The 2011 Canadian Cardiovascular Society Heart Failure (HF) Guidelines Focused Update reviews the recently published clinical trials that will potentially impact on management. Also reviewed is the less studied but clinically important area of sleep apnea. Finally, patients with advanced HF represent a group of patients who pose major difficulties to clinicians. Advanced HF therefore is examined from the perspectives of HF complicated by renal failure, the role of palliative care, and the role of mechanical circulatory support (MCS). All of these topics are reviewed from a perspective of practical applications. Important new studies have demonstrated in less symptomatic HF patients that cardiac resynchronization therapy will be of benefit. As well, aldosterone receptor antagonists can be used with benefit in less symptomatic HF patients. The important role of palliative care and the need to address end-of-life issues in advanced HF are emphasized. Physicians need to be aware of the possibility of sleep apnea complicating the course of HF and the role of a sleep study for the proper assessment and management of the conditon. Patients with either acute severe or chronic advanced HF with otherwise good life expectancy should be referred to a cardiac centre capable of providing MCS. Furthermore, patients awaiting heart transplantation who deteriorate or are otherwise not likely to survive until a donor organ is found should be referred for MCS.
Comment In: Can J Cardiol. 2011 Nov-Dec;27(6):871.e721885242
Forty consecutive patients with an extraabdominal primary tumor, later treated surgically for intraabdominal problems, were investigated. The most common causes of abdominal operations were intestinal obstruction (N = 17), intraabdominal tumor mass (N = 8), and intraabdominal hemorrhage (N = 5). The overall postoperative mortality was 25%, morbidity 48%, median survival 3 months, and cumulative 5 year survival 3%. The mortality after emergency procedures, 67%, was significantly higher (P less than 0.01) than after elective operations, 18%. Conditions requiring enterostomy (N = 14) were associated with a mortality of 36%, whereas the figures in resected (N = 13) and bypassed (N = 7) patients were 14% and 17%, respectively. Wound infection (N = 5) and pulmonary infection (N = 5) were the most common complications, and pulmonary infection was fatal in three of the five cases. Of the patients, 22 (55%) were discharged from hospital to their home; ten (25%) of them had postoperatively a 3 month relief of cancer symptoms and four (10%) a 6 month relief. Nine patients (25%) have survived for over 1 year and one (3%) for over 5 years. It is concluded that abdominal procedures seldom prevent further cancer growth within these patients and that symptoms are relieved only in one in every four patients. According to strict criteria, these operations are useful and can add to patient comfort.
The article emphasizes that the palliative medical care is considered in the Federal law "On the fundamentals of health care of citizen in the Russian Federation" (2011)as one of the types of medical care of population. The Orders of delivery of palliative care to adult population and children are in the process of development to determine in perspective the formation of palliative care services in the regions. The successful development of this service needs a clear-cut definition of palliative care to formulate the corresponding tasks and contingents of patients. The Preference is to be given to the definition which considers palliative medical care as a medical care of patients with diagnosis of active incurable progressing disease at the stage when possibilities of specialized/radical treatment are exhausted or limited.
Equal access to end-of-life care is important. However, social inequality has been found in relation to place-of-death. The question is whether social and economic factors play a role in access to specialist palliative care services.
The study analyzed the association between access to outreach specialist palliative care teams (SPCTs) and socioeconomic characteristics of Danish cancer patients who died of their cancer.
The study was a population-based, cross-sectional register study. We identified 599 adults who had died of cancer from March 1 to November 30, 2006, in Aarhus County, Denmark. Data from health registers were retrieved and linked based on the unique personal identifier number.
Multivariate analysis with adjustment for age, gender, and general practitioner (GP) involvement showed a higher probability of contact with an SPCT among immigrants and descendants of immigrants than among people of Danish origin (prevalence ratio [PR]: 1.55; 95% confidence interval (CI): 1.04;2.31) and among married compared to unmarried patients (PR: 1.25; 95% CI: 1.01;1.54). The trends were most marked among women.
We found an association between females, married patients, and female immigrants and their descendants and access to an SPCT in Denmark. However, no association with the examined economic factor was found. Need for specialized health care, which is supposed to be the main reason for access to an SPCT, may be related to economic imbalance; and despite the relative equality found, SPCT access may not be equal for all Danish residents. Further research into social and economic consequences in palliative care services is warranted.
Access to palliative care (PC) is a major need worldwide. Using hospital charts of all patients who died over one year (April 2008-March 2009) in two mid-sized hospitals of a large Canadian city, similar in size and function and operated by the same administrative group, this study examined which patients who could benefit from PC services actually received these services and which ones did not, and compared their care characteristics. A significantly lower proportion (29%) of patients dying in hospital 2 (without a PC unit and reliant on a visiting PC team) was referred to PC services as compared to in hospital 1 (with a PC unit; 68%). This lower referral likelihood was found for all patient groups, even among cancer patients, and remained after controlling for patient mix. Referral was strongly associated with having cancer and younger age. Referral to PC thus seems to depend, at least in part, on the coincidence of being admitted to the right hospital. This finding suggests that establishing PC units or a team of committed PC providers in every hospital could increase referral rates and equity of access to PC services. The relatively lower access for older and non-cancer patients and technology use in hospital PC services require further attention.