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The number of patients with end-stage renal disease is increasing substantially every year around the world. Renal transplantation is the best treatment option to improve survival and quality of life. Although the numbers of living, related and deceased transplant donors has also increased, this growth is insufficient to keep up with the expansion rate of the renal failure population. The introduction of laparoscopic donor nephrectomy has gained widespread acceptance by physicians and patients, and seems to be better than open donor nephrectomy in terms of reduced postoperative pain, quick recovery and improved cosmetic outcomes. Evidence strongly suggests that graft survival is similar in recipients of kidneys from living related and unrelated donors. Fortunately, this information has raised awareness of the suitability of potential live, unrelated donors, including spouses, friends, or even anonymous donors. In this Review we touch on sociological aspects of living related kidney transplantation and review the available and proposed methods of increasing the live donor pool, including organ exchange and desensitization protocols for ABO-incompatible and cross-match-positive donor pairs.
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PMID:Live donor nephrectomy for kidney transplantation. 1826 50

The aim of this study was to develop a measure for evaluating good death from the bereaved family member's perspective, and to examine the validity and reliability of the assessment. A cross-sectional anonymous questionnaire was administered to bereaved family members of cancer patients who had died in a regional cancer center from September 2004 to February 2006. We measured the Good Death Inventory (GDI), Care Evaluation Scale, and an overall care satisfaction scale. A retest was conducted one month after sending the questionnaire. Of the 344 questionnaires sent to bereaved family members, 189 responses were analyzed (57%). A factor analysis of the responses to the GDI identified 10 core domains: "environmental comfort," "life completion," "dying in a favorite place," "maintaining hope and pleasure," "independence," "physical and psychological comfort," "good relationship with medical staff," "not being a burden to others," "good relationship with family," and "being respected as an individual." Eight optional domains also were identified: "religious and spiritual comfort," "receiving enough treatment," "control over the future," "feeling that one's life is worth living," "unawareness of death," "pride and beauty," "natural death," and "preparation for death." The GDI had sufficient concurrent validity with the Care Evaluation Scale and overall care satisfaction, sufficient internal consistency (alpha=0.74-0.95), and acceptable test-retest reliability (ICC=0.38-0.72). Finally, we developed a short version of the GDI. The GDI is a valid scale to measure end-of-life care comprehensive outcomes from the bereaved family member's perspective in Japan.
J Pain Symptom Manage 2008 May
PMID:Good death inventory: a measure for evaluating good death from the bereaved family member's perspective. 1835 85

Sternal metastases from adenocarcinoma of the pancreas are extremely rare, and even more so when solitary. Two years earlier, the patient reported on here, a 67-year-old man with a solitary osteolytic lesion of the sternal manubrium, had undergone a duodeno-cephalopancreatectomy for adenocarcinoma of the pancreas (G2, pY3, pN1) followed by adjuvant radio-chemotherapy. PET/CT scans, in response to the onset of burning pain in the sternal region, revealed a hypermetabolic area only at the level of the manubrium, while MRI showed a bulging manubrium due to the presence of extensive solid pathological tissue towards the right articulations of the ribs. Abnormal tumour markers were: CEA = 12, n.v. 0-4; Ca 15-3 = 512, n.v. 0-51, Ca 19-9 = 8777, n.v. 0-18. A partial sternectomy was performed with en-bloc resection of the hemiclavicles and the anterior tract of the 1st and 2nd ribs bilaterally with a mediastinic lymphadenectomy and repair with a sandwich prosthesis of prolene mesh and methacrylate, protecting the supra-aortic trunks and the anonymous vein with a polytetrafluoroethylene patch. The histological examination revealed secondary adenocarcinoma with 3 mediastinal metastatic lymph nodes. In view of the severe prognosis, a resection with palliative intent was also performed, which, when carried out in specialised centres, presents no contraindications in terms of cost-benefits.
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PMID:[Solitary metachronous metastasis of the sternum from pancreatic adenocarcinoma]. 1836 Oct 1

We aimed to evaluate regional differences in women's motivations and in obstetricians' attitudes re 'caesarean section on request' between obstetricians practicing in Southern and Northern Italy. An anonymous questionnaire was sent to 70 randomly selected specialists practicing in the Veneto region and Sicily. Demographic characteristics, percentage of caesarean section, increase of caesarean section on demand, maternal motivations and the role played by anxiety, relatives and instrumental examinations were analysed. Moreover, obstetricians' opinion and their behaviour in fulfilling, or not, the maternal request were evaluated. Among the emotional reasons, fear of pain was more frequently reported in Sicily (p = 0.045), and previous negative experiences and gestational anxiety in the Veneto region (p = 0.009; p = 0.001). As regards instrumental examinations influencing maternal request, a significant difference was found for ultrasonography (28% in Sicily vs 60% in Veneto, p = 0.002). The husband's role was more frequently reported in the Veneto region (p = 0.006). Obstetricians of both regions noticed a rising rate of caesarean section on maternal request. The reasons for this upward trend are complex, vary from one region to another and are influenced by local socio-cultural and healthcare background.
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PMID:Caesarean section on request: are there loco-regional factors influencing maternal choice? An Italian experience. 1860 68

Little is known regarding patient preferences for method of delivery despite concern about rising cesarean section rates. We hypothesize that the majority of pregnant women desire a vaginal birth. An anonymous survey was distributed to pregnant women assessing demographics, pregnancy history, delivery preference, and concern for outcomes. Five-hundred fifty respondents completed the survey; 43% were nulliparous. The majority preferred vaginal delivery (89.6%). Reasons included reduced recovery pain (72%), scars (68%), and bleeding (48%). Cesarean deliveries were believed to cause more maternal injuries (39%), but affect sexual function less (35%). Nulliparas were more concerned about vaginal support damage (p = .005), sexual function changes (p < or = 0.001), and need for episiotomy (p < or = .001). Despite this, 93% of nulliparas chose vaginal birth. Increased parity was associated with preference for cesarean delivery (r = 0.108, p = 0.013). Despite nulliparas' concerns about complications of vaginal delivery, the majority of pregnant women would choose vaginal birth.
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PMID:Preferences and concerns for delivery: an antepartum survey. 1863 59

We aimed to improve internal medicine residents' deficiencies in pain management and evaluate the effectiveness of our intervention, which included an interactive conference series, e-mail vignettes, and didactic sessions. An anonymous survey was administered at the beginning and at the end of an academic year, before and after the intervention, respectively. We analyzed 65 preintervention and 63 postintervention surveys. Self-perception of competency in pain management increased from 40% to 60% (P = .02). Perception of adequacy of training increased from 38.5% to 55.6% (P = .05). Opioid conversion skills improved by 25% (P = .02). Overall, knowledge did not change significantly, except in the subgroup of residents who had completed the oncology rotation from 0.60 to 0.72 (P = .003). "Opiophobia'' improved by 20% (P = .05). Documentation of pain improved (rank correlation = 21; P = .02). We concluded that educational and institutional interventions administered over an academic year improved pain management skills and documentation and reduced "opiophobia'' among residents.
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PMID:Pain management practices by internal medicine residents--a comparison before and after educational and institutional interventions. 1881 15

The present study examines reasons for adolescent deliberate self-harm. A cross-sectional survey using an anonymous self-report questionnaire was carried out in seven countries (Australia, Belgium, England, Hungary, Ireland, the Netherlands and Norway). Data on 30,477 school pupils between the ages of 14-17 were analysed. Past year and lifetime deliberate self-harm were assessed, along with the self-reported reasons for deliberate self-harm. The results showed that 'wanted to get relief from a terrible state of mind' and 'wanted to die' were most commonly reported. Principal component analysis indicated two underlying dimensions in the reasons for deliberate self-harm, i.e. a cry of pain motive and/or a cry for help motive. The majority of self-harmers reported at least one cry of pain motive ('to die', 'to punish myself', and 'to get relief from a terrible state of mind') and an additional cry for help motive ('to show how desperate I was feeling', to frighten someone', 'to get my own back on someone', 'to find out whether someone really loved me', and 'to get some attention'). Females reported more reasons than males. Only females showed an age difference, with girls aged 16-17 more frequently reporting a cry for help motive. There was considerable consistency in choice of motives across countries and genders. Systematic assessment of the reasons for deliberate self-harm can help clinicians to better understand the meaning of self harming behaviour, select appropriate treatment, suggest alternative coping strategies, and hopefully prevent future suicidal behaviour.
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PMID:Reasons for adolescent deliberate self-harm: a cry of pain and/or a cry for help? Findings from the child and adolescent self-harm in Europe (CASE) study. 1902 7

Although several studies about quality indicators (QIs) in end-of-life (EOL) cancer care have been conducted, the bereaved family members' perspective of QIs has not been investigated in Japan. The primary aim of this study was to rate QIs for EOL cancer care from the bereaved family members' perspective in Japan. A cross-sectional anonymous questionnaire was administered to bereaved family members of cancer patients who had died in an inpatient palliative care unit. We mailed questionnaires to potential respondents in March 2007. Of 160 questionnaires sent, 109 responses were analyzed (effective response rate, 76%). Eighty-eight percent of participants rated the medical examination by the palliative care team or specialist positively, 80% rated the availability of emergency room (ER) services or after-hour examinations positively, and 77% agreed that medical orders to alleviate pain or suffering were documented in the chart. Only 15% of the respondents agreed that it was preferable to die at home. Additionally, 59% and 46% of participants agreed that the occurrence of a fall or pressure ulcer and death by an adverse event from surgery or chemotherapy were poor QIs, respectively. Moreover, only 17% and 14% rated the short interval from chemotherapy to dying and frequent visits to the ER or after-hour examination as poor QIs, respectively. In Japan, it would be appropriate to extract QIs from medical charts. However, many items suggested as QIs in a previous study were found to be different from the opinions expressed by bereaved family members in this study.
J Pain Symptom Manage 2009 Jun
PMID:Quality indicators of end-of-life cancer care from the bereaved family members' perspective in Japan. 1932 Dec 96

Historically, if a patient was dissatisfied with care, he or she could tell his or her friends and family. The criticism was limited to a small circle of people. If the patient was injured negligently, he or she could hire an attorney to prosecute a lawsuit. The threshold for finding an attorney and prevailing posed a significant barrier for the patient achieving redress. With the Internet, if a patient is unhappy he or she needs do little more than access a growing number of Internet physician rating sites. Such criticism can be rendered anonymously. The posts are disseminated worldwide, and once posted, the criticism rarely comes down. While transparency is a laudable goal, such sites often lack accountability. More formal sites run by authoritative bodies, such as medical licensing boards, also provide data about physicians, but such data is often unfiltered, making it difficult for the public to properly interpret. Given how important reputation is to physicians, the traditional remedy of suing for defamation because of libelous posts is ordinarily ineffective. First, many patients who post libelous comments, do so anonymously. Next, the Internet Service Providers (ISPs) hosting such sites are generally immune from liability for defamation. Finally, the law has a very formal definition for libel, and a negative rating does not necessarily equate to "defamation." A novel method of addressing un-policed physician rating sites in the Internet age is described. The system embraces the use of mutual privacy contracts to provide physicians a viable remedy to anonymous posts. In exchange, patients receive additional privacy protections above and beyond that mandated by law.
Pain Physician
PMID:The role of the Internet in doctor performance rating. 1946 33

The Japanese Society of Palliative Medicine has developed a clinical guideline to minimize the large variation in clinical practice of artificial hydration therapy for terminally ill cancer patients. The primary aim of this preliminary study was to explore the effects of a five-hour interactive workshop based on the guideline of nurses' knowledge, confidence, self-reported practice, and nurse-perceived usefulness. The study was designed as a pre-post anonymous questionnaire survey. The nurses attended a five-hour interactive workshop based on the guideline and were asked to complete a questionnaire before and after the workshop. The outcome measures were: nurses' knowledge (13 items; the total number of correct answers was defined as the Knowledge score), confidence in caring for terminally ill cancer patients with reduced oral intake (a single Likert-type scale from 1="not confident at all" to 7="very confident"), and self-reported practice (nine items assessing the degree to which nurses think they would perform more frequently recommended practices described in the guideline after the workshop). Of the 81 nurses who participated in this workshop, we obtained consent from 76 to complete the questionnaire. The Knowledge score significantly increased after the intervention from 7.7+/-2.3 to 11+/-1.4 (P<0.001), and the Confidence score significantly increased from 3.1+/-1.2 to 3.8+/-1.1 (P<0.001). More than 80% of the nurses reported they would perform six of nine recommended practices after the workshop. The percentages of nurses who evaluated this workshop as "useful" or "very useful" were: 84% (to know the medical indications of artificial hydration therapy), 89% (to know the effects of artificial hydration therapy on patient quality of life and survival), 71% (to know the physiology of appetite loss and cancer cachexia), 83% (to know how to provide nursing care), and 91% (to know ethical principles). Based on these results, it is possible that a five-hour interactive workshop on artificial hydration therapy, based on the clinical guideline of the Japanese Society of Palliative Medicine, improves nurses' knowledge, confidence, and self-reported practices. The workshop was generally perceived as useful for nurses. Nationwide dissemination of the guideline with interactive workshop education for nurses, in combination with physicians, is a promising method for improving the clinical practice of artificial hydration therapy for terminally ill cancer patients.
J Pain Symptom Manage 2009 Sep
PMID:Artificial hydration therapy for terminally ill cancer patients: a nurse-education intervention. 1973


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