Thirty-nine relapse-free testicular cancer patients were interviewed 1-6 years after completion of chemotherapy, in connection with a study of conditioned nausea. Some structured questions about experiences of diagnosis and treatment were included, but this report also summarizes spontaneously given information. The patients' first contact with a treatment setting appears to be an important determinant of the overall treatment experience. If resources are limited, they are used effectively if concentrated during the initial contact with the patient. Support from relatives and friends was reported as good for 90% of the men during treatment. Thirty-two distressing factors during the treatment period were mentioned; the most severe were nausea and vomiting. Other high-ranking factors were "being restricted for the infusion" and "the smell of food." There is a need for flexibility in ways to prepare and serve food on the ward. Some men argued for more information concerning the disease and chemotherapy; others said they received too much information. Several men suggested that a debriefing talk with the physician and someone from the staff should be arranged 6 months to 1 year after completion of treatment.
The cancer incidence was studied in 18,030 patients (33% males, 67% females) with skin hemangioma who were admitted to Radiumhemmet, Karolinska Hospital, Stockholm, Sweden, 1920-1959. Radium-226 sources were used in 12,821 patients, x-ray therapy was used in 2,515 patients, and no radiotherapy was given to 2,694 patients. Cancer incidence in the cohort was searched by record linkage with the Swedish Cancer Register for the period 1958-1982. The median age was 6 months for the treated patients and 8 months for the patients not receiving radiotherapy. In the group treated with radium-226 or orthovoltage x rays (greater than or equal to 100-kV peak), 224 cancers were observed [relative risk (RR) = 1.18; 95% confidence interval (CI) = 1.03-1.35]. In patients given contact x rays, 10 cancers were observed (RR = 0.71; 95% CI = 0.34-1.30). In patients not treated with ionizing radiation, 34 cancers were observed (RR = 0.93; 95% CI = 0.64-1.29). In patients treated with radium-226 or orthovoltage x rays, an RR of 1.65 was observed for breast cancer (95% CI = 1.26-2.13) and an RR of 2.73 was found for soft tissue tumors (95% CI = 1.18-5.38). Patients with brain tumors, thyroid cancers, and bone tumors had received radiotherapy close to the tumor site more often than expected. For patients with breast cancer, no such difference was found. For cancers of the breast and thyroid, the RR was higher in patients given more than one treatment.
The aim of the present study was to describe fatigue in a group of irradiated cancer patients. Fatigue was assessed prospectively in 81 Swedish cancer patients, using the Multidimensional Fatigue Inventory (MFI-20), which was also validated in the study, the Karolinska Sleepiness Scale and a Borg CR10 scale before curative radiotherapy, at the end of therapy and 1 and 3 months after treatment. The mean age of these patients was 56 years; 90% were female; and 65% were being treated for cancer of the breast. The absorbed radiation dose was 50 Gy or lower in 90% of the patients. A clear peak in experienced fatigue according to the three scales was seen at the end of treatment. In the MFI-20 the dimensions of General fatigue, Physical fatigue and Reduced activity, were more pronounced than the aspects of Mental fatigue and Reduced motivation. Comparison with other studies using the same instrument in other irradiated patients revealed a similar pattern. The internal consistency of the Swedish version of the MFI-20 was good. The MFI-20 is shown to be a valid instrument for assessing fatigue in patients undergoing radiotherapy.
The use of drug infusors is common in palliative care. Knowledge about the drugs being used and the handling of drug mixtures in insufficient and poorly documented. To clarify this practice, a questionnaire was sent to all departments of pain/anesthesiology and oncology, and to all home-care teams and palliative care units/hospices in Sweden (N = 156). The questions concerned specific qualities of the drug infusors and the different drugs and drug mixtures used by subcutaneous (s.c.) and intravenous (i.v.) administration. A total of 110 (70%) of the questionnaires were returned. A majority of the respondents reported the use of one or more of three different infusors. Morphine was used in 73% of all single drug infusions. Dosages ranged from 30 mg/24 hr to 5000 mg/24 hr. The most common drug mixture was morphine/haloperidol (22% of all drug mixtures). As many as three drugs were used in combination. The most frequent indication to switch from oral administration to parenteral administration was gastrointestinal disorders such as swallowing difficulties, nausea, vomiting, or bowel obstruction. In Sweden, there is extensive clinical experience administering opioids in infusors, but experience varies for different drug mixtures. There are few clinical and pharmacological investigations to support this practice and further studies are needed.
Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Flemingsberg, Sweden; Department of Health Care Sciences, Palliative Research Centre, Ersta Sköndal Bräcke University College, Stockholm, Sweden. Electronic address: email@example.com.
In high-income countries a large proportion of all deaths occur in hospitals. A common way to translate knowledge into clinical practice is developing guidelines for different levels of health care organisations. During 2012, national clinical guidelines for palliative care were published in Sweden. Later, guidance for palliative care was issued by the National Board of Health and Welfare. The aim of this study was two-fold: to investigate perceptions regarding these guidelines and identify obstacles and opportunities for implementation of them in acute care hospitals. Interviews were conducted with local politicians, chief medical officers and health professionals at acute care hospitals. The Consolidated Framework for Implementation Research was used in a directed content analysis approach. The results showed little knowledge of the two documents at all levels of the health care organisation. Palliative care was primarily described as end of life care and only few of the participants talked about the opportunity to integrate palliative care early in a disease trajectory. The environment and culture at hospitals, characterised by quick decisions and actions, were perceived as obstacles to implementation. Health professionals' expressed need for palliative care training is an opportunity for implementation of clinical guidelines. There is a need for further implementation of palliative care in hospitals. One option for further research is to evaluate implementation strategies tailored to acute care.
Mortality was studied in 18,357 patients (33% males and 67% females) with skin hemangioma admitted to Radiumhemmet between 1920 and 1959. The treatments of the hemangiomas were performed by radium-226 sources (13,094 patients) or x-ray therapy (2,540 patients). In 2,723 patients no radiotherapy was given. The median age was 6 months for the treated patients and 8 months for the patients not receiving radiotherapy. Between 1920 and 1951 a total of 154 patients were reported dead. The cohort was matched with the Swedish Cause of Death Register between 1952 and 1985. During that period 504 died, in 146 patients the cause of death was cancer or leukemia. The total number of person-years at risk was 587,426. In patients treated with radium-226 or orthovoltage x-rays, 410 deaths occurred (standardized mortality ratio (SMR) = 1.07; ns). In patients given contact therapy 34 deaths occurred (SMR = 0.82; ns) and in the not irradiated group 60 deaths occurred (SMR = 0.78; ns). Patients treated with radium-226 or orthovoltage x-rays had an SMR of 1.34 for all cancers combined (p less than 0.05). For patients treated between 1920 and 1939 the SMR for cancer was 1.53 (p less than 0.05) as compared to an SMR of 1.16 (ns) for those treated between 1940 and 1959.
In contrast to external X and gamma radiation, radiation from internally deposited 131I has not been clearly shown to cause thyroid tumors or nodules. Given the wide use of 131I in medicine and concern about health risks associated with the release of radioiodines from nuclear reactors, more information is needed. The purpose of this study was to evaluate the risk of thyroid nodularity among women previously exposed to radioiodine (131I) for diagnostic reasons. A clinical examination survey, including thyroid palpation, was conducted for a sample of women drawn from a cohort of patients exposed to 131I and a comparison group of women attending a mammography screening clinic. The study was conducted during 1991-1993 at Radiumhemmet, Karolinska Hospital, Stockholm, Sweden. A total of 1,005 women referred for a thyroid scintigraph or tracer test during the period 1952-1977 were included in the study. For comparison, 248 nonexposed women attending a mammography screening clinic were also enrolled. The primary outcome measure was the presence or absence of palpable thyroid nodules at the time of the clinical examination. Odds ratios were used as estimates of relative risk (RR). The mean dose to the thyroid from 131I was 0.54 Gy, and the average age at 131I administration was 26 years. The prevalence of thyroid nodularity was 10.6% among women who had been exposed to 131I and 11.7% among the nonexposed women [RR = 0.9; 95% confidence interval (CI) 0.6-1.4]. When analysis was restricted to women exposed to 131I, prevalence was associated positively with thyroid dose (excess RR = 0.9 per Gy; 95% CI 0.2-1.9). However, the excess RR was similar for women exposed before age 20 years and those exposed after age 20, which is contrary to findings for populations exposed to external radiation. While results demonstrated a positive association between diagnostic administration of 131I and the subsequent occurrence of thyroid nodules, it is unclear whether the association is causal, as the possibility of confounding by indication for 131I administration cannot be ruled out. No tumors that were subsequently diagnosed as cancer were found during the thyroid examinations, which supports the view that exposure to 131I administered for diagnostic reasons during adulthood rarely causes thyroid cancer.