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Background Symptom control is prioritized by cancer patients and may improve overall survival. Ontario, Canada thus offers all cancer patients screening using the Edmonton Symptom Assessment System (ESAS) at outpatient cancer‐related visits. We determined whether this initiative reached adolescents and young adults (AYA) and factors associated with screening in this population. Methods We linked all Ontario AYA diagnosed with cancer 2010–2018 aged 15–29 years to population‐based databases identifying outpatient visits and ESAS screening. For each 2‐week period in the year post‐diagnosis, AYA with cancer‐related visits were categorized as “unscreened” (no ESAS score) versus “screened” (≥1 ESAS score). Demographic and disease‐related covariates were examined. Results Among 5435 AYA, 4204 (77.4%) had ≥1 ESAS screen. Within any 2‐week period, only 30%–44% of AYA attending cancer‐related visits were screened. Patients with hematologic malignancies were least likely to be screened [odds ratio (OR) vs. breast cancer 0.77, 95% confidence interval (95% CI) 0.67–0.88; p, Symptom control is prioritized by cancer patients; we assessed whether a population‐based symptom screening program was effective in screening adolescents and young adults (AYA). AYA living in rural and remote areas had high rates of screening, but those living in low‐income urban areas and those with hematologic cancers had lower screening rates. AYA‐specific measures may be warranted.

Background: The same dosing schedule, 1000 SQ-U times three, with one-month intervals, have been evaluated in most trials of intralymphatic immunotherapy (ILIT) for the treatment of allergic rhinitis (AR). The present studies evaluated if a dose escalation in ILIT can enhance the clinical and immunological effects, without compromising safety. Methods: Two randomized double-blind placebo-controlled trials of ILIT for grass pollen-induced AR were performed. The first included 29 patients that had recently ended 3 years of SCIT and the second contained 39 not previously vaccinated patients. An up-dosage of 1000–3000–10,000 (5000 + 5000 with 30 minutes apart) SQ-U with 1 month in between was evaluated. Results: Doses up to 10,000 SQ-U were safe after recent SCIT. The combined symptom-medication scores (CSMS) were reduced by 31% and the grass-specific IgG4 levels in blood were doubled. In ILIT de novo, the two first patients that received active treatment developed serious adverse reactions at 5000 SQ-U. A modified up-dosing schedule; 1000–3000–3000 SQ-U appeared to be safe but failed to improve the CSMS. Flow cytometry analyses showed increased activation of lymph node-derived dendritic but not T cells. Quality of life and nasal provocation response did not improve in any study. Conclusion: Intralymphatic immunotherapy in high doses after SCIT appears to further reduce grass pollen-induced seasonal symptoms and may be considered as an add-on treatment for patients that do not reach full symptom control after SCIT. Up-dosing schedules de novo with three monthly injections that exceeds 3000 SQ-U should be avoided. (Less)

Chronic sialorrhea commonly occurs in patients with neurodevelopmental disorders. While conservative management can provide sufficient symptom control, surgical intervention is often required. One of the most common procedures utilized is submandibular gland excision (SMGE), with or without parotid duct ligation or rerouting (PDL or PDR). This study aims to compare these surgical approaches and their outcomes.PubMed, Web of Science, and Embase.This systematic review includes studies of patients with chronic sialorrhea treated with SMGE alone or SMGE plus PDR or PDL and reports on postintervention outcomes and complications. Two independent investigators assessed study eligibility, rated quality, and extracted data for analysis. A random effects model was used for meta-analysis of pooled data.Of 3186 studies identified, 21 met inclusion criteria, with 708 patients: 103 underwent SMGE alone (15%); 299 (42%), SMGE and PDL; and 306 (43%), SMGE plus PDR. Overall, a majority of patients had significant improvement, with very good to excellent control of symptoms after surgery: SMGE, 82% (95% CI, 73%-89%); SMGE and PDL, 79% (95% CI, 73%-85%); and SMGE and PDR, 85% (95% CI, 75%-92%). Importantly, there was no significant difference in outcomes with the addition of PDL or PDR. Reported complications included sialocele, parotitis, dental caries, and dry mouth.Our systematic review identified consistent positive outcomes with SMGE for patients with chronic sialorrhea but no additional benefit when PDR or PDL was performed as a concurrent procedure.

Two female patients aged 70 and 72 with video-urodynamics-confirmed detrusor overactivity and detrusor underactivity (DO-DU) were treated. Patients were refractory to medical therapies and had previously failed intravesical botulinum toxin type A (BoNT-A) at other centers secondary to urinary retention and difficulty with self-catheterization. Placement of an Interstim II device (Medtronic, Minneapolis, Minnesota) for sacral neuromodulation (SNM) as alternative third-line treatment partially improved overactive bladder (OAB) symptoms while significantly improving voiding symptoms. Postvoid residual (PVR) of patients improved from a median of 118 mL (110-125 mL) to 20 mL (18-26 mL) and 213 mL (195-230 mL) to 70 mL (60-73 mL), respectively. Addition of medical therapies post SNM failed to modify OAB symptoms further and a rechallenge with dose-reduced BoNT-A was undertaken.OAB symptoms were significantly improved by addition of BoNT-A, while urinary retention was avoided (median PVR post BoNT-A 38 mL [34-40 mL] and 185 mL [150-205 mL], respectively). Reduction in incontinence pad use as well as resolution of nighttime incontinence in both patients and daytime incontinence in one patient was achieved. DO-DU patients treated by SNM who have improved bladder emptying (PVR

This non‐interventional, national on‐line survey of 1541 parents of children aged 2–15 years sought to understand parents’ perceptions of allergic rhinitis (AR). Children were allocated to case (AR, n=1040) or control (No AR, n=501) groups based on a screening questionnaire. The survey questionnaire elicited data on parents’ beliefs about AR and current management practices. Most parents believed that AR could significantly impair wellbeing, but understanding of its causes was poor (Table). Amongst AR cases, parental recognition of AR was suboptimal: parents reported a history of AR in only 17% (178/1040) of case children. Amongst AR cases currently being treated (n=939), doctors (53%) and pharmacists (23%) were the main sources of treatment advice; 9% of children were managed based on parental decision. In children currently medicating, on average 1.40 medicines were being used; most used antihistamines (44% non‐sedating, 8% sedating) while 16% used intranasal corticosteroids. Half (49.5%, 515/1040) of AR case children reported adequate symptom control overall and less in children taking sedating antihistamines. Parents harbour many misconceptions about AR, which may explain why its burden in children remains so high. Solutions to better engage with parents should be explored.

Objectives To find out the proportion of children with poor symptom control in overweight/obese and normal weight children with mild persistent asthma and to know the sociodemographic and clinical correlates of poor symptom control in them. Materials and Methods Children aged 6 to 12 years with mild persistent asthma with BMI Z score for age and sex more than +1 Z score on WHO BMI Z score chart for age and sex formed the cases. Age‐ and sex‐matched asthmatics with BMI Z score for age and sex between −2 Z and +1 Z score formed the controls. FEV1, FEV1/FVC were measured in both groups using Care Fusion Jaeger spirometer. Symptom control was assessed by ACT score. Statistical analysis was done using SPSS version 19 and Vassarstats. Results The proportion of children with poor control was 19.1% in the overweight/obese group and 23.4% in the normal weight group. There was no significant correlation between BMI and symptom control as assessed by the ACT score. Overweight/obese children with good control showed a slightly lower FEV1/FVC ratio and higher median eosinophil count compared to children with normal weight. Gastroesophageal reflux and allergic rhinitis were more commonly seen in overweight/obese children. In the poor control group, FEV1, FEV1/FVC, and median eosinophil counts were not significantly different between overweight/obese and normal weight group but were less when compared to good control group. Conclusion The proportion of poor symptom control was not high in overweight/obese asthmatic children compared to normal weight asthmatic children. No significant risk factors for poor symptom control could be identified in our study for either of the groups.

Aims The use of complementary and alternative medicines (CAMs) during breastfeeding is increasing, mainly because of their presumed greater safety compared with conventional medications. However, CAMs can cause serious adverse effects, and there is limited high-quality evidence supporting their use during lactation. In Italy, specific investigations on the attitude of lactating women towards CAMs are lacking. The Herbal supplements in Breastfeeding InvesTigation (HaBIT) study aimed to explore attitudes to and knowledge on CAMs among lactating women. Methods A web-based survey was conducted over a 6-year period among lactating women resident in Tuscany, Italy. Data on lactating behaviour, CAMs use during pregnancy or breastfeeding, and women's knowledge about the efficacy and safety of CAMs were collected. Results A total of 388 lactating women answered the questionnaire. The majority of them were primiparae, with a high educational level. Of these, 204 women declared themselves to have used CAMs during breastfeeding. Moreover, 61% and 48% of subjects reported also using CAMs before and during pregnancy, respectively. A significant proportion of subjects were unable to identify correctly the types of CAMs they were using. Seventy-three per cent of women were convinced that CAMs were equally safe or safer than conventional medications; nevertheless, 65% of women admitted to have no scientific information about the potential risks of CAMs, and 14 CAMs users reported that they had experienced side effects. Conclusions These results demonstrate the need for healthcare providers to increase the awareness of breastfeeding women about CAMs. Further research is needed to support the evidence base for nonpharmaceutical approaches for symptom control during breastfeeding.

Background The Global Allergy and Asthma European Network (GA2 LEN) Taskforce has requested more data on correlations between various patient-reported outcomes (PROs) in clinical trials on allergy. We compared three tools-the Rhinitis Control Assessment Test (RCAT), Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) and Rhinitis Total Symptom Score (RTSS)-to determine whether the RCAT alone is a sufficient primary outcome parameter in clinical trials on allergic rhinoconjunctivitis. Methods In two double-blind, placebo-controlled immunotherapy studies, 33 patients allergic to grass pollen and 94 to birch pollen completed two questionnaires (RCAT and RQLQ) and kept their own symptom diary from which the RTSS was calculated. Results Upon comparing RCAT and RQLQ results, we found strong correlations of r = -0.871 for grass pollen-allergic patients and r = -0.795 for birch pollen-allergic patients. The comparison between RCAT and RTSS results showed a strong correlation of r = -0.811 (grass pollen-allergic patients) and a moderate correlation of r = -0.539 (birch pollen-allergic patients). In the RCAT, 69.7% of grass pollen-allergic patients and 45.7% of birch pollen-allergic patients receiving guideline-concordant therapy were regarded as having insufficiently controlled symptoms. Conclusion The strong correlations suggest that the RCAT alone is equivalent to the RQLQ with respect to patients' symptom control and quality of life. Patients with uncontrolled symptoms can be identified using the RCAT. Hence, the physician can decide whether symptomatic therapy can be intensified or allergy immunotherapy should be administered.

Aim Postoperative patients with lung cancer have a high recurrence rate and poor prognosis; hence, we aimed to identify the factors affecting hope to help develop a care-oriented perspective focused on the levels of hope in postoperative patients with lung cancer. Methods In the study, we included postoperative patients with lung cancer and collected data for treatment-related symptoms, coping, and support-related factors as the primary variables. We used the Herth Hope Index, Quality of Life Questionnaire Lung Cancer Module (QLQ-LC13) of the European Organization for Research and Treatment of Cancer, Japanese version of the Coping Inventory for Stressful Situations (CISS), and Social Support Scale for Cancer Patients. Results For the 82 patients included in our study, 55% of the variance in the level of hope was explained using a model that included the following: (1) symptoms of dyspnea, sore mouth, and chest pain; (2) support, including satisfaction with postoperative symptom control by healthcare providers, satisfaction with the amount of information provided by healthcare providers, and the trust in nurses during treatment and recovery; and (3) task-oriented and social diversion coping behaviors. Conclusion As a result of this study, the support-related factors had no direct influence on hope, but they did have a significantly negative influence on treatment-related symptoms, with improved symptoms also having influencing hope.

Background Patient-reported control of chronic rhinosinusitis (CRS) symptoms is associated with the quality of life impact of CRS. We sought to determine if 22-item Sino-Nasal Outcome Test (SNOT-22) score is predictive of patient-perceived CRS symptom control. Methods Prospective cross-sectional study of 202 patients with CRS. Participants were asked to rate their CRS symptom control as “not at all,” “a little,” “somewhat,” “very,” and “completely.” The severity of patient CRS symptomatology was measured using the SNOT-22. The relationship between SNOT-22 score and patient-reported CRS symptom control was determined using regression, analysis of variance (ANOVA), and receiver operating characteristic (ROC) curve analysis. Results SNOT-22 was negatively associated with patient-reported CRS symptom control (adjusted β = −0.03; 95% CI, −0.04 to −0.02; p < 0.001), after controlling for demographic and clinical characteristics. There was a significant difference in SNOT-22 scores of participants reporting each level of symptom control (p < 0.001) with the greatest differences between participants who rated their CRS symptom control as “not at all,” “a little,” and “somewhat,” which we deem poor CRS symptom control, and the group who described their level of CRS symptom control described as “very” and “completely,” which we deem well-controlled CRS symptoms. These results were true across all SNOT-22 subdomains scores as well. Using ROC analysis, a SNOT-22 score of 35 identified patients reporting poor vs well-controlled CRS symptom control with 71.4% sensitivity and 85.5% specificity. Conclusion SNOT-22 score is associated with how well patients feel their CRS symptomatology is controlled. Moreover, SNOT-22 score can be used to accurately distinguish patients with poor vs well-controlled CRS symptoms.

Epithelial sheath neuroma (ESN) is a rare entity, histologically showing enlarged nerves in the superficial dermis surrounded by cytologically bland keratinocytes, classically presenting clinically as an erythematous papule or nodule on the back of middle-aged to elderly individuals. Clear-cut recommendations for treatment are not available, with many reports citing biopsy alone or simple excision as curative. We report a case of biopsy-proven ESN presenting as a significantly painful nodule in an elderly woman. Surgical excision was performed for symptom control and the residual ESN was found to extend deep into the subcutis.

In patients receiving end of life care at home, anticipatory prescribing can provide a back-up for when urgent symptom control is needed. This article discusses the practicalities surrounding anticipatory prescribing, including the use of ‘just in case’ boxes, the role of family members and how to handle difficult conversations with patients.

Outcomes After Third or More Catheter Ablation for Atrial Fibrillation Introduction Pulmonary vein (PV) status, arrhythmia sources, and outcomes with ≥3 ablation procedures have not been characterized. Methods and Results All patients with ≥3 procedures were included and underwent antral reisolation of reconnected PVs and ablation of non-PV triggers. Of 2,886 patients who underwent PVI, 181 (6%) had more than 2 ablation procedures (3 procedures in 146 and ≥4 procedures in 35). In 12 patients, the clinical arrhythmia was other than AF. Of the remaining 169 patients, 69 (41%) had 4 reconnected PVs, 27 (16%) had 3, 31 (18%) had 2, and 29 (17%) had 1. Only 13 (8%) had all PVs still isolated. Provocative techniques in 127 patients initiated PV triggers in 92 patients, including AF or PV atrial tachycardia in 64 (50%), and reproducible PV APDs in 28 (22%). Thirty-six (20%) had a new non-PV trigger targeted. At a mean of 36 months (12–119 months) after last procedure, 63 patients (47%) had no AF off antiarrhythmic drugs (AAD); 28 (21%) had no AF with AAD; and 18 (13%) had rare AF with good symptom control; 26 patients (19%) had recurrent AF. Conclusions At time of third or greater AF ablation, PV reconnection is the rule (92%) and PV triggers initiating AF can be demonstrated. Following repeat PVI and targeting non-PV triggers, 81% of patients had clinical AF control. Our findings suggest that PV reisolation and attempts to identify and eliminate non-PV triggers are effective and support the role of multiple repeat procedures for AF recurrence.

To examine audiometric outcomes, symptom control rates, and complication rates following semicircular canal plugging for superior semicircular canal dehiscence syndrome.Retrospective chart review.Private, neurotologic tertiary referral center.Patients undergoing semicircular canal plugging for superior semicircular canal dehiscence syndrome from January 1, 2007, to December 31, 2012. Pre- and postoperative audiometry, vestibular testing, operative findings, and clinical symptoms were assessed through chart review.A total of 24 ears underwent a canal plugging procedure during the study period for superior canal dehiscence syndrome. Pre- and postoperative air conduction pure-tone averages were 21.1 and 22.5 dB (P = .42, not significant [NS]). The average pre- and postoperative word recognition scores were 95.8% and 95.1% (P = .48, NS). Vestibular evoked myogenic potential data showed reduced thresholds in 7 patients with canal dehiscence. Complications were limited to a single, temporary facial weakness. Complete symptom improvement was noted in 35.7% of all patients, while at least partial symptom improvement was found in over 80% of patients.Semicircular canal plugging procedures are associated with excellent hearing outcomes and may reduce preoperative symptoms in patients with superior semicircular canal dehiscence.

Attention-deficit hyperactivity disorder (ADHD) and its associated behavioural manifestations develop and progress as the result of complex gene-environment interactions. Parents exert a substantial influence and play a major role in their child's social environment. Despite this, recent evidence has suggested that adapting the child's environment via parenting interventions has minimal effects on child ADHD symptoms when analysing data from informants who are probably blind to treatment allocation. However, adverse parenting and family environments may act as a source of environmental risk for a number of child outcomes beyond ADHD symptoms. This is a narrative review that critically discusses whether parenting interventions are beneficial for alternative functioning outcomes in ADHD including neuropsychological, academic and social functioning and disruptive behaviour and how parenting and familial environments may be associated with these outcomes. In addition, the review explores how parental depression and parenting efficacy impact on capacity for optimal parenting and whether parenting interventions benefit parents too. A review of the evidence suggests that with modification, parenting interventions are beneficial for a number of outcomes other than ADHD symptom reduction. Improving the parent-child relationship may have indirect benefits for disruptive behaviour. Furthermore, parenting behaviours may directly benefit child neuropsychological, academic and social functioning. Parenting interventions can have therapeutic benefits for parents as well as children, which is important as parent and child well-being is likely to have a transactional relationship. Evaluation of the clinical success of parenting interventions should focus on a wider range of outcomes in order to aid understanding of the multifaceted benefits that they may be able to offer. Parenting interventions should not be seen as a redundant adjunct to medication in multi-modal treatment approaches for ADHD; they have the potential to target outcomes that, at present, medication seems less able to improve.

There has been a steep rise in the burden of atopic dermatitis (AD), and up to 20% of children in developed countries now suffer of the disease. At present, treatment at best achieves symptom control rather than cure, and there is a strong need to identify new methods of disease prevention. While earlier approaches focused on allergen avoidance strategies, there has been a clear shift towards attempts to induce tolerance and enhancement of skin barrier function, as skin barrier breakdown plays an important role in AD development. This article reviews the latest developments in the prevention of AD.

Background and objective We evaluated effective treatments of broncholithiasis based on its radiographical and bronchoscopic features. Methods This retrospective study conducted at Samsung Medical Center, Korea enrolled patients who were suspected of having broncholithiasis based on chest computed tomography (CT). The broncholiths were classified as intraluminal, mixed (both intraluminal and extraluminal) and extraluminal based on chest CT and bronchoscopic findings. Results The study enrolled 46 patients between 1995 and 2009. Symptoms included cough (n = 21, 45.7%), hemoptysis (n = 19, 41.3%) and purulent sputum (n = 11, 23.9%). Cough was more common in intraluminal boncholiths than in other type of broncholiths (P = 0.03). Based on chest CT, there were 15 (32.6%) intraluminal, 15 (32.6%) mixed and 16 (34.8%) extraluminal broncholiths. All 15 intraluminal broncholiths were removed completely via flexible (n = 2) or rigid (n = 13) bronchoscopy. For the 15 mixed broncholiths, seven (46.7%) bronchoscopic interventions were performed, but complete removal of the broncholiths was not accomplished. Six (40%) mixed and four (25%) extraluminal broncholiths were treated by surgical resection for symptom control. None of the patients who underwent surgical resection suffered morbidity or postoperative mortality. Conclusions The treatment of broncholithiasis should be based on chest CT and bronchoscopic findings. Intraluminal broncholiths can be removed via bronchoscopy, while surgery should be considered for symptomatic mixed or extraluminal broncholiths.

The care of dying patients begins long before they approach the last few days of life. The authors explain how advance care planning, involving the whole multidisciplinary team and supporting the family are as important as symptom control in the last few hours of life.

SUMMARY Patients with chronic kidney disease, particularly those with diabetes, often have a heavy burden of vascular comorbidity and hence a poor overall prognosis. Unfortunately, patients and their healthcare teams often have unrealistic expectations about outcomes and receive ineffective and often harmful interventions towards their end of life. We need to move away from death being perceived as a failure and realise, instead, that our goal of care at the end of life is to achieve as good a quality of life for the patient as possible. To be able to achieve this, it is important to be realistic about prognosis, be able to recognise predictors of poor outcome and then be able to discuss these with the patient and their family to ensure symptom control, avoid interventions that could do harm and then as the end approaches, determine the wishes of the patient regarding preferred place of care for their inevitable death.

Aim To investigate prescribing patterns of antiemetics for palliative care hospital patients and to compare them with best practice guidelines. Method A retrospective audit of nausea and vomiting management was undertaken for 70 patients referred to the hospital Palliative Care Service. Results 19 patients presented with uncontrolled nausea and/or vomiting. An antiemetic was prescribed for 43 (61%) patients, with dopamine antagonists the most commonly prescribed. Patients taking regular antiemetics had better symptom control compared to patients taking prn (when required) doses. The 5-hydroxytryptamine type 3 receptor antagonists were prescribed in accordance with best practice guidelines in only one-quarter of cases. Conclusion In the majority of cases, antiemetics were prescribed according to best practice guidelines. Regular antiemetics (rather than prn) provide better symptom management.

The prevalence of pain increases with advancing age. Pain is often undiagnosed or under-treated in older patients, particularly those with cognitive impairment, communication problems or residents of aged-care facilities. The most definitive approach to the management of pain is to treat the underlying cause. As this is often not feasible in the elderly, the emphasis then shifts to symptom control. Pharmacological approaches form the mainstay of therapy. They are convenient and often cost-effective, and may be used alone, or in combination with physical and psychological therapies. J Pharm Pract Res 2007; 37: 63-8.

BACKGROUND: Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited disorder causing kidney disease. Current clinical management of ADPKD focuses primarily on symptom control and reducing associated complications, particularly hypertension. In recent years, improved understanding of molecular and cellular mechanisms involved in kidney cyst growth and disease progression has resulted in new pharmaceutical agents to target disease pathogenesis to prevent progressive disease. OBJECTIVES: We aimed to evaluate the effects of interventions for preventing ADPKD progression on kidney function, kidney endpoints, kidney structure, patient‐centred endpoints (such as cardiovascular events, sudden death, all‐cause mortality, hospitalisations, BP control, quality of life, and kidney pain), as well as the general and specific adverse effects related to their use. SEARCH METHODS: We searched the Cochrane Renal Group's Specialised Register to 6 June 2015 using relevant search terms. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing any interventions for preventing the progression of ADPKD with other interventions or placebo were considered for inclusion without language restriction. DATA COLLECTION AND ANALYSIS: Two authors independently assessed study risks of bias and extracted data. We summarised treatment effects on clinical outcomes, kidney function and structure and adverse events using random effects meta‐analysis. We assessed heterogeneity in estimated treatment effects using the Cochran Q test and I(2) statistic. Summary treatment estimates were calculated as a mean difference (MD) or standardised mean difference (SMD) for continuous outcomes and a risk ratio (RR) for dichotomous outcomes together with their 95% confidence intervals. MAIN RESULTS: We included 30 studies (2039 participants) that investigated 11 pharmacological interventions (angiotensin‐converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs), calcium channel blockers, beta blockers, vasopressin receptor 2 (V2R) antagonists, mammalian target of rapamycin (mTOR) inhibitors, somatostatin analogues, antiplatelet agents, eicosapentaenoic acids, statins and vitamin D compounds) in this review. ACEi significantly reduced diastolic blood pressure (9 studies, 278 participants: MD ‐4.96 mm Hg, 95% CI ‐8.88 to ‐1.04), but had uncertain effects on kidney volumes (MD ‐42.50 mL, 95% CI ‐115.68 to 30.67), GFR (MD ‐3.41 mL/min/1.73 m(2), 95% CI ‐15.83 to 9.01), and SCr (MD ‐0.02 mg/dL, 95% CI ‐0.14 to 0.09), in data largely restricted to children. ACEi did not show different effects on GFR (MD ‐8.19 mL/min/1.73 m(2), 95% CI ‐29.46 to 13.07) and albuminuria (SMD ‐0.19, 95% CI ‐1.77 to 1.39) when compared with beta‐blockers, or SCr (MD 0.00 mg/dL, 95% CI ‐0.09 to 0.10) when compared with ARBs. Data for effects of V2R antagonists on kidney function and volumes compared to placebo were limited to narrative information within a single study while these agents increased thirst (1444 participants: RR 2.70, 95% CI 2.24 to 3.24) and dry mouth (1455 participants: RR 1.33, 95% CI 1.01 to 1.76). Compared with no treatment, mTOR inhibitors had uncertain effects on kidney function (2 studies, 115 participants: MD 4.45 mL/min/1.73 m(2), 95% CI ‐3.20 to 12.11) and kidney volume (MD ‐0.08 L, 95% CI ‐0.75 to 0.59) but in three studies (560 participants) caused angioedema (RR 13.39, 95% CI 2.56 to 70.00), oral ulceration (RR 6.77, 95% CI 4.42 to 10.38), infections (RR 1.14, 95% CI 1.04 to 1.25) and diarrhoea (RR 1.70, 95% CI 1.26 to 2.29). Somatostatin analogues (6 studies, 138 participants) slightly improved SCr (MD ‐0.43 mg/dL, 95% CI ‐0.86 to ‐0.01) and total kidney volume (MD ‐0.62 L, 95% CI ‐1.22 to ‐0.01) but had no definite effects on GFR (MD 9.50 mL/min, 95% CI ‐4.45 to 23.44) and caused diarrhoea (RR 3.72, 95% CI 1.43 to 9.68). Data for calcium channel blockers, eicosapentaenoic acids, statins, vitamin D compounds and antiplatelet agents were sparse and inconclusive. Random sequence generation was adequate in eight studies, and in almost half of the studies, blinding was not present or not specified. Most studies did not adequately report outcomes, which adversely affected our ability to assess this bias. The overall drop‐out rate was over 10% in nine studies, and few were conducted using intention‐to‐treat analyses. AUTHORS' CONCLUSIONS: Although several interventions are available for patients with ADPKD, at present there is little or no evidence that treatment improves patient outcomes in this population and is associated with frequent adverse effects. Additional large randomised studies focused on patient‐centred outcomes are needed.

This study aimed to describe the experience of living with a venous leg ulcer from the patient's perspective, to answer the question 'What is it like to live with a venous leg ulcer?' Investigating the experience of illness is important in understanding how disease processes affect people, how they understand and cope with these processes, and how care may be given most effectively. Little research was identified which examined these areas with reference to people with leg ulceration. A qualitative approach was taken in the following study, using phenomenological methods to describe the experience of venous leg ulceration. Informal unstructured interviews were conducted with 13 informants, guided by their descriptive priorities. Tape recordings were then transcribed and analysed for recurrent themes and their meanings. It was found that certain symptoms of ulceration, principally pain, were the overwhelming feature of the experience. These symptoms caused significant restrictions in people's lives, particularly in their ability to walk and go out. Treatment was not described as being efficacious in ameliorating these symptoms, but nevertheless great confidence and trust was placed in the expertise of nurses. People coped with the experience mainly by a process of normalizing its components. It is concluded that if treatment is to meet the needs of those suffering venous leg ulceration, then symptom control must be the highest priority.

Approximately 50% of patients with colorectal cancer (CRC) will eventually die of metastatic disease. Effective palliative management can be used within a shared care model in CRC to provide optimum symptom control, psychological well-being and maintenance of quality of life for patients, their families and carers, including bereavement support. Maintenance of realistic hope and early goal setting are equally important in end-of-life discussions with patients and families. Palliative care should be incorporated early in the course of the illness, concurrent with disease-modifying therapies. Within shared care, the palliative medicine specialist, surgeon and other members of the multidisciplinary team can each bring their own expertise to provide a patient-centred approach. A case is presented that incorporates some of these principles and exemplifies the benefits of contemporary palliative care for patients with advanced CRC.

Introduction: At some time, every general surgeon will be faced with the task of trying to decide what to do with a patient who presents with rectal cancer and unresectable distant metastases. How safe is resectional surgery? What sort of palliation may be expected following resection of the primary tumour? In an attempt to answer these questions, the management and outcomes of all patients with rectal cancer and distant metastases, who were primarily referred to the colorectal unit at King Faisal Specialist Hospital were examined. Methods: All patients who underwent primary surgery for rectal cancer in the presence of metastatic disease were identified. The charts of these patients were examined and their morbidity, mortality and survival were determined. Results: Over an 8-year period 22 patients (average age 54 years) underwent rectal resectional surgery in the presence of metastatic disease. There were 13 men and nine women. The commonest complaint was rectal bleeding. All patients had chest radiographs. Pulmonary metastases were identified in four patients. Nineteen abdominal and pelvic computed tomography scans were performed and eight showed evidence of metastases. Skeletal radiographs in two patients showed evidence of bone metastasis. At operation, intraperitoneal metastases were found in 18 patients. Nine of these were not identified preoperatively. Six patients underwent abdomino-perineal resection, nine anterior resection and seven a Hartmann's procedure. Eight patients developed a significant postoperative complication and one died 42 days after surgery. The mean length of hospital stay was 18.6 days. Nine patients received preoperative radiotherapy. Four patients had palliative radiotherapy, two for bony, one for liver and one for peritoneal metastases. Patients were followed up for a mean of 1.1 years. During follow up, 11 returned to the emergency room on 24 occasions. Two patients required readmission. No patient had further rectal bleeding. The mean survival was 1.3 years. Conclusion: Patients with rectal cancer and unresectable distant metastases can be successfully palliated by resection of the primary tumour with low morbidity and mortality. The early involvement of a palliative care team facilitates patient management and helps patients enjoy what remains of the rest of their lives at home, in comfort and with good symptom control.

Background: Patients with haematological malignancies are not referred to palliative care services as frequently as those with solid cancers (non haematological malignancies). Aims: The present study surveyed haematologists in Australia and New Zealand. We aimed to record theoret­ical referral times, identify problems with referral to palliative care and clarify elements used to decide whether a patient was ‘terminally ill’. Methods: A questionnaire based on the case-histories of three patients (with acute leukaemia, lymphoma or mul­tiple myeloma) was distributed at the Haematology Society of Australia and New Zealand Congress 2000, Perth, Australia. Each case was divided into stages by transitional points in the illness to include issues or prognostic variables that may stimulate referral to ­palliative care. Questions were asked about: (i) referral ­triggers, (ii) problems previously experienced, (iii) definition of when the patient was ‘terminally ill’, (iv) prognostication difficulties and (v) communication about prognosis. Results: The response rate was 11%, which may represent up to 32% of Australian specialists. Eighty per cent had access to all types of palliative care services and refer for symptom control, regardless of illness stage. Twenty-nine per cent had experienced difficulties in referring. There was a variation as to exactly when referral would occur and when each case was considered ‘terminally ill’. Reasons for early or later referral were explored. Prognostication difficulties were common. Conclusions: In theory there is a willingness to refer to palliative care, however this has yet to be translated to day-to-day practice. This may be due to prognostication difficulties, logistical factors and medical concerns. Models of referral are suggested for further study. (Intern Med J 2003; 33: 566−571)

This is a commentary on a Cochrane review, published in this issue of EBCH, first published as: Candy B, Hotopf M. Steroids for symptom control in infectious mononucleosis (Review). Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD004402. DOI: 10.1002/14651858.CD004402.pub2. Further information for this Cochrane review is available in this issue of EBCH in the accompanying Summary article. Published by John Wiley & Sons, Ltd. The Cochrane Collaboration

Summary Allergic seasonal and perennial rhinitis are common diseases that have a considerable adverse impact on the quality of life of the sufferer. Despite the excellent available treatment, the morbidity of allergic rhinitis remains high, because patients often do not seek medical advice and also because physicians tend to underestimate the disruptive problems caused by the disease. In order to improve patient compliance with medication, the diagnosis of allergic rhinitis should be confirmed and the treatment prescribed should be effective with a simple dosage regimen.

Parkinson's disease is a neurological condition, managed symptomatically by medications aimed at the underlying dopaminergic deficit. After several years of treatment, some sufferers experience marked fluctuations in symptom control, including akinetic or 'off' periods. A sample of 15 Parkinson disease sufferers who experienced off periods participated in a small-scale study examining their experience and the coping strategies used. There was a trend for those experiencing significant levels of distress to make more frequent use of 'attempted activity' coping strategies, responses that may inadvertently exacerbate distress. Clinical implications for adjuvant psychological techniques are discussed.

Aims To evaluate the use, efficacy and adverse effects of nonprescription H2-receptor antagonists and alginate-containing preparations obtained from community pharmacies. Methods Questionnaires were distributed to customers from 39 pharmacies in Scotland and Wales. Results Of 767 customers recruited, 608 (79.3%) returned an initial questionnaire and 472 (61.5%) customers a second questionnaire. The vast majority of respondents (424, 69.7%) had suffered their symptoms on three or more occasions and 369 (60.7%) had previously tried medicines to relieve their symptoms. Referrals to a doctor were less frequent than recommended in guidelines and few of those who were referred actually saw a doctor. Over a quarter of those returning the second questionnaire claimed to be taking more than one product simultaneously for symptom control. Eight customers who were taking prescribed ulcer-healing drugs obtained H2-receptor antagonists. The majority of respondents (355/472, 75.2%) obtained some or complete symptom relief using the product obtained and 369/472 (78.2%) were completely satisfied with their product. H2-receptor antagonists were more likely to produce complete relief of symptoms than alginate-containing preparations (P

The canalith repositioning procedure has recently gained controversial recognition as a treatment for benign paroxysmal positional vertigo. Some authors contend that the canalith repositioning maneuver is no more effective than no treatment at all. Unfortunately, its technique has not been uniformly applied and its outcomes have not been uniformly assessed. I have found the use of mastoid oscillation to be critical in the success of this procedure. Another important factor is the time interval between diagnosis and relief of symptoms. Because it is well known that benign paroxysmal positional vertigo can spontaneously resolve after many months, the time frame for comparison should be short. A 1-week time interval was chosen for study purposes. Sixty patients were randomly assigned to three initial groups. The control group (n = 23) was not given any treatment. A second group (n = 27) was given treatment with the canalith repositioning maneuver with mastoid vibration. A third group (n = 10) was assigned to receive the canalith repositioning maneuver without mastoid vibration. Resolution was defined as no symptoms and negative Dix-Hallpike test results. The results showed that none of the control group's symptoms resolved completely in 1 week. Although 60% of those who received the canalith repositioning maneuver without mastoid vibration felt improved, none was free of nystagmus. An overwhelming 92% of those who received the canalith repositioning maneuver with mastoid vibration felt improved, and 70% were free of rotatory nystagmus after only one treatment. A review of all patients diagnosed with benign paroxysmal positional vertigo and treated with the canalith repositioning maneuver with mastoid vibration was also undertaken. In a series of 67 patients with a minimum of four weeks of follow-up, only two have not responded to the canalith repositioning maneuver, yielding a 97% rate of symptom control.

Objective: To review our experience with endoscopic posterior cricoid split and costal cartilage graft placement in the management of pediatric bilateral vocal fold immobility (BVFI), posterior glottic stenosis (PGS), and subglottic stenosis (SGS).Method: Multi-institutional retrospective case series of all patients treated with endoscopic posterior cricoid split and costal cartilage graft placement (EPCSCG) by any of the authors. Outcomes measured include: indications, complications, outcome.Results: Twenty-six patients underwent EPCSCG. Age range at time of surgery was 1 month to 15 years. Overall, there was an excellent success rate with 25/26 either never requiring tracheostomy or achieving decannulation and 24/26 having adequate symptom control. The mean follow-up was 23.15 months. Sixteen patients had resolution of their symptoms. Fourteen patients had SGS in isolation or in combination with cricoarytenoid fixation, glottic stenosis or vocal fold immobility. Thirteen achieved decannulation and/or ha...

A major thrust in psychosocial oncology has been to use psychosocial and behavioral techniques to prevent and manage the adverse symptoms associated with cancer and its treatment. This article defines the field of symptom management in psychosocial oncology and reviews its early and recent history. Recent progress in the field is reviewed, with a focus on several thematic advances in theory and practice. Finally, an agenda is suggested for the next decade of research, with attention given to research needs, research policy, and training issues.

Cancer and death have so often been synonymous in the minds of many. We who dedicate ourselves to the treatment of children realize that this is no longer true and work diligently to help the public see that indeed many children are cured of their malignancies. It is important to do this because the view that cancer is a terminal event is simply not true. However, how do we prevent the pendulum from swinging in the opposite direction? For it cannot be denied that care of the dying and bereaved is unavoidable in the professional life of health-care providers in pediatric oncology. This article is not meant to review physical care for the terminally ill child, although the importance of pain and symptom control will be addressed. Rather, the purpose is to identify issues that are central in the treatment of dying children and their families. This is born of a belief that the management of the terminal phase of illness has a dramatic effect on the psychosocial recovery of the family. Bereavement follow-up care of parents and siblings, an integral part of terminal care, will be discussed. The issue of caregiver bereavement will also be addressed. Specific attention is given to home care as an option for terminal care. Current practice, research, and problems will be presented followed by recommendations to improve care.

Ovarian cancer is the sixth most common cancer among women and is usually diagnosed at an advanced stage. Bowel obstruction is a common feature of advanced or recurrent ovarian cancer. Patients with bowel obstruction are generally in poor physical condition with a limited life expectancy. Therefore, maintaining their QoL with effective symptom control is the main purpose of the management of bowel obstruction.To compare the effectiveness and safety of palliative surgery (surgery performed to control the cancer, reduce symptoms and improve quality of life for those whose cancer is not able to be entirely removed) and medical management for bowel obstruction in women with ovarian cancer.We searched the Cochrane Gynaecological Cancer Group Trials Register, The Cochrane Central Register of Controlled trials (CENTRAL), Issue 1 2009, MEDLINE and EMBASE up to February 2009. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.Studies that compared palliative surgery and medical interventions, in adult women diagnosed with ovarian cancer who had either full or partial obstruction of the bowel. Randomised controlled trials (RCTs) and non-RCTs that used multivariable statistical adjustment for baseline case mix were eligible.Two review authors independently assessed whether potentially relevant studies met the inclusion criteria, abstracted data and assessed risk of bias. One non-randomised study was identified so no meta-analyses were performed.The search strategy identified 183 unique references of which 22 were identified as being potentially eligible on the basis of title and abstract. Only one study met our inclusion criteria and was included in the review. It analysed retrospective data for 47 women who received either palliative surgery (n = 27) or medical management with Octreotide (n = 20) and reported overall survival and perioperative mortality and morbidity. Women with poor performance status were excluded from surgery. Although six (22%) women who received surgery had serious complications of the operation and three (11%) died of complications, multivariable analysis found that women who received surgery had significantly (p0.001) better survival than women who received Octreotide, after adjustment for important prognostic factors. However, the magnitude of this effect was not reported. Quality of life (QoL) was not reported and adverse events were incompletely documented.We found only low quality evidence comparing palliative surgery and medical management for bowel obstruction in ovarian cancer. Therefore we are unable to reach definite conclusions about the relative benefits and harms of the two forms of treatment, or to identify sub-groups of women who are likely to benefit from one treatment or the other. However, there is weak evidence in support of surgical management to prolong survival.

Perceptions and expectations reflecting what constitutes a 'good' death that seem to exist in Western societies are explored and compared with those presented by five symptom control team nurses at their home visits to 54 terminally ill cancer patients. These perceptions and expectations are termed 'scripts' for dying and are derived from the nurses', patients' and relatives' audio-recorded conversations over a 3-month period. The elements of the 'scripts' used were identified as: (a) control of physical symptoms, (b) acceptance of cancer and its prognosis, (c) preservation of hope and 'will to live', (d) mobility and 'fighting back', (e) enjoyment of life, (f) a peaceful death at home. How these components are determined from the conversations are presented and the responses of the patients to the nurses' 'scripts' are analysed. The dilemmas created by putting the 'scripts' into action for nurses, patients and relatives are discussed.

Audio-recordings of naturally occurring conversations over a three-month period between five nurses in a Symptom Control Team and fifty four terminally ill cancer patients and their relatives in their own homes form the focus of this study. The SCT nurses specialised in the care of the dying but did not carry out ‘hands on’ nursing which was given by community nurses. The SCT nurses carried out their work through ‘talk’. The main aim of the study is therefore, through analysis of the audio-recordings, to determine how conversational interactions are used by nurses, patients and relatives in dealing with the process of dying. The aspect of the study discussed in this paper deals with the process at first home visits whereby the nurses, patients and relatives establish ‘family’ memberships and determine eligible sources of help in relation to expected sets of rights and obligations.

The aspect of the study discussed is part of the analysis of audio-recorded, naturally occurring conversations between symptom control team (SCT) nurses, terminally ill cancer patients and their relatives in their own homes over a 3-month period. Using an ethnographic, extended case-study approach, four 'role formats' were identified as consistently used by the SCT nurses to carry out their work through conversation, one of them being 'friendly and informal'. The SCT nurses explicitly made it known to patients and their relatives that they intended to be 'friendly and informal'. How such a claim was translated into practice, both non-conversationally and through conversation, is the focus of this paper. Being 'friends' and being 'friendly and informal' with patients and clients is frequently advocated in medical and nursing literature, but how this is achieved in practice and the responses of patients seems unstudied. Therefore, the analysis discussed in this paper opens up for critical reflection an unquestioned, taken-for-granted aspect of practice where it is demonstrated how 'friendliness and informality' are conveyed through chatting and how it differs from 'formal' conversations.

Thirty-five individuals with fibromyalgia (fibrositis), 22 of their physicians, and 49 rheumatologists on an Arthritis Foundation referral list rated the importance of 24 aspects of fibromyalgia treatment. These encompassed symptom control, psychosocial factors, information, and physical therapy. Respondents with fibromyalgia rated their satisfaction with the way each aspect of treatment had been managed by their physician, and each completed a health status questionnaire. Fibromyalgia patients viewed 8 of the 24 aspects of treatment as significantly more important than did their own physician, and 18 of the 24 as significantly more important than did area rheumatologists. Satisfaction with the way treatment had been managed was generally low. Some evidence suggested that patients' health status was affected positively by the extent to which their physician viewed certain aspects of treatment as important. The results are expected to be useful in the design of fibromyalgia education programs for both lay and health professional audiences.

Vocal cord dysfunction (VCD) is characterized by paradoxical inspiratory abduction of the vocal cords. Gastro-oesophageal reflux disease (GORD) is a known trigger. We studied 77 patients referred to a tertiary VCD clinic. VCD was diagnosed in 62, of which 83.9% had proven GORD. Following 8 weeks of acid suppression, 24.2% reported improvement in the severity and frequency of VCD attacks. This study suggests that empirical treatment of GORD in VCD marginally improves symptom control.