Publications by authors named "Herbert Watzke"

42 Publications

Using medical comics to explore challenging everyday topics in medicine: lessons learned from teaching medical humanities.

Ann Palliat Med 2020 Jul 27;9(4):1841-1846. Epub 2020 May 27.

Teaching Center, Medical University of Vienna, Vienna, Austria.

Background: Studying medicine requires an extensive acquisition of knowledge, skills and attitudes. At the MedUni Vienna, this wide range of skills is strengthened by discussing aspects of medical humanities (MH) with medical students in their pre-clinical fifth study year. Medical comics (MCs), as a part of MH, offer the possibility to address challenging situations within medical settings through the use of graphic illustrations. Thus, patient stories as well as different perspectives of patients, caregivers, and medical staff can be addressed.

Methods: A total of 506 medical students were randomly assigned to one of three MCs within a blended learning setting via the Moodle online learning platform. The medical students were instructed to reflect on the MC by answering three questions within one week. Depending on the MC assigned, the learning objectives were to (I) comprehend demands on a young doctor during a night shift, (II) reflect on a patient examination situation, or (III) recognize patients' physical and/or emotional needs. The word counts of the answers and the time spent online answering the questions in the learning platform were analyzed. This was followed by an analysis in which the answers and their content were rated on a three-point Likert scale (insufficient, sufficient, exceptional). Subsequently, an MH and MCs lecture was held that incorporated the medical students' reflections. After the lecture, a one-minute paper (OMP) survey comprising two questions was conducted on the learning platform.

Results: Of the 506 medical students assigned the online task, 505 completed it. On average, each medical student wrote 110.87 words (SD: 78.54; range, 4.00-602.00) and spent 12.75 minutes (SD: 11.60) on the task. Of all the answers, 84% were rated as sufficient or exceptional. Two OMP questions: (I) "What was the most important thing you learned today?", and (II) "What questions remain unanswered?" were answered by the medical students. "What was the most important thing you learned today?" was answered by 78% (n=393) of the medical students with a profound statement. When asked "What questions remain unanswered?", 85% (n=429) of the medical students stated that nothing was left unanswered. All the answers included 154 positive and 28 negative comments on the lecture.

Conclusions: The study results indicate that medical students saw great potential in the use of MCs in medical teaching in terms of addressing challenging topics and reflecting on them deeply. This kind of blended learning (a form of learning in which the advantages of face-to-face events and e-learning are combined) successfully showed that medical students can gain a deeper understanding of MH and be inspired through the use of MCs.
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http://dx.doi.org/10.21037/apm-20-261DOI Listing
July 2020

[A German version of the Palliative Performance Scale (PPS) as a supportive structure to assess survival in palliative patients].

Wien Med Wochenschr 2019 Nov 14;169(15-16):387-393. Epub 2019 Nov 14.

Klinische Abteilung für Palliativmedizin, Medizinische Universität Wien, Wien, Österreich.

The original English version of the palliative performance scale (PPS) has been used for two decades to describe the functional status of palliative patients. Based on clinical parameters PPS helps to estimate the survival time of palliative patients: the higher the functional status the longer the survival. This is interesting for patients, their family caregivers and health care professionals in order to plan for care. Until now there has not been published an official German version of the PPS.The functional status via a German version of the PPS of 394 patients of a palliative consulting team and their survival times were analyzed. Kaplan-Meier-curves were drawn and tested for differences. The hypothesis was tested if functional status using the German version of the PPS and survival are correlated. In this population differences in survival could clearly be shown for any category of PPS.This German version of the PPS is a useful and possible tool to estimate survival time of palliative patients using just clinical information.
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http://dx.doi.org/10.1007/s10354-019-00714-4DOI Listing
November 2019

Telemedically augmented palliative care : Empowerment for patients with advanced cancer and their family caregivers.

Wien Klin Wochenschr 2019 Dec 30;131(23-24):620-626. Epub 2019 Oct 30.

Department of Dermatology, Medical University of Vienna, Vienna, Austria.

Background: Studies have shown that initiating early palliative care of patients with end-stage cancer can improve their quality of life and decrease symptoms of depression. The challenge is to find an effective way to care for these patients while minimizing the burden on healthcare resources. Telemedicine can play a vital role in solving this problem.

Methods: A user-friendly telemedical device enabling patients encountering medical problems to send a direct request to a palliative care team was developed. A controlled feasibility study was conducted by assigning 15 patients with advanced cancer and their family caregivers to receive either standard palliative care or telemedically augmented palliative care. Th quality of life (QoL) was assessed using standardized validated questionnaires as well as frequency and duration of hospital admissions and user satisfaction. The primary goal of this study was to increase the QoL of patients and their family caregivers. The secondary goal of this study was to decrease the frequency and duration of hospital admissions.

Results: This study showed a good feasibility despite the low overall willingness to participate in a relatively "technical" trial. The hospital anxiety and depression scale (HADS) was significantly lower in the intervention group, suggesting an improved quality of life. Although a decrease in the number of hospital admissions could not be shown, the user satisfaction was very good.

Conclusion: Telemedicine could be a useful tool to enhance the general well-being of palliative oncology patients. Now that the feasibility of this approach has been confirmed, larger studies are needed to verify its positive impact on the QoL.
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http://dx.doi.org/10.1007/s00508-019-01562-3DOI Listing
December 2019

Retrospective qualitative pilot study incorporating patients' personal life aspects on admission to palliative care : What should we know about patients to give them the best possible care?

Wien Klin Wochenschr 2019 Nov 1;131(21-22):576-581. Epub 2019 Oct 1.

Clinical Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.

Background: This pilot study examined which of a patient's personal aspects should be taken into account in a hospital setting on admission to the palliative care unit (PCU) by asking patients the question "what should I know about you as a person to help me take the best care of you that I can?"

Methods: This retrospective study used qualitative methodology to thematically analyze answers from 14 patients admitted to the PCU of the Medical University of Vienna during July and August 2018. The question "what should I know about you as a person to help me take the best care of you that I can?" was asked on the day of admission, notes were taken during the interview and the patient's answers were written out immediately afterwards. Data were analyzed using NVivo 12.

Results: Results revealed four topics: characterization of one's personality, important activities, social bonding, and present and future concerns regarding the patient's illness. Data showed that this question enabled patients to describe themselves and what was important to them. This might result in an improved sense of self-esteem in patients and represents an opportunity for professionals to treat patients in a more individualized manner; however, patient reactions also revealed a reluctance to address certain personal issues within a medical context.

Conclusion: The study results provide insights into the benefits of paying more attention to personal life aspects of severely ill patients on admission to a PCU. Addressing individual aspects of patients' lives might improve the healthcare professional-patient relationship.
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http://dx.doi.org/10.1007/s00508-019-01552-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6851040PMC
November 2019

Patients' attitude and knowledge towards resuscitation and advance care planning at the palliative care unit.

Eur J Cancer Care (Engl) 2019 Sep 29;28(5):e13109. Epub 2019 May 29.

Clinical Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria.

Objective: There is a lack of information about patients' attitudes towards and knowledge of resuscitation and advance care planning (ACP) in the palliative care unit (PCU). The aims of this study were to examine (a) patients' attitudes towards and knowledge of the topic of resuscitation, (b) patients' level of education about their illness and (c) their concept of ACP.

Methods: This study used a qualitative methodology that involved semi-structured interviews with advanced cancer patients admitted to the PCU. Interviews were conducted during the first week after admission, recorded digitally and transcribed verbatim. Data were analysed through content analysis using NVivo 12.

Results: Eighteen interviews revealed the following themes: (a) ambivalence regarding preference for or refusal of resuscitation, (b) patient confidence concerning their level of education, (c) lack of information about ACP and (d) positive perception of the stay in the PCU. The data showed that a high percentage of PCU patients desired resuscitation even though education about their illness was mostly perceived as good. Many patients did not receive information about ACP. Patients perceived the stay in the PCU positively.

Conclusion: The study results reveal that there is lack of knowledge about ACP and resuscitation in patients in the PCU.
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http://dx.doi.org/10.1111/ecc.13109DOI Listing
September 2019

Migrate your mind: the role of palliative care in transcultural cancer treatment : A qualitative analysis.

Wien Klin Wochenschr 2019 May 17;131(9-10):191-199. Epub 2019 Apr 17.

Department of Psychiatry and Psychotherapy, University Hospital Tulln, Karl Landsteiner University of Health Sciences, Tulln, Austria.

Background: In increasingly multi-ethnic societies fostering cultural awareness and integration of immigrants is not only a political duty but also an obligation for social and healthcare systems. Importantly, cultural beliefs and needs strongly impact on the quality of life of cancer patients and may become even more crucial at the end of life. However, to date, ethnic and cultural aspects of palliative care are insufficiently researched.

Methods: This qualitative study at the Medical University of Vienna included 21 staff members from different disciplines in oncology and palliative care working with patients with various cultural backgrounds at the end of life. Semi-structured interviews were performed to gain insights into specific aspects of palliative care that are important in the clinical encounter with terminally ill cancer patients with migrant backgrounds and their relatives.

Results: Interviews revealed specific aspects of palliative care, which fell into four fundamental categories and were all perceived as beneficial in the clinical encounter with migrant clients: (A) structural and (B) personal conditions of the palliative care setting, (C) specific care and treatment intentions and (D) personnel requirements and attitudes.

Conclusion: This study revealed first insights into possibilities and prospects of transcultural palliative care for migrants and their relatives. The results might have important implications for the end of life care in this growing population.
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http://dx.doi.org/10.1007/s00508-019-1474-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6520309PMC
May 2019

Correlation of affective temperament and psychiatric symptoms in palliative care cancer patients.

Wien Klin Wochenschr 2018 Nov 22;130(21-22):653-658. Epub 2018 Oct 22.

Department for Psychoanalysis and Psychotherapy, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.

Background: Psychiatric symptoms are common in terminally ill patients. Studies linking temperamental traits and psychiatric disorders in patients suffering from advanced disease are rare. This study investigated the influence of temperament on depression and anxiety in palliative care cancer patients.

Methods: A total of 53 patients at the palliative care unit (PCU) of the Medical University of Vienna were enrolled in the study. Patients filled out the TEMPS-M and the brief PHQ-9 questionnaires to examine associations between temperament, psychiatric symptoms and sociodemographic parameters.

Results: Pain (67%), anorexia (58%), constipation (42%) and nausea/vomiting (40%) were the most prevalent self-reported symptoms. Self-reported symptoms of depression were less commonly reported (21.8%) than unveiled by the structured assessment by the PHQ-9 questionnaire: 26.4% (n = 14) showed mild symptoms of depression and 64.1% (n = 34) had a major depressive disorder (MDD) according to PHQ-9. The depressive and cyclothymic temperaments showed significant associations with depressive (both: p < 0.001) as well as symptoms of anxiety (p = 0.002; p = 0.036). Furthermore, the anxious temperament was significantly associated with symptoms of depression (p = 0.027).

Conclusions: Mood disorders are common in palliative care patients, as the majority of the patients were suffering from MDD. The depressive, cyclothymic and anxious temperaments were found to be correlated with depressive and anxious symptoms. A sensitization in this field might bring further improvements for the quality of life of palliative care patients and help to appropriately address psychiatric symptoms in palliative care.
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http://dx.doi.org/10.1007/s00508-018-1400-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6244865PMC
November 2018

Establishing end-of-life boards for palliative care of patients with advanced diseases.

Wien Klin Wochenschr 2018 Apr 23;130(7-8):259-263. Epub 2018 Feb 23.

Clinical Division of Palliative Care, Department of Medicine I and Comprehensive Cancer Center, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.

Background: Interdisciplinary tumor board decisions improve the quality of oncological therapies, while no such boards exist for end-of-life (EOL) decisions. The aim of this study was to assess the willingness of hemato-oncological and palliative care professionals to develop and participate in EOL boards. An aim of an EOL board would be to establish an interdisciplinary and comprehensive care for the remaining lifetime of patients suffering from advanced incurable diseases.

Study Design: Staff from the interdisciplinary teams of all hemato-oncological and palliative care wards in Vienna were invited to anonymously participate in an online survey.

Results: 309 professionals responded. 91% respondents reported a need to establish an EOL board, 63% expressed their willingness to actively participate in an EOL board, and 25% were indecisive. Regarding patient presence, 50% voted for an EOL board in the presence of the patients, and 36% voted for an EOL board in the absence of the patients. 95% had the opinion that an EOL board could improve patient care in the last phase of life. 64% stated that the development of an EOL board would be worthwhile, while 28% did not see enough resources available at their institutions. Regarding the desired type of documentation, 61% voted for a centrally available EOL decision, and 31% supported an in-house-based documentation. 94% voted for the availability of an information folder about EOL care.

Conclusion: The willingness of professionals to establish an EOL board was very high. Further steps should be taken to implement such boards to improve EOL care.
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http://dx.doi.org/10.1007/s00508-018-1323-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5916986PMC
April 2018

Vitamin "G"arden: a qualitative study exploring perception/s of horticultural therapy on a palliative care ward.

Support Care Cancer 2018 Jun 19;26(6):1799-1805. Epub 2017 Dec 19.

Division of Palliative Care, Department of Internal Medicine I, Comprehensive Cancer Center, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.

Purpose: In a palliative care setting, the preservation of quality of life is of particular importance. Horticultural therapy (HT) is reported as an excellent way to improve physical as well as psychological well-being, reduce levels of anxiety and depression, and promote social interaction. The use of horticultural interventions in palliative care has not yet been explored. The aim of this study was to explore the effects of HT in patients and team members on a palliative care ward.

Methods: This study was based on a qualitative methodology, comprising 20 semistructured interviews with 15 advanced cancer patients participating in HT and with 5 members of the palliative care team. Interviews were analyzed using NVivo 10 software based on thematic analysis.

Results: The results revealed the following themes: (1) well-being, (2) variation of clinical routine, (3) creation, and (4) building relationships. Patients experienced positive stimulation through HT, were distracted from daily clinical routines, enjoyed creative work, and were able to build relationships with other patients. HT was also welcomed by the members of the palliative care team. Thirty-six percent of the patients did not meet the inclusion criteria, and 45% could not participate in the second or third HT session.

Conclusions: Our study showed that the availability of HT was highly appreciated by the patients as well as by the palliative care team. Nevertheless, the dropout rate was high, and therefore, it might be more feasible to integrate green spaces into palliative care wards.
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http://dx.doi.org/10.1007/s00520-017-3978-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5919982PMC
June 2018

Fentanyl buccal tablet for breakthrough cancer pain in clinical practice: results of the non-interventional prospective study ErkentNIS.

Support Care Cancer 2018 02 28;26(2):491-497. Epub 2017 Aug 28.

Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.

Purpose: Several patients with advanced cancer suffer from breakthrough cancer pain (BTcP). BTcP is pain exacerbation despite opioid baseline therapy. Fentanyl buccal tablet (FBT) is a rapid-onset opioid for the treatment of BTcP. The aim of this study is to document the feasibility of FBT in patients with BTcP.

Methods: The study was performed in 64 centers. Basic pain score was rated on a numeric rating scale (NRS) before and after treatment. BTcP episodes, baseline opioid therapy, and FBT dose were rated as well as individual dose titration, findings on tolerability, patient satisfaction, and safety of the drug.

Results: Two hundred sixty-three patients were available for analysis. Patients rated a basic pain score of 6 (range 2-10) points on an NRS and described an average of 2 to 5 BTcP episodes per day. After titration of FBT, BTcP control was achieved within 5 min in 36%, within 10 min in 68%, and within 15 min in 95%. Basic pain score decreased to a mean NRS of 4 and BTcP episodes decreased to < 1 to 3 episodes per day. BTcP control, onset of action of FBT, potency of FBT, tolerability of FBT, and safety of FBT were rated as excellent or good by 89 to 99% of the patients. Adverse drug reactions were registered in 3%.

Conclusions: Treatment with FBT led to rapid pain relief and reductions in the number of BTcP episodes and patient satisfaction was rated as excellent or good.
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http://dx.doi.org/10.1007/s00520-017-3853-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5752740PMC
February 2018

Heart rate variability during treatment of breakthrough pain in patients with advanced cancer: a pilot study.

J Pain Res 2016 12;9:1215-1220. Epub 2016 Dec 12.

Clinical Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria.

Background: Decisions on the intensity of analgesic therapy and judgments regarding its efficacy are difficult at the end of life, when many patients are not fully conscious and pain is a very common symptom. In healthy individuals and in postoperative settings, nociception and subsequent pain relief have been shown to induce changes in the autonomic nervous system (ANS), which can be detected by measuring heart rate variability (HRV).

Objectives: The changes in the ANS were studied by measuring HRV during opioid therapy for cancer breakthrough pain (CBTP) in palliative-care patients with cancer and compared these changes with patient-reported pain levels on a numeric rating scale (NRS).

Patients And Methods: The study included ten patients with advanced cancer and baseline opioid therapy. In each patient, a 24-hour peak-to-peak HRV measurement with a sampling rate of 4,000 Hz was performed. High frequency (HF), low frequency (LF), total power, pNN50 (indicating parasympathetic activity), and log LF/HF were obtained in two intervals prior to therapy and in four intervals thereafter. Intensity of CBTP was recorded using a patient-reported NRS prior to therapy and 30 minutes afterward.

Results: CBTP occurred in seven patients (three males and four females; mean age: 62 ± 5.2 years) and was treated with opioids. A highly significant positive correlation was found between opioid-induced reduction in patient-reported pain intensity based on NRS and changes in log LF/HF ( > 0.700; < 0.05). Log LF/HF decreased in patients who had a reduction in pain of >2 points on the NRS but remained unchanged in the other patients.

Conclusion: Our data suggest that log LF/HF may be a useful surrogate marker for alleviation of CBTP in patients with advanced cancer and might allow detection of pain without active contribution from patients.
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http://dx.doi.org/10.2147/JPR.S120343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5161332PMC
December 2016

[Austrian guideline for palliative sedation therapy (long version) : Results of a Delphi process of the Austrian Palliative Society (OPG)].

Wien Med Wochenschr 2017 Feb 6;167(1-2):31-48. Epub 2016 Dec 6.

Universitätsklinik für Innere Medizin I, Klinische Abteilung für Palliativmedizin, Medizinische Universität Wien, 1090, Wien, Österreich.

Background: Palliative sedation therapy (PST) is an important and ethically accepted therapy in the care of selected palliative care patients with otherwise unbearable suffering from refractory distress. PST is increasingly used in end-of-life care. Austria does not have a standardized ethical guideline for this exceptional practice near end of life, but there is evidence that practice varies throughout the country.

Objective: The Austrian Palliative Society (OPG) nominated a multidisciplinary working group of 16 palliative care experts and ethicists who established the national guideline on the basis of recent review work with the aim to adhere to the Europeans Association of Palliative Care's (EAPC) framework on palliative sedation therapy respecting Austrians legal, structural and cultural background.

Methods: Consensus was achieved by a four-step sequential Delphi process. The Delphi-process was strictly orientated to the recently published EUROIMPACT-sedation-study-checklist and to the AGREE-2-tool. Additionally national stakeholders participated in the reflection of the results.

Results: As a result of a rigorous consensus process the long version of the Austrian National Palliative Sedation Guideline contains 112 statements within eleven domains and is supplemented by a philosophers excursus on suffering.

Conclusions: By establishing a national guideline for palliative sedation therapy using the Delphi technique for consensus and stakeholder involvement the Austrian Palliative Society aims to ensure nationwide good practice of palliative sedation therapy. Screening for the practicability and efficacy of this guideline will be a future task.
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http://dx.doi.org/10.1007/s10354-016-0533-3DOI Listing
February 2017

Critically ill patients with cancer: chances and limitations of intensive care medicine-a narrative review.

ESMO Open 2016 13;1(5):e000018. Epub 2016 Sep 13.

Department of Medicine I, Intensive Care Unit 13i2 , Medical University of Vienna , Vienna , Austria.

This narrative review deals with the challenge of defining adequate therapy goals and intensive care unit (ICU) admission criteria for critically ill patients with cancer. Several specific complications of critically ill patients with cancer require close collaborations of intensive care and cancer specialists. Intensivists require a basic understanding of the pathophysiology, diagnosis and therapy of common cancer-specific problems. Cancer specialists must be knowledgeable in preventing, detecting and treating imminent or manifest organ failures. In case of one or more organ dysfunctions, ICU admissions must be evaluated early. In order to properly define the therapy goals for critically ill patients with cancer, decision-makers must be aware of the short-term intensive care prognosis as well as the long-term oncological options and perspectives. Multidisciplinary teamwork is key when it comes down to decisions on ICU admission, planning of therapeutic aims, patient management in the ICU and tailored therapy limiting with smooth transition into a palliative care (PC) setting, whenever appropriate.
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http://dx.doi.org/10.1136/esmoopen-2015-000018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5070251PMC
September 2016

Palliative care units in lung cancer in the real-world setting: a single institution's experience and its implications.

Ann Palliat Med 2017 Jan 1;6(1):6-13. Epub 2016 Sep 1.

Clinical Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, 1090 Vienna, Austria.

Objective: Palliative care plays a crucial role in the overall management of patients with advanced lung cancer and was shown to lead to clinically meaningful improvement in quality of life, less aggressive endof-life care, and potentially prolonged survival. Here we summarize our single institution experience on palliative care in patients with lung cancer.

Methods: The data of patients with lung cancer treated at the palliative care unit of the Medical University of Vienna between June 2010 and March 2013 were retrospectively reviewed. Patient characteristics, reasons for admissions, treatment as well as interventions during hospitalization, and clinical outcomes were determined.

Results: The study enrolled 91 lung cancer patients, who represented 19.8% of the 460 patients admitted to the palliative care unit. They had the following clinical characteristics: 39% females, 61% males; median age 62 years; median Karnofsky performance status 50%, 92% metastatic disease, 74% non-small cell lung cancer (NSCLC), 19% small-cell lung cancer (SCLC), 7% neuroendocrine carcinomas of the lung. Primary reasons for admission were deterioration of performance status in 40%, uncontrolled cancer-related pain in 38%, dyspnea in 13%, and psychosocial factors in 8% of the patients. Median duration of hospitalization was 16 days (range, 1-101 days). Improvement or stabilisation of tumor-related symptoms was achieved in 25% of the patients. Seventy-five percent of all patients died during their first admission. Their median survival from primary diagnosis until death was 16 months (95% confidence interval, 13.7-18.3 months).

Conclusions: Patients with lung cancer admitted to the palliative care unit had late-stage disease. In order to provide early palliative care, the management of lung cancer patients should guarantee access to ambulatory care, inpatient care and home care as well as cooperation and communication between oncologists and palliative care physicians.
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http://dx.doi.org/10.21037/apm.2016.08.06DOI Listing
January 2017

Pushing boundaries-culture-sensitive care in oncology and palliative care: a qualitative study.

Psychooncology 2017 06 12;26(6):763-769. Epub 2016 Aug 12.

Clinical Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria.

Objective: In increasingly globalized societies, patient-centered cancer care requires culture-sensitive approaches in order to ensure patients well-being. While migrant patients' needs are frequently reported in the literature, staff members' perception of work with migrant patients, associated challenges, or individual work approaches are largely unknown. This study addresses this research gap through qualitative exploration of experiences of multicultural health care professionals in supportive oncology and palliative care, working with patients from different cultural backgrounds. This study aims to understand staff experience of the impact of culture on cancer care.

Methods: This study was conducted at the Medical University of Vienna, including staff from different settings of oncology and palliative care, in different professional positions, and with a range of individual migration backgrounds. Semistructured interviews were conducted with 21 staff members working with patients from different cultural backgrounds. Interviews explored views on the impact of culture on care were audio-taped, transcribed, and analyzed using a rigorous method of thematic analysis, enhanced with grounded theory techniques.

Results: Interviews revealed 4 key topics: culture-specific differences, assumed reasons for differences, consequences of multicultural care, and tools for culture-sensitive care. Strategies to better deal with migrant patients and their families were suggested to improve work satisfaction amongst staff.

Conclusions: This study identifies relevant staff challenges in work with migrant patients. Concrete suggestions for improvement include measures on an organizational level, team level, and personal tools. The suggested measures are applicable to improve work satisfaction and culture-sensitive care not only in cancer care but also in other areas of medicine.
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http://dx.doi.org/10.1002/pon.4217DOI Listing
June 2017

What Makes a Good Palliative Care Physician? A Qualitative Study about the Patient's Expectations and Needs when Being Admitted to a Palliative Care Unit.

PLoS One 2016 7;11(7):e0158830. Epub 2016 Jul 7.

Department of Internal Medicine I, Division of Palliative Care, Medical University of Vienna, Vienna, Austria.

Objective: The aims of the study were to examine a) patients' knowledge of palliative care, b) patients' expectations and needs when being admitted to a palliative care unit, and c) patient's concept of a good palliative care physician.

Methods: The study was based on a qualitative methodology, comprising 32 semistructured interviews with advanced cancer patients admitted to the palliative care unit of the Medical University of Vienna. Interviews were conducted with 20 patients during the first three days after admission to the unit and after one week, recorded digitally, and transcribed verbatim. Data were analyzed using NVivo 10 software, based on thematic analysis enhanced with grounded theory techniques.

Results: The results revealed four themes: (1) information about palliative care, (2) supportive care needs, (3) being treated in a palliative care unit, and (4) qualities required of palliative care physicians. The data showed that patients lack information about palliative care, that help in social concerns plays a central role in palliative care, and attentiveness as well as symptom management are important to patients. Patients desire a personal patient-physician relationship. The qualities of a good palliative care physician were honesty, the ability to listen, taking time, being experienced in their field, speaking the patient's language, being human, and being gentle. Patients experienced relief when being treated in a palliative care unit, perceived their care as an interdisciplinary activity, and felt that their burdensome symptoms were being attended to with emotional care. Negative perceptions included the overtly intense treatment.

Conclusions: The results of the present study offer an insight into what patients expect from palliative care teams. Being aware of patient's needs will enable medical teams to improve professional and individualized care.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0158830PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4936709PMC
July 2017

Sedation at the end of life - a nation-wide study in palliative care units in Austria.

BMC Palliat Care 2016 May 14;15:50. Epub 2016 May 14.

Clinical Division of Palliative Care, Department for Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.

Background: Sedation is used to an increasing extent in end-of-life care. Definitions and indications in this field are based on expert opinions and case series. Little is known about this practice at palliative care units in Austria.

Methods: Patients who died in Austrian palliative care units between June 2012 and June 2013 were identified. A predefined set of baseline characteristics and information on sedation during the last two weeks before death were obtained by reviewing the patients' charts.

Results: The data of 2414 patients from 23 palliative care units were available for analysis. Five hundred two (21 %) patients received sedation in the last two weeks preceding their death, 356 (71 %) received continuous sedation until death, and 119 (24 %) received intermittent sedation. The median duration of sedation was 48 h (IQR 10-72 h); 168 patients (34 %) were sedated for less than 24 h. Indications for sedation were delirium (51 %), existential distress (32 %), dyspnea (30 %), and pain (20 %). Midazolam was the most frequently used drug (79 %), followed by lorazepam (13 %), and haloperidol (10 %). Sedated patients were significantly younger (median age 67 years vs. 74 years, p ≤ 0.001, r = 0.22), suffered more often from an oncological disease (92 % vs. 82 %, p ≤ 0.001, φ = 0.107), and were hospitalized more frequently (94 % vs. 76 %, p ≤ 0.001, φ = 0.175). The median number of days between admission to a palliative care ward/mobile palliative care team and death did not differ significantly in sedated versus non-sedated patients (10 vs. 9 days; p = 0.491).

Conclusion: This study provides insights into the practice of end-of-life sedation in Austria. Critical appraisal of these data will serve as a starting point for the development of nation-wide guidelines for palliative sedation in Austria.
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http://dx.doi.org/10.1186/s12904-016-0121-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4868021PMC
May 2016

Walking the line. Palliative sedation for existential distress: still a controversial issue?

Wien Med Wochenschr 2015 Dec 1;165(23-24):487-90. Epub 2015 Dec 1.

Clinical Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.

Adequate symptom relief is a central aspect of medical care of all patients especially in those with an incurable disease. However, as an illness progresses and the end of life approaches, physical or psychoexistential symptoms may remain uncontrollable requiring palliative sedation. Although palliative sedation has become an increasingly implemented practice in the care of terminally ill patients, sedation in the management of refractory psychological symptoms and existential distress is still a controversial issue and much debated. This case report presents a patient who received palliative sedation for the treatment of existential distress and discusses considerations that may arise from such a therapeutic approach.
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http://dx.doi.org/10.1007/s10354-015-0402-5DOI Listing
December 2015

Polypharmacy in the terminal stage of cancer.

Support Care Cancer 2016 May 5;24(5):2067-2074. Epub 2015 Nov 5.

Unit of Palliative Care, Department of Internal Medicine I, University Hospital of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria.

Purpose: This study aims to determine the numbers of patients with advanced cancer receiving polypharmacy at the end of their lives and analyze differences in drug prescription at a general oncology ward and a dedicated palliative care ward.

Methods: A retrospective single-center cohort study at a university hospital with a large cancer center was conducted. The charts of 100 patients who had died because of advanced cancer were reviewed; data concerning sociodemographic variables and medications were collected at four predefined time points (9, 6, 3, 0 days before death).

Results: Nine days before death, polypharmacy was registered in 95 % of patients; they had prescriptions for 11 (9-13) different medications per day (median, IQR). Although this number dropped significantly, on the last day as many as 61 % of the patients were still taking more than 4 drugs (median 6.5, IQR 4-9). No significant difference was noted between the oncology ward and the palliative care ward. Polypharmacy was largely dependent on the patients' ECOG performance status as well as the type of ward, the number of days before death, and age. It was not influenced by gender, the duration of hospital stays, and the devices facilitating drug administration. The medications fulfilled the requirements of palliative care in the majority of patients; 90 % received treatment for pain and anxiety. Patients treated at the palliative ward received more opioids and psychoactive drugs while those at the oncology ward received more anti-cancer drugs and fluids.

Conclusions: Polypharmacy still is a problem in the large majority of patients with terminal cancer. Further studies should be focused on the patients' quality of life, drug interactions, and adverse events.
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http://dx.doi.org/10.1007/s00520-015-3007-zDOI Listing
May 2016

Gender differences in caregiver burden and its determinants in family members of terminally ill cancer patients.

Psychooncology 2016 Jul 18;25(7):808-14. Epub 2015 Oct 18.

Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria.

Objective: Female family caregivers consistently report higher levels of stress and burden compared to male caregivers. Explanations for the apparently higher psychological vulnerability of female caregivers are largely missing to date. This study assesses the correlates and determinants of caregiver burden in family caregivers of advanced cancer patients with a specific focus on gender differences.

Methods: Three hundred and eight self-identified main informal caregivers of advanced cancer patients were cross-sectionally assessed using structured questionnaires for caregiver burden and hypothesised determinants of burden, including sociodemographic characteristics, caring arrangements, support needs, hope and coping style. Gender differences and predictors of burden were assessed using t-tests, chi-squared tests and univariate linear regression. Significant univariate predictors were entered in an analysis of covariance separately for men and women.

Results: Burden was significantly higher in women. Hope was the most significant protective factor against burden in both genders, together with perceived fulfilment of support needs. Only in women emotion-oriented coping and being in employment while caring were significantly predictive of higher burden in the multivariate analysis. The model explained 36% of the variance in burden in men and 29% in women.

Conclusion: Psychological support interventions for family caregivers should take gender-specific risk factors into account. Interventions focusing on keeping up hope while caring for a terminally ill family member may be a valuable addition to palliative services to improve support for family carers. Women may benefit from interventions that address adaptive coping and strategies to deal with the dual demands of employment and caring. Copyright © 2015 John Wiley & Sons, Ltd. Copyright © 2015 John Wiley & Sons, Ltd.
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http://dx.doi.org/10.1002/pon.4005DOI Listing
July 2016

Psyche at the end of life: Psychiatric symptoms are prevalent in patients admitted to a palliative care unit.

Palliat Support Care 2016 06 8;14(3):250-8. Epub 2015 Oct 8.

Department of Psychiatry and Psychotherapy,Medical University of Vienna,Vienna,Austria.

Objective: Our aim was to evaluate the frequency and treatment of psychiatric symptoms in patients at palliative care units (PCUs).

Method: Patients admitted to one of five participating PCUs in Austria were included. The short version of the Patient Health Questionnaire (PHQ-D) was used to evaluate their mental health status. Pain intensity was rated on a numeric rating scale (NRS) from 0 to 10 by patients and physicians. Patients with a previously diagnosed psychiatric disorder were compared to those without or with newly diagnosed psychiatric symptoms, based on PHQ-D results. Pain and psychopharmacological medication were assessed. Opioid doses were converted into oral morphine equivalents (OMEs).

Results: Some 68 patients were included. Previously undetected psychiatric symptoms were identified in 38% (26 of 68), preexisting psychiatric comorbidities were evident in 25% (17), and no psychiatric symptoms were observed in 37% (25). Patients with a preexisting psychiatric comorbidity received antidepressants and benzodiazepines significantly more often than patients without or with previously undetected psychiatric symptoms (p < 0.001). Patient and physician median NRS ratings of pain intensity correlated significantly (p = 0.001). Median NRS rating showed no significant difference between patients with preexisting, previously undetected, or without psychiatric symptoms. OMEs did not differ significantly between preexisting, without, or previously undetected psychiatric symptoms. Patients with undetected and preexisting psychiatric comorbidities had a greater impairment in their activities of daily living than patients without psychiatric symptoms (p = 0.003).

Significance Of Results: Undetected psychiatric comorbidities are common in patients receiving palliative care. Screening for psychiatric symptoms should be integrated into standard palliative care to optimize treatment and reduce the psychosocial burden of the disease.
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http://dx.doi.org/10.1017/S1478951515000899DOI Listing
June 2016

War and peace? The oncologic and the palliative care perspective on personalized cancer treatment in a patient with advanced cancer.

Wien Klin Wochenschr 2015 Aug 19;127(15-16):635-8. Epub 2015 May 19.

Clinical Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria,

Personalized cancer treatment utilizing targeted therapies in a tailored approach is based on tumor and/or patient-specific molecular profiles. Recent clinical trials continue to look for new potential targets in heavily pretreated patients or rare disease entities. Careful selection of patients who may derive benefit from such therapies constitutes a challenge. This case report presents an experimental personalized cancer treatment in an advanced cancer patient and provides a list of issues for discussion: How can we combine treatment goals and simultaneously meet the individual needs in advanced cancer reconciling both perspectives: oncology and palliative care?
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http://dx.doi.org/10.1007/s00508-015-0803-xDOI Listing
August 2015

Predicting discharge of palliative care inpatients by measuring their heart rate variability.

Ann Palliat Med 2014 Oct;3(4):244-9

Clinical Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090 Vienna, Austria.

Objectives: Home discharge after hospital admission to an inpatient palliative care unit (PCU) is a major challenge. Dysfunction of the autonomic nervous system is commonly observed in patients with advanced cancer in this setting. The aim of this prospective observational study was to determine whether the measurement of heart rate variability (HRV) by assessing parameters of the autonomic nervous system on a 24-h-ECG at the time of admission to the PCU was correlated with the likelihood of discharge.

Methods: Sixty hospitalized patients with advanced cancer of distinct origin, admitted to a PCU, were enrolled consecutively. The Karnofsky performance status scale (KPS) and the palliative performance scale (PPS) were obtained. HRV was measured over one day (20-24 hours) using a portable five-point ECG. The aim of the study was to compare HRV measurements in patients who could be discharged and those who died. The association of these variables with home discharge or death at the PCU was calculated.

Results: Discharge was achieved in 45% of patients while 55% of patients died. Median KPS and median PPS on admission were significantly higher in discharged patients than in those who died (P=0.001). Patients who were discharged tended to have a higher HRV, although the difference was not significant.

Conclusions: KPS and PPS were significant predictors of the likelihood of discharge while HRV did not predict discharge.
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http://dx.doi.org/10.3978/j.issn.2224-5820.2014.08.01DOI Listing
October 2014

Information preferences regarding cure rates and prognosis of Austrian patients with advanced lung cancer.

Strahlenther Onkol 2015 Jul 18;191(7):549-56. Epub 2015 Feb 18.

Department of Radiation Oncology, Comprehensive Cancer Center, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.

Introduction: Due to concerns about patients' wellbeing, open end-of-life communication is associated with reservation. Furthermore, sociocultural differences must be considered. The objective of this pilot study was therefore to investigate the information preferences of Austrian patients regarding cure rates and prognosis.

Patients And Methods: The information preferences of 50 advanced lung cancer patients were assessed at their first visit to the Department of Radiation Oncology, Medical University of Vienna. Preferences in terms of content (cure rates and/or prognosis) and depth of the information (additional quantitative estimates) were addressed. After the individually adapted medical consultation, patients' satisfaction with the consultation and the emotional responses to the information were evaluated.

Results: The majority of patients (76 %) requested information about cure rates and/or prognosis; nearly half of these (47 %) wanted additional quantitative estimates. Neither sociodemographic variables, disease characteristics, nor time since diagnosis had an impact on the information preferences. The individually adapted medical information showed no overall negative influence on the emotional responses; only patients receiving prognostic information had significantly higher distress scores after the consultation. High satisfaction with the individually adapted medical consultation was reported by 92 % of patients.

Conclusion: Austrian physicians may offer end-of-life communication and directly ask patients about their information preferences, since patients seem able to decide whether or not prognostic information would overwhelm their emotional capacity and therefore to accept or reject the invitation. The disclosure of cure rates and/or prognosis with or without quantitative estimates-according to the patients' preferences-shows overall no negative impact on emotional reactions. The individually adapted consultation results in high patient satisfaction. Nevertheless, prognostic information may lead to higher distress.
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http://dx.doi.org/10.1007/s00066-015-0816-4DOI Listing
July 2015

Coming and going: predicting the discharge of cancer patients admitted to a palliative care unit: easier than thought?

Support Care Cancer 2015 Aug 11;23(8):2335-9. Epub 2015 Jan 11.

Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Waehringer Guertel 18-20, A-1090, Vienna, Austria,

Purpose: Discharging a patient admitted to an inpatient palliative care unit (PCU) is a major challenge. A predictor of the feasibility of home discharge at the time of admission would be very useful. We tried to identify such predictors in a prospective observational study.

Methods: Sixty patients with advanced cancer admitted to a PCU were enrolled. Sociodemographic data were recorded and a panel of laboratory tests performed. The Karnofsky performance status scale (KPS) and the palliative performance scale (PPS) were determined. A palliative care physician and nurse independently predicted whether the patient would die at the ward. The association of these variables with home discharge or death at the PCU was determined.

Results: Sixty patients (26 men and 34 women) with advanced cancer were included in the study. Discharge was achieved in 45 % of patients, while 55 % of patients died at the PCU. The median stay of discharged patients was 15.2 days, and the median stay of deceased patients 13.6 days. Median KPS and PPS on admission was 56.2 % for the entire group and significantly higher for discharged patients (60.7 %) compared to deceased patients (52.4 %). Median BMI on admission was 22.8 in the entire group and was similar in discharged and deceased patients. No correlation was found between a panel of sociodemographic variables and laboratory tests with regard to discharge or death. In a binary logistic regression model, the probability of discharge as estimated by the nurse/physician and the KPS and PPS were highly significant (p = 0.008).

Conclusion: Estimation by a nurse and a physician were highly significant predictors of the likelihood of discharge and remained significant in a multivariate logistic regression model including KPS and PPS. Other variables, such as a panel of laboratory tests or sociodemographic variables, were not associated with discharge or death.
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http://dx.doi.org/10.1007/s00520-015-2601-4DOI Listing
August 2015

[Consensus statement: Stroke prevention in nonvalvular atrial fibrillation in special consideration of the new direct oral anticoagulants].

Wien Klin Wochenschr 2014 Dec 3;126(23-24):792-808. Epub 2014 Oct 3.

Klin. Abt. für Hämatologie u. Hämostaseologie, Univ.-Klin. f. Innere Medizin I, MedUni Wien, Währinger Gürtel 18-20, 1090, Wien, Österreich,

The introduction of new direct oral anticoagulants has changed the treatment of nonvalvular atrial fibrillation. However, these changes are not yet fully reflected in current guidelines.This consensus statement, endorsed by six Austrian medical societies, provides guidance to current prophylactic approaches of thromboembolic events in nonvalvular atrial fibrillation on the basis of current evidence and published guidelines. Furthermore, some special subjects are treated, like changes in laboratory parameters and their interpretation under treatment with direct oral anticoagulants, treatment of bleedings, approach to operations, cardioversion and ablation, and specific neurological aspects. For a CHA2DS2-VASc-Score of ≥ 2, anticoagulation is recommended with a high level of evidence (1A). At the end of the consensus statement, recommendations for a number of specific patient subgroups can be found, in order to help treating physicians to arrive at appropriate therapeutic decisions.
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http://dx.doi.org/10.1007/s00508-014-0586-5DOI Listing
December 2014

Validation of the Family Inventory of Needs (FIN) for family caregivers in palliative care.

Palliat Support Care 2015 Jun 20;13(3):485-91. Epub 2014 May 20.

Division of Social Psychiatry,Department of Psychiatry and Psychotherapy,Medical University of Vienna.

Objective: Caregivers of cancer patients are faced with significant demands that can seriously impact their physical and mental health. It is important for healthcare professionals to be aware of caregivers' support needs in order for these to be adequately addressed. Our study develops a German version of the Family Inventory of Needs (FIN) and provides a comprehensive evaluation of its acceptability and psychometric properties.

Method: Cross-sectional data from 308 participants were taken from the baseline assessment of an ongoing prospective study. Retests were completed by 46 participants approximately one week after baseline. Informal caregivers of terminally ill cancer patients were recruited from three hospitals in Vienna. Questionnaires for hope (IHS), traumatic stress (IES-R), and depression and anxiety (HADS) were employed together with the translated FIN to assess concurrent and discriminant validity.

Results: The internal consistency of FIN-Importance had a Cronbach's α of 0.94, and that for FIN-Fulfillment was α = 0.96. Retest reliability for FIN-Importance was r = 0.97, while that for FIN-Fulfillment could not be calculated due to missing responses to this subscale. Concurrent and discriminant validity tests for the scale and the discriminative power of items were adequate. However, missing responses may limit the feasibility of using this scale in research settings. We identified six questions that could be excluded from the scale in order to increase its acceptability and further improve its psychometric properties.

Significance Of Results: Our results suggest that the FIN is suitable for clinical settings. For use in research, we suggest four adaptations to increase the scale's acceptability and psychometric properties. The FIN can be a valuable tool for informing the emotional, physical, and psychological support provided to family carers of people who are terminally ill with cancer.
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http://dx.doi.org/10.1017/S1478951514000261DOI Listing
June 2015

Validation of the "Quality of Life in Life-Threatening Illness--Family Carer Version" (QOLLTI-F) in German-speaking carers of advanced cancer patients.

Support Care Cancer 2014 Oct 9;22(10):2783-91. Epub 2014 May 9.

Division of Palliative Care, Department of Internal Medicine I, Medical University of Vienna, Währingergürtel 18-20, 1090, Vienna, Austria.

Background: Palliative care is a multidisciplinary approach that focuses on the improvement of quality of life (QOL) of patients as well as their families. QOL research in palliative care has so far primarily focused on patients, but interest in the QOL of their relatives is increasing. For instruments measuring QOL in relatives, data on psychometric properties are often limited, and so far, none has been available in German.

Objective: This study translates and validates the "Quality of Life in Life-Threatening Illness-Family Carer Version" (QOLLTI-F) in German-speaking carers of advanced cancer patients.

Methods: The QOLLTI-F was translated from English into German according to the World Health Organisation's recommendations and validated in informal caregivers of terminally ill cancer patients of three Viennese hospitals. Hope was measured to assess concurrent validity; traumatic stress, anxiety, depression and subjective burden were measured to assess discriminant validity. Internal consistency, test-retest reliability and discriminative power were established. The scale's factor structure was explored using a set of factor analyses.

Results: Of the 308 caregivers participating in the study, 42 completed the QOLLTI-F retest after a mean of 5 days. The internal consistency was α = 0.85 for the overall scale, Pearson correlation between test and retest lay at r = 0.92. As expected, a significant positive correlation was found with hope (r = 0.40) and significant negative correlations with traumatic stress (r = -0.41), depression (r = -0.51), anxiety (r = -0.52) and overall subjective burden (r = -0.55). The original seven-factor structure was not reproduced, but the scale showed a stable four-factor structure with factors capturing (1) feelings about carers' own life, (2) professional care, (3) interaction with the patient and others and (3) carers' outlook on life.

Conclusion: This study provides a sound translation and validation of the first QOL assessment tool for caregivers of palliative care patients in German. It also adds to the knowledge on the scale's psychometric properties, which prove to be highly satisfactory. The QOLLTI-F may serve as an outcome measure in palliative care practice, clinical trials and epidemiological research.
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http://dx.doi.org/10.1007/s00520-014-2272-6DOI Listing
October 2014

Decanucleotide insertion polymorphism of F7 significantly influences the risk of thrombosis in patients with essential thrombocythemia.

Eur J Haematol 2014 Aug 23;93(2):103-11. Epub 2014 Apr 23.

Division of Hematology and Blood Coagulation, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria.

Objective: There is strong evidence that certain thrombophilic single nucleotide polymorphisms (SNPs) account for an increased risk of thrombosis. The additive impact of inherited thrombotic risk factors to a certain disease- immanent thrombotic risk is vastly unknown. Therefore, we aimed to investigate the influence of three novel, preselected SNPs on the risk of thrombosis in patients diagnosed with myeloproliferative neoplasm (MPN).

Method: In 167 patients with a diagnosis of essential thrombocythemia (ET) or prefibrotic primary myelofibrosis (PMF) thrombophilic SNPs in the genes of factor VII (F7), nitric oxide synthase 3 (NOS3) and FcɣRIIa (FCGR2A) were determined. Subsequently, the polymorphic variants were correlated with the incidence of major thrombosis after diagnosis.

Results: Decanucleotide insertion polymorphism of F7 emerged as an independent, significant risk factor for total thrombosis and arterial thrombosis in particular in the whole group of patients (P = 0.0007) as well as in the separate analysis of patients with ET (P = 0.0002).

Conclusion: Our results illustrate that the risk of thrombosis in MPN is significantly multiplied by inherited thrombophilic SNPs. This result points to the importance of a combined consideration of the inherited and the acquired hypercoagulable state in patients with MPN. Larger studies are needed to confirm and extend these important findings.
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http://dx.doi.org/10.1111/ejh.12307DOI Listing
August 2014

[Periprocedual management of vitamin K antagonist's with low molecular weight heparins during invasive procedures--Consensus of experts].

Wien Klin Wochenschr 2013 Jul;125(13-14):412-20

AKH Wien, Univ.-Klinik für Innere Medizin I, Währinger Gürtel 18–20, 1090 Wien, Österreich.

Interruption of an ongoing therapy with vitamin K antagonists (VKAs) is necessary in almost all patients undergoing major surgery. The purpose of the following expert recommendations is to provide easy to use guidance for the periprocedural management of patients on VKAs based on current evidence from the literature. Management of anticoagulation during the time of interruption of VKAs is based on balancing the thromboembolic (TE) risk of underlying conditions against the bleeding risk of the surgical procedure. VKAs should be stopped 3–7days prior to surgery. Low molecular weight heparin (LMWH) is used to cover (“bridge”) the progressive pre-operative loss of anticoagulation and the slow post-operative onset of anticoagulant activity of VKAs. Patients with high risk of TE should receive a therapeutic dose of LMWH, patients with a moderate risk of TE should receive half of this dose. Patients with a low risk of TE do not need bridging therapy with LMWH. In case of an uneventful postoperative course, patients with a therapeutic pre-operative dose should be treated post-operatively with the same dose, starting on day 4 in case of major surgery and on day 2 in case of minor procedures. Patients with a half-therapeutic preoperative dose should be treated post-operatively with the same dose, starting on day 3 in case of major surgery and on day 1 in case of minor procedures. Therapy with VKAs should be re-instituted on the second post-operative day based on the preoperative dosage. Procedure-related post-operative thromboprophylaxis should be given irrespective of these recommendations on days without “bridging” anticoagulation.
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http://dx.doi.org/10.1007/s00508-013-0390-7DOI Listing
July 2013