and chemotherapy with the alkylating agent temozolomide. Several mechanisms underlying the inherent and acquired temozolomide resistance have been identified and contribute to treatment failure. Early identification of temozolomide-resistant GBM patients and improvement of the therapeutic strategies available to treat this malignancy are of uttermost importance. This review initially looks at the molecular pathways underlying GBM formation and development with a particular emphasis placed on recent therapeutic advances made in the field. Our focus will next be directed toward the molecular mechanisms modulating temozolomide resistance in GBM patients and the strategies envisioned to circumvent this resistance. Finally, we highlight the diagnostic and prognostic value of metabolomics in cancers and assess its potential usefulness in improving the current standard of care for GBM patients.     

Development and challenges of palliative care in Indonesia: role of psychosomatic medicine

Purpose of review

To summarize the current status of palliative care and the role of psychosomatic medicine in Indonesia.

Recent findings

Palliative care is not a new issue in Indonesia, which has been improving palliative care since 1992 and developed a palliative care policy in 2007 that was launched by the Indonesian Ministry of Health. However, the progress has been slow and varied across the country. Currently, palliative care services are only available in a few major cities, where most of the facilities for cancer treatment are located. Psychosomatic medical doctors have advantages that contribute to palliative care because of their special training in communication skills to deal with patients from the standpoints of both mind and body.

Summary

Palliative care services in Indonesia are established in some hospitals. Future work is needed to build capacity, advocate to stakeholders, create care models that provide services in the community, and to increase the palliative care workforce. Psychosomatic medicine plays an important role in palliative care services.

     

Optimizing reactive responses to outbreaks of immunizing infections: balancing case management and vaccination

For vaccine-preventable infections, immunization generally needs to be supplemented by palliative care of individuals missed by the vaccination. Costs and availability of vaccine doses and palliative care vary by disease and by region. In many situations, resources for delivery of palliative care are independent of resources required for vaccination; however we also need to consider the conservative scenario where there is some trade-off between efforts, which is of potential relevance for resource-poor settings. We formulate an SEIR model that includes those two control strategies - vaccination and palliative care. We consider their relative merit and optimal allocation in the context of a highly efficacious vaccine, and under the assumption that palliative care may reduce transmission. We investigate the utility of a range of mixed or pure strategies that can be implemented after an epidemic has started, and look for rule-of-thumb principles of how best to reduce the burden of disease during an acute outbreak over a spectrum of vaccine-preventable infections. Intuitively, we expect the best strategy to initially focus on vaccination, and enhanced palliative care after the infection has peaked, but a number of plausible realistic constraints for control result in important qualifications on the intervention strategy. The time in the epidemic when one should switch strategy depends sensitively on the relative cost of vaccine to palliative care, the available budget, and [Formula: see text]. Crucially, outbreak response vaccination may be more effective in managing low-[Formula: see text] diseases, while high [Formula: see text] scenarios enhance the importance of routine vaccination and case management.     

Rawlsian Justice and Palliative Care

Palliative care serves both as an integrated part of treatment and as a last effort to care for those we cannot cure. The extent to which palliative care should be provided and our reasons for doing so have been curiously overlooked in the debate about distributive justice in health and healthcare. We argue that one prominent approach, the Rawlsian approach developed by Norman Daniels, is unable to provide such reasons and such care. This is because of a central feature in Daniels' account, namely that care should be provided to restore people's opportunities. Daniels' view is both unable to provide pain relief to those who need it as a supplement to treatment and, without justice‐based reasons to provide palliative care to those whose opportunities cannot be restored. We conclude that this makes Daniels' framework much less attractive.     

Palliative Care among Heart Failure Patients in Primary Care: A Comparison to Cancer Patients Using English Family Practice Data

Introduction

Patients with heart failure have a significant symptom burden and other palliative care needs often over a longer period than patients with cancer. It is acknowledged that this need may be unmet but by how much has not been quantified in primary care data at the population level.

Methods

This was the first use of Clinical Practice Research Datalink, the world''s largest primary care database to explore recognition of the need for palliative care. Heart failure and cancer patients who had died in 2009 aged 18 or over and had at least one year of primary care records were identified. A palliative approach to care among patients with heart failure was compared to that among patients with cancer using entry onto a palliative care register as a marker for a palliative approach to care.

Results

Among patients with heart failure, 7% (234/3 122) were entered on the palliative care register compared to 48% (3 669/7 608) of cancer patients. Of heart failure patients on the palliative care register, 29% (69/234) were entered onto the register within a week of their death.

Conclusions

This confirms that the stark inequity in recognition of palliative care needs for people with heart failure in a large primary care dataset. We recommend a move away from prognosis based criteria for palliative care towards a patient centred approach, with assessment of and attention to palliative needs including advance care planning throughout the disease trajectory.     

Radiation oncologists role,training and perceptions in palliative care: a systematic review

AimTo assess the educational needs, role and perceptions in palliative care issues of radiation oncologists (ROs) and trainees.Background1/3 of radiotherapy patients are treated with palliative intent. Conversely, education and role that ROs have in the palliative care process are not well established, neither in terms of how they perceive their competence nor whether it is important to improve training, research and attention in palliative care issues at radiotherapy congresses.Material and MethodsLiterature systematic review in National Library of Medicine and Cochrane databases with 11 relevant issues to be identified. One doctor made first selection of articles, a second one confirmed their eligibility.Results722 articles reviewed, 19 selected. 100% recognize the importance of palliative care in radiotherapy, 89.4% the need of training in palliative care for ROs, 68.4% the necessity of improving the resident programs, 63.1% the importance of skilled ROs in palliative care, 63.1% the need of better communication skills and pain management (47.3%), 52.6%, the perception of inadequate training in palliative care, 36.8% the lack of research and palliative care topics in radiotherapy meetings, 21% the absence of adequate guidelines regarding palliative care approaches, 42.1% the importance of the ROs in palliative care teams and 26.3% the lack of their involvement.ConclusionPalliative care has an important role in radiotherapy but it seems ROs still need more training. It is necessary to improve training programs, increment palliative care research in radiotherapy, giving more attention to palliative care themes at radiotherapy congresses. This could lead to a better integration of radiotherapists in multidisciplinary palliative care teams in the future.     

Palliative care in dementia and the dismantling of the treatment function of nursing homes

Palliative care is mostly restricted to the terminal phase of incurable illness. According to the WHO revised definition palliative care is specifically directed towards patients and families facing life-threatening illness. This definition is not adequate to orient and direct palliative care policies in non-cancer diseases such as dementia. Although dementia is incurable from the outset, its course is often protracted, resulting in a terminal stage only after several years. This disease trajectory necessitates an alternative palliative approach, implying a proactive attitude of nursing home physicians in facilitating early and timely discussions with patients and their proxies on advance care planning and treatment of complications and concomitant diseases. This, together with their specific training in the treatment of the long-term sequelae of chronic diseases, defines the success of Dutch nursing home medicine in foregoing inappropriate hospital admissions and providing adequate medical care in the nursing home. However, recent reorganisations of nursing home care and its funding threaten to downgrade the quality of medical care for patients with dementia in Dutch nursing homes by focusing unilaterally on welfare ideology and 'marketization' of long term care, thus underestimating the importance of a palliative care policy in dementia.     

Abandoning personalization to get to precision in the pharmacotherapy of depression

Effectiveness studies and analyses of naturalistic cohorts demonstrate that many patients with major depressive disorder do not experience symptomatic remission with antidepressant treatments. In an effort to better match patients with effective treatments, numerous investigations of predictors or moderators of treatment response have been reported over the past five decades, including clinical features as well as biological measures. However, none of these have entered routine clinical practice; instead, clinicians typically personalize treatment on the basis of patient preferences as well as their own. Here, we review the reasons why it has been challenging to identify and deploy treatment‐specific predictors of response, and suggest strategies that may be required to achieve true precision in the pharmacotherapy of depression. We emphasize the need for changes in how depression care is delivered, measured, and used to inform future practice.     

Palliative care dentistry

The importance of dental care is often overlooked due to the omission of the dentist as a member of the palliative care team. However, many terminal patients exhibit oral difficulties that affect their quality of life. Palliative care dentists must exhibit empathy and compassion, and must be excellent communicators Dentists can play an important role in alleviating both the physical and psychological pain of dying. This paper describes the role of dentistry in palliative care.     

Palliatieve zorg bij dementie en de ontmanteling van de behandelfunctie van het verpleeghuis

Palliative care in dementia and the dismantlement of nursing home medicinePalliative care is mostly restricted to the terminal phase of incurable illness. According to the WHO revised definition palliative care is specifically directed towards patients and families facing life-threatening illness. This definition is not adequate to orient and direct palliative care policies in non-cancer diseases such as dementia. Although dementia is incurable from the outset, its course is often protracted, resulting in a terminal stage only after several years. This disease trajectory necessitates an alternative palliative approach, implying a proactive attitude of nursing home physicians in facilitating early and timely discussions with patients and their proxies on advance care planning and treatment of complications and concomitant diseases. This, together with their specific training in the treatment of the long term sequelae of chronic diseases, defines the success of Dutch nursing home medicine in foregoing inappropriate hospital admissions and providing adequate medical care in the nursing home. However, recent reorganisations of nursing home care and its funding threaten to downgrade the quality of medical care for patients with dementia in Dutch nursing homes by focusing unilaterally on welfare ideology and ‘marketization’ of long term care, thus underestimating the importance of a palliative care policy in dementia.     

PALLIATIVE CARE, PUBLIC HEALTH AND JUSTICE: SETTING PRIORITIES IN RESOURCE POOR COUNTRIES

Many countries have not considered palliative care a public health problem. With limited resources, disease-oriented therapies and prevention measures take priority. In this paper, I intend to describe the moral framework for considering palliative care as a public health priority in resource-poor countries. A distributive theory of justice for health care should consider integrative palliative care as morally required as it contributes to improving normal functioning and preserving opportunities for the individual. For patients requiring terminal care , we are guided less by principles of justice and more by the duty to relieve suffering and society's commitment to protecting the professional's obligation to uphold principles of beneficence, compassion and non-abandonment. A fair deliberation process is necessary to allow these strong moral commitments to serve as reasons when setting priorities in resource poor countries.     

Living with the dying: use of the technique of participant observation.

Through participant observation, questions concerning optimal care of dying patients and needs of their families were answered. A general surgical ward and a palliative care unit were the sites of observation. The observations support the belief that a palliative care unit, specifically designed to meet the known needs of dying patients and their families, is preferable to a general surgical ward. The main findings, of less concern in the palliative care unit than on the surgical ward, were the following: the importance of patient-to-patient support; the discomfort of sick-role behaviour; the impersonal and sometimes intimidating nature of patient care; the limitation of the patient''s need (as a person) to give as well as to receive; and the value of families, student nurses and volunteers in total care. These findings emphasize the importance of personal interest in relieving the distress suffered by many terminally ill patients.     

Specific recommendations (or lack thereof) for older patients with cardiovascular disease in the current European Society of Cardiology guidelines

Due to population ageing, the number of older and frail patients with cardiovascular disease is increasing. In the current guidelines of the European Society of Cardiology specific recommendations for this older population are missing or scarce, probably due to limited evidence concerning diagnosis and treatment of cardiovascular disease in older patients. Moreover, recommendations on shared decision making, palliative care and advanced care planning are also essential in these guidelines. In this article we evaluate the current European of Society of Cardiology guidelines (2013–2020) to determine whether specific recommendations for older patients have been included.

     

Facets of patient complaints: pain, suffering, and the importance of consideration

Patient complaints, as it has often been recognized, serve to express multiple and varied experiences and needs. A number of options for filing complaints and a variety of ways for doing so have arisen recently, among which are ethics committees, support groups, palliative care units, and complaint examination committees. Today patients have many occasions for expressing their experiences, talking about distressing incidents, and making their needs known. Three orally related experiences are examined here, both from the viewpoint of the patient and in light of their cultural meanings: pain, suffering, and the importance of consideration. These are three expectations of care providers, but also three experiences that dispose patients to rethink their individuality and their relationships with others, to take stock of their pasts, and to reflect on who they are and who they want to become. The experience of illness has thus become pivotal in the process of constructing individual identity.     

The Kansas City palliative care curriculum--medical schools improve end-of-life training

Midwest Bioethics Center believes that encouraging palliative care training in the school milieu is one of the keys to achieving lasting improvement in end-of-life care. Therefore, a cooperative venture to increase palliative care education in medical schools was among the first strategies envisioned in the Center's PATHWAYS initiative. Its implementation, no less than its goal, requires both time and effort.