Research shows how females choose the 'right' sperm

Main Category: Biology / Biochemistry
Also Included In: Pregnancy / Obstetrics
Article Date: 20 Aug 2013 - 0:00 PDT Current ratings for:
Research shows how females choose the 'right' sperm

University of East Anglia scientists have revealed how females select the 'right' sperm to fertilize their eggs when faced with the risk of being fertilized by wrong sperm from a different species. Researchers investigated salmon and trout, which fertilize externally in river water. The two species occasionally hybridize in the wild, but since hybrid offspring become reproductive dead-ends, females of both species are under selection to avoid hybrid fertilizations, and instead promote external fertilization by their own species' sperm.

Findings published in the journal Evolution show that when eggs from each species are presented with either salmon or trout, they happily allow complete fertilization by either species' sperm. However, if eggs are given a simultaneous choice of both species' sperm, they clearly favour their own species' sperm.

Lead researcher Prof Matt Gage (pictured), from UEA's School of Biological Sciences, said: "The salmon-trout system is ideal for studying sperm-egg compatibilities because we are able to conduct controlled fertilization experiments and measure sperm behaviour under conditions to which the gametes are naturally adapted. Although we found almost 100% interfertility between salmon and trout sperm and eggs, when we mixed equal amounts of sperm from both species together, we found that sperm from their own species won 70 per cent of the fertilizations."

"Since we are conducting in vitro fertilizations without interference or control from males or females, this provides clear evidence that eggs favour the sperm of their own species, but only when given a choice."

The team then went on to investigate what mechanisms allow female eggs to encourage the right sperm to fertilize by examining two key components of reproduction in female fish - the egg, and the ovarian fluid that coats the egg. Ovarian fluid is a protein-rich solution that bathes the eggs and released at spawning - but little has been known about its function.

Prof Gage said: "We ran further sperm competition trials but this time we rinsed eggs of their ovarian fluid and then added back either their own fluid, or that from the other species. Remarkably, we found that the egg itself plays no significant role in promoting fertilization precedence by their own species' sperm. Instead, it is actually the ovarian fluid that controls which species' sperm wins the fertilizations, which was very unexpected. If we put salmon ovarian fluid onto salmon eggs, then salmon sperm win, but if we put trout ovarian fluid onto eggs from that same salmon female, trout sperm now win."

The researchers then used Video Tracking Analysis to analyse how salmon and trout sperm behave in ovarian fluid.

"We found that activating sperm in ovarian fluid makes them live about twice as long as in river water. Importantly, both species' sperm also switch from swimming in tight elliptical circles in river water, to swimming in straightened trajectories in ovarian fluid. This behaviour allows sperm to navigate towards the egg by following a chemical cue."

"So what we're seeing is that ovarian fluid gives a specific chemical signal to the sperm of its own species, causing changes in the way their tails beat, so that they swim in a straighter trajectory, and therefore guided more effectively towards the site of fertilization."

To establish that this was the mechanism which promoted fertilization precedence by their own species' sperm, the research team ran a final experiment in which they measured sperm migration across a membrane permeated with tiny pores mimicking the single entrance into the egg. They found that many more sperm swam through the membrane into their own ovarian fluid, compared with numbers crossing into the other species' ovarian fluid or water.

"These findings allow us to establish that females have indeed evolved mechanisms of 'cryptic choice' at the intimate level of the sperm and egg. The results also give us a valuable insight into why female salmon mate so promiscuously - typically being fertilized by eight, and up to 16, males in one nest. By promoting sperm competition, females provide their eggs with greater choice, allowing ovarian fluid to avoid potentially hybridizing sperm, and instead encourage fertilization by the right sperm."

'Cryptic Choice of Conspecific Sperm Controlled by the Impact of Ovarian Fluid on Sperm Swimming Behaviour' * is published by the journal Evolution.

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our biology / biochemistry section for the latest news on this subject.

The research was funded by the Natural Environment Research Council (NERC) and a collaboration between UEA, the Norwegian Institute for Nature Research, and the Institute of Zoology.

* CRYPTIC CHOICE OF CONSPECIFIC SPERM CONTROLLED BY THE IMPACT OF OVARIAN FLUID ON SPERM SWIMMING BEHAVIOR

Article first published online: 12 AUG 2013; DOI: 10.1111/evo.12208

University of East Anglia

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Spouse in pain? Love affects sleep, study shows

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Academic Journal
Main Category: Pain / Anesthetics
Also Included In: Sleep / Sleep Disorders / Insomnia;  Bones / Orthopedics
Article Date: 17 Aug 2013 - 0:00 PDT Current ratings for:
Spouse in pain? Love affects sleep, study shows

Spouses who have a close relationship share many things - material and non-material, highs and lows. And when one spouse experiences chronic pain, it can have a ripple effect for the other spouse, affecting sleep and even increasing risks for health problems, say researchers from Penn State University.

A study recently published in the journal PAIN analyzed relationships in which one spouse experienced chronic knee pain. The researchers said they chose knee pain because it oftentimes causes difficulties staying comfortable in bed at night for many patients.

As a result, the team was able to study the effects on the other spouse's slumber.

The researchers, led by Dr. Lynn Martire, had 138 knee osteoarthritis (OA) patients and their spouses complete interviews and 22-day diaries. The subjects were all at least 50 years of age, lived with their partners and were either in long-term relationships or married.

Results from the study showed that the greater a patient's knee pain was at the end of the day, the worse quality of sleep their spouse experienced that night.

By contrast, the researchers noticed that the quality of sleep the spouse experienced did not equate to greater pain for the patient the following day.

So it appears that spouses who have pain are not affected by their partner's lack of sleep, even though the reverse is true.

The effects that the patients' pain had on spousal sleep were not a result of their own disturbances in sleep, the researchers said.

Dr. Martire noted that "spouses whose sleep is compromised may be less able to respond empathically to patients' symptoms and need for support," potentially also putting them at risk for "physical and psychiatric problems."

The researchers predicted that closer relationships would yield stronger results, and they were correct. They found that, with spouses who had a closer relationship, patient pain resulted in "less refreshing sleep for spouses."

The family experts warn that a groggy morning may not be the only effect on the spouses.

Dr. Lynn Martire said:

"Compromised sleep caused by exposure to a loved one's suffering may be one pathway to spousal caregivers' increased risk for health problems, including cardiovascular disease.

Our findings suggest that assessing the extent to which partners are closely involved in each other's lives would help to identify spouses who are especially at risk for being affected by patient symptoms and in need of strategies for maintaining their own health and well-being."

Research published in the Journal of the American Geriatrics Society in 2010 found that people caring for a spouse with dementia were more likely to develop it themselves.

Other research in the same year, however, reported positive elements to caring for a loved one.

Written by Marie Ellis

Copyright: Medical News Today
Not to be reproduced without permission of Medical News Today Visit our pain / anesthetics section for the latest news on this subject.

The impact of daily arthritis pain on spouse sleep Lynn M. Martire, et al., PAIN, published online 15 August 2013.

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Expanded role of paramedics shows promise for closing California's health-care gaps

Main Category: Public Health
Article Date: 16 Aug 2013 - 2:00 PDT Current ratings for:
Expanded role of paramedics shows promise for closing California's health-care gaps

In a new report, the UC Davis Institute for Population Health Improvement (IPHI) recommends that the state launch pilot programs to test a new model of community-based health care that would expand the role of paramedics under certain circumstances.

In "Community Paramedicine: A Promising Model for Integrating Emergency and Primary Care," Kenneth W. Kizer, director of the IPHI and professor of emergency medicine in the UC Davis School of Medicine and Betty Irene Moore School of Nursing, and his colleagues explore a new model of community-based care in which paramedics, after undergoing additional training, would function outside of their usual emergency response and transport roles to facilitate more appropriate use of emergency departments and to increase access to primary care for medically underserved populations.

This feasibility study is the first of its kind in California and reflects the perspectives of stakeholders from nearly 40 different organizations, including emergency medical services (EMS) associations, health-care providers, health plans and payers.

"Expanding the role of paramedics is a very promising model of community-based care that uses existing health-care workers in new and innovative ways," said Kizer. "It is a model of care that several other states and countries have implemented to better leverage the skills of paramedics to meet specific community needs and to help ensure that emergency departments are more appropriately utilized."

Community paramedicine programs begin with a community health-needs assessment, during which local health-care service delivery gaps are identified. These programs then typically look at how locally developed collaborations among EMS and other health-care and social-service providers could fill the identified gaps in services.

The expanded roles of paramedics might include transporting patients with conditions not needing emergency care to care settings more appropriate than hospital emergency departments; releasing individuals at the scene of an emergency response rather than transporting them to hospital emergency departments if it is determined that emergency care is not needed; or helping frequent 9-1-1 callers access primary care or social services instead of emergency department care. The new roles of paramedics might also include making home visits to check on patients recently discharged from the hospital or emergency department, to check on individuals with certain types of chronic conditions, or even to provide immunizations or other disease prevention services.

Kizer notes that EMS data show that about a third of 9-1-1 medical emergency calls are not for true medical emergencies, but EMS providers are required by law to take all 9-1-1 patients to a hospital emergency department. In such cases, instead of transporting the person to a hospital emergency department, it might be more appropriate to take these persons to a primary care or mental health clinic or their doctor's office.

"Community paramedicine could be an important part of the solution to California's growing health-care access problem," Kizer said. "There already are not enough health-care workers in California, especially in rural and other medically underserved areas, and the situation is likely to get considerably worse in the next few years as a result of the Affordable Care Act expanding health-insurance coverage to many previously uninsured persons, as well as continuing population growth and increasing numbers of people having chronic diseases like diabetes."

The report recommends that 10 to 12 community paramedicine pilot or demonstration projects be launched to refine and evaluate details about the need for additional education and training, possible changes in the paramedic scope of practice, and how best to provide medical supervision of paramedics, among other things.

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our public health section for the latest news on this subject.

The report was commissioned by the California Healthcare Foundation and state Emergency Medical Services Authority, and was funded by the California HealthCare Foundation. It includes a history of EMS systems and paramedicine in California; an overview of the development of community paramedicine in other states and countries, as well as early efforts to establish community paramedicine programs in San Francisco and San Diego; a summary of current perspectives on community paramedicine based on interviews with stakeholders; and a discussion of legal and other barriers to implementing community paramedicine programs in California.

The complete report is available on the UC Davis Institute for Population Health Improvement website

UC Davis Health System

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US consumers don't understand health insurance, Carnegie Mellon research shows

Main Category: Health Insurance / Medical Insurance
Article Date: 03 Aug 2013 - 0:00 PDT Current ratings for:
US consumers don't understand health insurance, Carnegie Mellon research shows

This fall, as part of the 2010 Affordable Care Act (ACA), Americans will have a greater range of health care insurance options to choose from, including, for many, state-based plans. But will they make the right decisions? That's doubtful, according to a new study led by Carnegie Mellon University's George Loewenstein.

Previous research has shown that competition at the consumer level is only likely to result in reduced prices and improved quality when sufficient numbers of consumers make informed decisions. The study led by Loewenstein shows that consumers do not understand health insurance and therefore casts doubt on whether they will make the best decisions under the ACA.

Published in the Journal of Health Economics, the researchers report findings from two surveys of representative samples of Americans between the ages of 25 and 64 who have private health insurance and are the primary or shared decision maker for their own or their families' health care. Behavioral economists at the University of Pennsylvania, Stanford, Harvard and Yale universities and the University of Chicago, as well as professionals at a health insurance company participated in the research.

The first survey was designed, in part, to uncover how well the insurance holders understand four basic traditional health insurance concepts - deductible, copay, co-insurance and out-of-pocket maximum - as well as how well they believe they understand them. Analysis of responses revealed that while insured Americans felt confident about their own understanding of these concepts, their actual understanding was much lower; only 14 percent of all respondents accurately understood all four concepts.

The first survey also found that only 11 percent of respondents presented with a traditional insurance plan incorporating all four of these elements were able to compute the cost of a four-day hospital stay when given the information that should have enabled them to do so. Finally, the survey revealed that a simplified insurance plan that eliminated deductibles and copays - the two least well understood elements of insurance plan design - would appeal to consumers.

"It is strange, in my opinion, that the insurance market has evolved so, that so few individuals understand the fundamentals of the medical insurance plans they are insured under," said Loewenstein, the Herbert A. Simon University Professor of Economics and Psychology in CMU's Dietrich College of Humanities and Social Sciences. "Insurance plans incorporate all sorts of incentives designed to encourage customers to make specific types of decisions. What is the likelihood that they are going to respond to these incentives if they can't understand the most basic elements of plan design?"

Based on the finding that consumers had trouble understanding deductibles and co-insurance, the researchers then collaborated with the insurance professionals on the team to design a simplified insurance plan using only copays (no deductibles), which was later marketed to the insurer's customers. The second survey then compared the ability of respondents to compute costs under the simplified plan as compared with a traditional plan with similar copays. The survey also asked respondents to make hypothetical health care decisions based on the simplified and traditional insurance plans, such as whether to go to the emergency room or to an urgent care clinic with an earache. Half of the participants gave responses first using the traditional plan, then using the simplified plan, while the other half were exposed to the two plans in the reverse order. Finally, the second survey elicited respondents' preferences between the two plans. Both plans had the same premium.

Analysis of survey responses revealed that respondents were somewhat more likely to make lower cost choices, such as going to an urgent care clinic under the simplified plan, and were much better able to understand the cost ramifications of these decisions under the simplified plan. Examining consumer preferences, the researchers found that respondents were initially relatively indifferent between the two plans, but after attempting to compute costs of services under the two plans, their preferences shifted sharply in favor of the simplified plan.

"The ACA deals with the problem of consumer misunderstanding by requiring insurance companies to publish standardized and simplified information about insurance plans, including what consumers would pay for four basic services," noted lead author Loewenstein. "However, presenting simplified information about something that is inherently complex introduces a risk of 'smoothing over' real complexities. A better approach, in my view, would be to require insurance companies to offer truly simplified insurance products that consumers are capable of understanding."

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our health insurance / medical insurance section for the latest news on this subject.

In addition to Loewenstein, the research team included the University of Pennsylvania's Joelle Y. Friedman, Jonathan Kolstad and Kevin G. Volpp; Colchester Consulting Group's Barbara McGill; Stanford University's John Beshears; Yale University's James Choi; Harvard University's David Laibson and Brigitte Madrian; the University of Chicago's John List, and employees of the insurance company.

For more information, visit http://www.cmu.edu/dietrich/sds/people/faculty/george-loewenstein.html.

Carnegie Mellon University

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Southerners are less trusting, but people who trust are more likely to cooperate to save the environment, baylor study shows

Main Category: Water - Air Quality / Agriculture
Also Included In: Psychology / Psychiatry
Article Date: 03 Aug 2013 - 0:00 PDT Current ratings for:
Southerners are less trusting, but people who trust are more likely to cooperate to save the environment, baylor study shows

Southerners are generally not as trusting as people who live in other parts of the country, but trusting people are more likely to cooperate in recycling, buying green products and conserving water, a new Baylor University study on environmental protection shows.

"A lot of researchers have reported trust as kind of a cure-all for protecting the environment through cooperation. Southerners are just as willing, but less trusting," said lead author Kyle Irwin, Ph.D., an assistant professor in Baylor's College of Arts & Sciences.

"The question our study raised was that if trust isn't a catalyst for environmental cooperation for Southerners, what is?"

The study, published in The Sociological Quarterly, was based on analysis of a data sample of 650 respondents - 238 of them Southerners - from the 2010 General Social Survey, Irwin said. "The South" as defined by the U.S. Census Bureau includes 16 states (listed below) and Washington D.C.

Previous studies by other researchers have shown that trust is important in working together to protect the environment, but the study by Irwin and co-researcher Nick Berigan, Ph.D., a visiting assistant professor at East Tennessee State University, is the first to look at cultural factors, Irwin said.

"Southerners are relatively close-knit and interact within small and dense networks," he said. "Social spheres often overlap: People that work together may go to church together, attend sports events for their kids. This type of network often produces a lot of solidarity and trust within the 'in group,' but distrust toward outsiders."

Compared to Southerners, non-Southerners have a large number of weak and transient friendships. Social networks in the non-South are considered individualistic, and that promotes trust of people who might be considered outsiders, he said.

"There's been a slew of research on the relationship between trust and environmental protection," Irwin said. "The more trust people have, the more willing they are to make sacrifices to hold up their end to solve problems."

But Southerners' cooperation in pro-environment efforts does not hinge on trust as much as non-Southerners' cooperation does.

The new study measured trust with the question of "Generally speaking, would you say that most people can be trusted, or that you can't be too careful in dealing with people?" Among Southern respondents, 24.9 percent of respondents trusted others; 38.7 of non-Southern respondents did so.

The study shows that political views and education are associated with cooperation in the South, with Democrats more willing to make cuts in living standards and more educated people more willing to pay higher taxes to help protect the environment. Also in the South, confidence in the government was associated with greater willingness to pay higher taxes.

Irwin said that further study is needed to draw firm conclusions, but the research suggests that pro-environmental efforts in the South might target Republicans by assuring them that long-term benefits of conservation outweigh short-term costs and are consistent with their values, rather than mandated by those with liberal political views.

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our water - air quality / agriculture section for the latest news on this subject.

*States listed as Southern by the U.S. Census Bureau include Alabama, Arkansas, Delaware, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, South Carolina, Tennessee, Texas, Virginia and West Virginia. Washington, D.C. also is included.

Baylor University

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US consumers don't understand health insurance, Carnegie Mellon research shows

Main Category: Health Insurance / Medical Insurance
Article Date: 03 Aug 2013 - 0:00 PDT Current ratings for:
US consumers don't understand health insurance, Carnegie Mellon research shows

This fall, as part of the 2010 Affordable Care Act (ACA), Americans will have a greater range of health care insurance options to choose from, including, for many, state-based plans. But will they make the right decisions? That's doubtful, according to a new study led by Carnegie Mellon University's George Loewenstein.

Previous research has shown that competition at the consumer level is only likely to result in reduced prices and improved quality when sufficient numbers of consumers make informed decisions. The study led by Loewenstein shows that consumers do not understand health insurance and therefore casts doubt on whether they will make the best decisions under the ACA.

Published in the Journal of Health Economics, the researchers report findings from two surveys of representative samples of Americans between the ages of 25 and 64 who have private health insurance and are the primary or shared decision maker for their own or their families' health care. Behavioral economists at the University of Pennsylvania, Stanford, Harvard and Yale universities and the University of Chicago, as well as professionals at a health insurance company participated in the research.

The first survey was designed, in part, to uncover how well the insurance holders understand four basic traditional health insurance concepts - deductible, copay, co-insurance and out-of-pocket maximum - as well as how well they believe they understand them. Analysis of responses revealed that while insured Americans felt confident about their own understanding of these concepts, their actual understanding was much lower; only 14 percent of all respondents accurately understood all four concepts.

The first survey also found that only 11 percent of respondents presented with a traditional insurance plan incorporating all four of these elements were able to compute the cost of a four-day hospital stay when given the information that should have enabled them to do so. Finally, the survey revealed that a simplified insurance plan that eliminated deductibles and copays - the two least well understood elements of insurance plan design - would appeal to consumers.

"It is strange, in my opinion, that the insurance market has evolved so, that so few individuals understand the fundamentals of the medical insurance plans they are insured under," said Loewenstein, the Herbert A. Simon University Professor of Economics and Psychology in CMU's Dietrich College of Humanities and Social Sciences. "Insurance plans incorporate all sorts of incentives designed to encourage customers to make specific types of decisions. What is the likelihood that they are going to respond to these incentives if they can't understand the most basic elements of plan design?"

Based on the finding that consumers had trouble understanding deductibles and co-insurance, the researchers then collaborated with the insurance professionals on the team to design a simplified insurance plan using only copays (no deductibles), which was later marketed to the insurer's customers. The second survey then compared the ability of respondents to compute costs under the simplified plan as compared with a traditional plan with similar copays. The survey also asked respondents to make hypothetical health care decisions based on the simplified and traditional insurance plans, such as whether to go to the emergency room or to an urgent care clinic with an earache. Half of the participants gave responses first using the traditional plan, then using the simplified plan, while the other half were exposed to the two plans in the reverse order. Finally, the second survey elicited respondents' preferences between the two plans. Both plans had the same premium.

Analysis of survey responses revealed that respondents were somewhat more likely to make lower cost choices, such as going to an urgent care clinic under the simplified plan, and were much better able to understand the cost ramifications of these decisions under the simplified plan. Examining consumer preferences, the researchers found that respondents were initially relatively indifferent between the two plans, but after attempting to compute costs of services under the two plans, their preferences shifted sharply in favor of the simplified plan.

"The ACA deals with the problem of consumer misunderstanding by requiring insurance companies to publish standardized and simplified information about insurance plans, including what consumers would pay for four basic services," noted lead author Loewenstein. "However, presenting simplified information about something that is inherently complex introduces a risk of 'smoothing over' real complexities. A better approach, in my view, would be to require insurance companies to offer truly simplified insurance products that consumers are capable of understanding."

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our health insurance / medical insurance section for the latest news on this subject.

In addition to Loewenstein, the research team included the University of Pennsylvania's Joelle Y. Friedman, Jonathan Kolstad and Kevin G. Volpp; Colchester Consulting Group's Barbara McGill; Stanford University's John Beshears; Yale University's James Choi; Harvard University's David Laibson and Brigitte Madrian; the University of Chicago's John List, and employees of the insurance company.

For more information, visit http://www.cmu.edu/dietrich/sds/people/faculty/george-loewenstein.html.

Carnegie Mellon University

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Saliva from heavy cell phone users shows increased risk factors for cancer

Main Category: Cancer / Oncology
Also Included In: Public Health
Article Date: 31 Jul 2013 - 1:00 PDT Current ratings for:
Saliva from heavy cell phone users shows increased risk factors for cancer

Scientists have long been worried about the possible harmful effects of regular cellular phone use, but so far no study has managed to produce clear results. Currently, cell phones are classified as carcinogenic category 2b - potentially carcinogenic to humans - by the International Agency for Research on Cancer (IARC). A new Tel Aviv University study, though, may bring bad news.

To further explore the relationship between cancer rates and cell phone use, Dr. Yaniv Hamzany of Tel Aviv University's Sackler Faculty of Medicine and the Otolaryngology Head and Neck Surgery Department at the Rabin Medical Center, looked for clues in the saliva of cell phone users. Since the cell phone is placed close to the salivary gland when in use, he and his fellow researchers, including departmental colleagues Profs. Raphael Feinmesser, Thomas Shpitzer and Dr. Gideon Bahar and Prof. Rafi Nagler and Dr. Moshe Gavish of the Technion in Haifa, hypothesized that salivary content could reveal whether there was a connection to developing cancer.

Comparing heavy mobile phone users to non-users, they found that the saliva of heavy users showed indications of higher oxidative stress - a process that damages all aspects of a human cell, including DNA - through the development of toxic peroxide and free radicals. More importantly, it is considered a major risk factor for cancer.

The findings have been reported in the journal Antioxidants and Redox Signaling.

Putting stress on tissues and glands

For the study, the researchers examined the saliva content of 20 heavy-user patients, defined as speaking on their phones for a minimum of eight hours a month. Most participants speak much more, Dr. Hamzany says, as much as 30 to 40 hours a month. Their salivary content was compared to that of a control group, which consisted of deaf patients who either do not use a cell phone, or use the device exclusively for sending text messages and other non-verbal functions.

Compared to the control group, the heavy cell phone users had a significant increase in all salivary oxidative stress measurements studied.

"This suggests that there is considerable oxidative stress on the tissue and glands which are close to the cell phone when in use," he says. The damage caused by oxidative stress is linked to cellular and genetic mutations which cause the development of tumors.

Making the connection

This field of research reflects longstanding concerns about the impact of cell phone use, specifically the effects of radiofrequency non-ionizing electromagnetic radiation on human tissue located close to the ear, say the researchers. And although these results don't uncover a conclusive "cause and effect" relationship between cellular phone use and cancer, they add to the building evidence that cell phone use may be harmful in the long term, and point to a new direction for further research.

One potential avenue of future research would be to analyze a person's saliva prior to exposure to a cell phone, and then again after several intense minutes of exposure. This will allow researchers to see if there is an immediate response, such as a rise in molecules that indicate oxidative stress, Dr. Hamzany says.

Article adapted by Medical News Today from original press release. Click 'references' tab above for source.
Visit our cancer / oncology section for the latest news on this subject.

Yaniv Hamzany, Raphael Feinmesser, Thomas Shpitzer, Aviram Mizrachi, Ohad Hilly, Roy Hod, Gideon Bahar, Irina Otradnov, Moshe Gavish, and Rafael M. Nagler. Is Human Saliva an Indicator of the Adverse Health Effects of Using Mobile Phones? Antioxidants & Redox Signaling. February 20, 2013, 18(6): 622-627. doi:10.1089/ars.2012.4751

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Liverpool care pathway review shows challenges in palliative care

The Liverpool care pathway has been encouraged to avoid unnecessary interventions in the care of people who are dying. Photograph: Voisin/Phanie/Rex Features

The law of unintended consequences can be insidious. The Liverpool care pathway (LCP) has been encouraged over the last decade with the express objective of avoiding unnecessary interventions in the care of people who are clearly dying, and ensuring they achieve a good death. However, it should now be phased out and replaced by an individual end-of-life care plan, according to the findings of the independent review led by Lady Julia Neuberger.

Almost a decade ago, the House of Commons health select committee conducted an inquiry into palliative care and while it supported the take up of tools such as the Gold Standards Framework and the LCP, the committee cautioned "that there are significant challenges in raising the skills and awareness of all healthcare staff in palliative care." The findings of the independent review provide testimony to the continued failures of training around the LCP, with the result that far from providing a model of good practice in palliative care, the LCP too often leads to poor practice – "uncaring, rushed and ignorant".

This is a shocking indictment of the care of people in their final days of life, often very elderly people whose relatives were left with the impression that their life was no longer valued. Withholding food and drink has caused the greatest concern and distress with staff apparently on occasion refusing to allow liquids for people who were thirsty and dehydrated. The review is in no doubt that the failure to provide oral hydration and nutrition "when still possible and desired should be regarded as professional misconduct."

Poor communication with patients and relatives is at the root of many of the failures and criticisms of the LCP, and evidence to the review found significant numbers did not feel involved in discussions about the care plan, or were not given the chance to be involved. People are sometimes not told that a loved one is dying or what they can expect to happen.

Inappropriate use of opiate pain killers and tranquillisers was also the focus of criticism, particularly when this led to a patient becoming drowsy, and relatives left wondering if the use of drugs had hastened death.

The review has recommended that the LCP should be phased out, and this has been accepted by health minister Norman Lamb. However, it is vital not to abandon the core principles which underpin the model. The failure of the LCP has been in its application and poor support; the review found that when used appropriately "patients die a peaceful and dignified death", but that implementation is sometimes associated with poor care.

The clear thinking and pithy recommendations of this review will be welcomed, so too will the speed of response from government. It is clear that when the LCP is operated "by well trained, well-resourced and sensitive clinical teams, it works well." The reverse is also true and the need for new guidance and training for all staff is evident. Nonetheless, existing guidance is not being adequately followed or understood and major cultural change is needed at all levels of health and care to prioritise good quality end-of-life care. The review identifies the need for a strategic approach from NHS England down to clinical commissioning groups, and with the Care Quality Commission taking a lead in reviewing how well dying patients are treated.

It is distressing that what began as a model to raise the quality of care for the dying has too often been reduced to a tick box procedure which takes insufficient account of individual needs or wishes, and where vital care and compassion are absent. It is a tragedy however for families and carers who have lost relatives who have been cared for under the LCP, and for whom there will remain considerable distress and unanswered questions. Did their relative die a hastened death? Did they suffer unnecessarily because of the interpretation of the LCP? And would they actually have been able to live longer and die better without the involvement of the LCP?

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