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CARING FOR THE DYING IN ONCOLOGY. M.J. Silveira1; J. Forman2. 1Ann Arbor VAMC, Health Services Research and Development Center of Excellence, Ann Arbor, MI; 2Ann Arbor VAMC, Ann Arbor, MI. Tracking ID # 174157 ; BACKGROUND: Efforts to improve care of the dying have focused how subspecialists in palliative care, rather than physicians with pre-existing relationships with those patients, can meet the growing demand for end-of-life care. Presumably, providing end-of-life care through existing sources of care could expand access to endof-life care more quickly and cost-efficiently than would creating sub-specialty palliative care services. With this idea in mind, we conducted focus groups with oncologists to ask BWhat does it take to care for the dying in oncology? METHODS: We conducted 11 focus groups with oncologists and their nursing staff at 5 sites throughout Southeast Michigan to explore their care of patients with incurable and advanced cancer. Physicians and nurses were interviewed separately. Interviews were taped, transcribed, and analyzed using cross-case comparison. Transcripts were reviewed by multiple readers to: 1 ; develop a coding scheme, 2 ; identify themes, and 3 ; design an interpretive model. RESULTS: Oncologists and their nursing staff feel they have the knowledge and desire to provide competent end-of-life care to their patients with incurable and advanced cancer. Their ability to do so, however, depends upon the following care delivery issues that are often beyond their control: 1 ; A system to maintain continuity between a single provider or group of providers with patients until death; 2 ; Time to assess patients thoroughly and identify and address their needs - especially when those needs were psychosocial; 3 ; Care coordination to provide a point of contact for patients, facilitate information sharing between patient and provider or among providers, and identify and access community services such as hospice; and 4 ; Clear role delineation among providers caring for mutual patients. Subjects feel that palliative care experts are needed only for the most challenging of cases; otherwise, they present an obstacle to continuity with oncology. Clinics in which long-term continuity is not established with patients e.g., resident-run clinics ; , however, may benefit from the availability of dedicated palliative care services. CONCLUSIONS: For oncologists to provide end-of-life care, they need better support within oncology rather than education or palliative care services to refer patients to. Support tailored to the specific needs of each oncology practice may allow patients to have greater access to end-of-life care through their established source of care
CURE AND PEDICURE SERVICES, BODY WAXING SERVICES, MASSAGE SERVICES AND BEAUTY SALON SERVICES, IN CLASS 44 U.S. CLS. 100 AND 101 ; . FIRST USE 8-1-2002; IN COMMERCE 8-1-2002. THE LINING IS A FEATURE OF THE MARK AND IS NOT INTENDED TO INDICATE COLOR. THE DRAWING DEPICTS A STYLIZED DESIGN OF THE SUN. SN 78-131, 743, FILED 5-29-2002.
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Legal education, and to subtly guide me in the pursuit of a successful career in law librarianship. More often than not, his remarks would turn to the importance of scholarship for law librarians as a way to stay mentally engaged, as well as an avenue to gain credibility with one's faculty colleagues. He also was adamant about the importance of full tenure for academic law library directors. He often repeated stories about how he and his contemporaries, including Roy M. Mersey, Dan Henke, and Julius Marke, stood firm in requiring tenured or a tenure-track position when offered a law library directorship. And, of course, he always interspersed in his conversation the latest news about his beloved children Ellen and Bennett, as well as his cherished wife Belle. 9 As so often happens, one vice, in this case jelly beans, leads to another. About mid-point in my career at Stanford, I took a vacation to Greece and Yugoslavia. In this beautiful corner of the world I was introduced to slivovitz, a potent plum-based brandy that resonates with hints of anise. Although definitely an acquired taste, I soon became quite fond of slivovitz and suspected that Mike might like it also. Upon my return to the law library, I presented a bottle of slivovitz to Mike, offering effusive praise about the liquor's many fine and distinct qualities. Just as the law library opened the next morning, I received a call from Mike who, in an exasperated and louder than usual voice, said, "Joan, what are you trying to do--kill me? That hooch you gave me tastes like butane." I plaintively responded, quite worried that perhaps I really had made a misstep, "But it tastes like licorice." After a pause, Mike corrected himself by stating, "Well, O.K. then. It tastes like butane laced with licorice." Then, after another pause, I heard the familiar "hmmm ." and I knew that all was well. I don't think Mike ever gained a true appreciation for the subtle, if potentially corrosive, attributes of slivovitz. However, in the years after I moved on from Stanford to other professional positions, whenever we got together for dinners at AALL or AALS meetings, we usually ended our meals with glasses of slivovitz and a toast to good friends. 10 Although I know that he is now at peace, I selfishly wish there was still the opportunity to share lunch or a bag of jelly beans with Mike. I know that is not possible. However, I would like to raise a final lonely glass of slivovitz in a toast to Mike--a devoted husband, a loving father, a brilliant law librarian, a productive and creative scholar, a true and generous mentor, an individual who knew that life should never be taken too seriously, and, perhaps most importantly, a genuinely decent human being. We are all better people for having known Mike. Let us now all try to be more like him.
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Downloaded from bmj on 14 March 2008 incompletely understood. Factors that can initiate this process include acute obstruction of the pancreatic Conditions associated with acute pancreatitis15 duct, exposure to toxins and venoms, and ischaemia.7 Cholelithiasis, choledocholithiasis, Vasculitis Once initiated, the biochemical and pathophysior biliary microlithiasis Ischaemia or embolism ological processes resulting in acute pancreatitis Ethanol misuse Pregnancy cannot be inhibited or reversed. Treatments aimed at Drugs see other box ; Organ transplantation halting the cycle of pancreatic autodigestion glucaTrauma End stage renal failure Major abdominal surgery Mycoplasma infection gon, somatostatin, anticholinergics ; have generally Cardiopulmonary bypass Viral infection mumps, coxsackie B, been disappointing. A recent meta-analysis of six trials Hypercalcaemia HIV, etc ; using somatostatin showed a small benefit, 8 but further Hyperlipidaemia Venoms scorpion bite, certain research is needed before this drug should be routinely Penetrating gastric or duodenal ulcer spider bites ; considered. Efforts to prevent acute pancreatitis in well Pancreatic tumours Intraductal parasites ascariasis, defined subgroups of patients such as those undergoPancreas divisum * for example ; Familial pancreatitis Idiopathic causes ing endoscopic retrograde cholangiopancreatography ERCP have yielded more encouraging results. A * A normal variant in 7%-8% of white populations recent European trial using intravenous infusion of gabexate not yet available in the United States ; to presmall gallstones and biliary sludge at ERCP; these vent post-ERCP pancreatitis found this drug to be effipatients responded favourably to endoscopic sphinccacious, although cumbersome to administer.9 terotomy or cholecystectomy, or both.13 14 For a more detailed discussion of the pathophysiolERCP is indicated in patients with recurrent ogy of acute pancreatitis, interested readers are episodes of acute pancreatitis of undetermined referred to recent reviews.7 10 aetiology to look for biliary stones including microlithiasis ; , anomalous or pathological biliary or Conditions associated with acute pancreatic anatomy such as choledochocele ; , and pancreatitis unsuspected obstructing lesions of the ampulla of Vater. Cross sectional imaging of the liver, gall bladder, Calculi in the common bile duct choledocholithiasis ; biliary tree, and pancreas by transabdominal ultraand alcohol account for 80% of cases of acute pancreasound, computed tomography, and magnetic resotitis. Many other conditions are associated with the nance imaging are all helpful in identifying specific disease box ; . causes of pancreatitis. Not all patients who have an Identifying the underlying cause is important: the attack of pancreatitis require ERCP. risk of recurrence may be predicted, and eliminating the underlying cause discontinuing a drug, for example ; may prevent further attacks. In specific instances, such as Clinical presentation severe pancreatitis with cholangitis due to impaction of a The hallmark of acute pancreatitis is a continuous, gallstone at the ampulla of Vater fig 1 ; , identifying the boring epigastric pain. It is usually poorly localised, is problem and dealing with it immediately by ERCP and often worse in the supine position, and radiates to the sphincterotomy for biliary decompression ; may favourback in about 50% of patients. In contrast to the often ably influence the course of the disease.11 12 abrupt onset of pain that accompanies perforation of In about 10% of cases of acute pancreatitis, no an abdominal viscus, the pain increases in severity to a underlying cause can be identified idiopathic pancreapeak in 30 to minutes, then remains steady for many titis ; . Recently, two prospective studies of patients with hours or days. Localised epigastric tenderness can be idiopathic pancreatitis found that about two thirds had intense, but signs of peritoneal irritation such as rebound tenderness are typically absent on initial presentation, consistent with the retroperitoneal location of the pancreas. Acute ischaemia of the bowel should be considered in the differential diagnosis and pentasa.
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11.4. Opti-a1 characterization Initial operation of the beamline was rendered very easy by the care bestowed on the surveying and alignment. In foct, it was possible to see some synchrotron light comine; out of the sample chamber rear viewport see figure I ; almost immediatly after opening a11 valves and shutters, on the very first trial. Later on, the light beam had t3 be centered a little moved sideways by 2 mrn ; because it was hitting a side guard in the exit slit assembly. These guards were inadvertently left very close slit lmght 4 mm ; and will be opened up. It is not clear at the time of this writing whether the photon beam was hitting the guard due to beamline misalignment, or b x a the stored electron beam might be following a displaced orbit. Whenever it was possible to see the photon beam, its shape was ~ e r close to that expected from ray-tracings y of toroidal mirrors, but careful measurements of focal spot size h: , ve not yet been done at this beamline. A few intensity measurements have already been performed, with a stored electron beam of 4 mA, 1.2 GeV. In order to do that, a windowless Hamamatsu GaAsP - Au Schottky diode G 1127-02 was mounted to the sample chamber; its position could not be optimized, but from a nearby viewport it was visually ascertained tliat it intercepted most OSthe photon beam when the gvating angle was set to zero-order reflection. The diode vas connected to a Keithley digital picoammeter, on the short circuit mode. The int msity measurements were made with both entrance ar d exit slits set to a width of 0.25 mm. When the grating angle was set to zero-order reflection, a current of 30 pA was registered. Figure 6 shows wavelength scans made over the full range of each gratin; , which we now proceed to discuss.
T e.g. fist, squash ball t history: injury, ocular history, drug allergy, tetanus status t exam: VA first, pupil size and reaction, EOM diplopia ; , external and slit lamp exam, ophthalmoscopy t if VA normal or slightly reduced, globe less likely to be perforated t if VA reduced, may be perforated globe, corneal abrasion, lens dislocation, retinal tear t bone fractures blow out fracture: restricted upgaze, diplopia ethmoid fracture: subcutaneous emphysema of lid t lids swelling, laceration, emphysema ; t conjunctiva subconjunctival hemorrhage ; t cornea abrasions - detect with fluorescein and cobalt blue ; t anterior chamber assess depth, hyphema, hypopyon ; t iris prolapse, iritis ; t lens cataract, dislocation ; t refer if you observe any of these signs of ocular trauma: decreased VA, shallow anterior chamber, hyphema, abnormal pupil, ocular misalignment or retinal damage t include ruptured globe + prolapsed iris, intraocular foreign body t be suspicious if history of "metal striking metal" t initial management: refer immediately ABCs don't press on eyeball! check vision, diplopia apply rigid eye shield to minimize further trauma keep head elevated 30-45 degrees to keep IOP down t alkali burns have a worse prognosis, because acids coagulate tissue and inhibit further corneal penetration t poor prognosis if cornea opaque, likely irreversible stromal damage and pentobarbital.
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Delegates expressed the view that increased emphasis should be placed in the C 4 document on ethical, legal and societal challenges and implications of the development of ICTs as well as on the impact of globalization on information and knowledge societies. The need to promote the development of multilingual and diverse local content was recognized by many speakers. One delegate suggested that, in addition to the three critical dimensions for creating digital and information literate societies the "3 C's" for content, capability and connectivity" UNESCO should also address a fourth "C" standing for "cost". 49. Several delegates highlighted the utmost importance of UNESCO's work in promoting both universal access to information and knowledge and freedom of expression. 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The importance of free and open-source software in facilitating access to educational and scientific information should also be reflected in the next C 4 document. 53. Further, specific attention should be devoted to media literacy and information literacy. Several delegations drew attention to the needs of women and stressed the role of ICTs as a tool for the social, economic and political integration of women. Overall, strong emphasis was placed on the pursuit of cross-cutting issues such as ICTs and human rights and the use of ICTs in e-governance, ICTs and citizenship, as well as activities pertaining to and involving youth. The initiatives proposed in the Report of the 2005 UNESCO Youth Forum, and especially those related to the development of youth-specific media content and the participation of young people in media production, were highlighted and supported by a number of delegates. 54. The importance of building partnerships and close cooperation and consultations with intergovernmental and non-governmental organizations, as well as the public and private sectors, was deemed essential by a large number of delegations. Document 34 C 4 should also give new impetus to partnerships across UNESCO's priorities, avoiding overlaps, building on complementarities and the sharing of resources. One delegate called for the creation of a global network for cooperation in the field of ICTs. 55. Some delegations also suggested that the Organization should continue to retain the five functions of the Organization laid out in document 31 C 4: laboratory of ideas, standard-setter, clearing house, capacity-builder in Member States, and catalyst for international cooperation. 56. Delegations agreed that document 34 C 4 should include not only specific, measurable, achievable and accountable, but also realistic and time-bound targets and performance indicators, which should allow proper measuring and monitoring. Many delegates stressed that there was a need to continue refining the results-based programming.
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That results in lower activities 34. In heterozygote patients, chitotriosidase levels may be multiplied by two to allow adequate comparison with Gaucher patients with normal chitotriosidase genotypes 29. The clinical usefulness of chitotriosidase has been the subject of a limited number of studies. First of all it was documented that in patients after cessation of treatment, chitotriosidase impressively precedes deterioration of clinical symptoms 35. It was also established that patients who did not reach a decrease in chitotriosidase of 15% from baseline within the first 12 months also had a lack of clinical response 36. These data provide an indication that the persistence of high chitotriosidase levels reflect the presence of a high burden of Gaucher cells. Whether this can be translated into an increased risk for Gaucher related morbidity, remains to be determined. Of all disease parameters, bone disease is the most difficult to evaluate. MR imaging is the preferred modality, due to its sensitivity for the detection of both focal and diffuse disease 3739 and percodan.
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