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ObjectivesTo explore intercountry and intracountry differences in physician opinions about continuous use of sedatives (CUS), and factors associated with their approval of CUS.SettingsSecondary analysis of a questionnaire study.ParticipantsPalliative care physicians in Germany (N=273), Italy (N=198), Japan (N=334) and the UK (N=111).Primary and secondary outcome measuresPhysician approval for CUS in four situations, intention and treatment goal, how to use sedatives and beliefs about CUS.ResultsThere were no significant intercountry or intracountry differences in the degree of agreement with statements that (1) CUS is not necessary as suffering can always be relieved with other measures (mostly disagree); (2) intention of CUS is to alleviate suffering and (3) shortening the dying process is not intended. However, there were significant intercountry differences in agreement with statements that (1) CUS is acceptable for patients with longer survival or psychoexistential suffering; (2) decrease in consciousness is intended and (3) choice of neuroleptics or opioids. Acceptability of CUS for patients with longer survival or psychoexistential suffering and whether decrease in consciousness is intended also showed wide intracountry differences. Also, the proportion of physicians who agreed versus disagreed with the statement that CUS may not alleviate suffering adequately even in unresponsive patients, was approximately equal. Regression analyses revealed that both physician-related and country-related factors were independently associated with physicians’ approval of CUS.ConclusionVariations in use of sedatives is due to both physician- and country-related factors, but palliative care physicians consistently agree on the value of sedatives to aid symptom control. Future research should focus on (1) whether sedatives should be used in patients with longer survival or with primarily psychoexistential suffering, (2) understanding physicians’ intentions and treatment goals, (3) efficacy of different drugs and (4) understanding the actual experiences of patients receiving CUS.

ObjectiveResection of (pre) malignant lesions in the vulvoperineal area may result in large defects that cannot be closed primarily. The lotus petal flap technique is widely used for reconstruction. The aim of this study was to evaluate both quality of life (QoL) and sexual functioning of patients who underwent the lotus petal flap procedure, because no data are available on this topic.MethodsA cross-sectional study was performed on all eligible patients (N = 38) who underwent the lotus petal flap procedure between 2005 and 2016. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30, Female Sexual Function Index, and Body Image Scale were used to evaluate QoL and sexual functioning. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 and Female Sexual Function Index scores were compared with scores of age-matched healthy women.ResultsTwenty-six patients (68%) responded. The mean (SD) age was 65.5 (16.3) years, and the median follow-up time was 38.5 months (range 16–141 months). Quality of life scores were lower compared with healthy women in the domains physical, role, and social functioning. Sexual activity rates were comparable with healthy women; however, sexual functioning was worse. Although patients were satisfied about their sexual life, pain was reported.ConclusionsPatients who underwent vulvar reconstructive surgery with lotus petal flaps seem to have a lower QoL compared with healthy women. Patients report more pain during sexual activity but are satisfied about their sexual functioning. These results should be included in preoperative counseling and follow-up of future patients eligible for vulvar reconstruction with a lotus petal flap.

ObjectiveTo examine recent time trends in the incidence of osteonecrosis (ON) in Denmark and to investigate different common comorbidities association with ON in a population-based setting.MethodsUsing Danish medical databases, we included all patients with a first-time hospital diagnosis of ON during 1995–2012. Each ON case was matched with 10 randomly selected population control subjects from general population. For all participants, we obtained a complete hospital history of comorbidities included in the CharlsonComorbidity Index 5 years preceding the inclusion date.Results4107 ON cases and 41 063 controls were included. The incidence of ON increased from 3.9 in 1995 to 5.5 in 2012 per 100 000 inhabitants. Solid cancer was the most common comorbidity, associated with an adjusted OR (aOR) for ON of 2.0 (95% CI 1.7 to 2.2). For advanced metastatic cancer, leukaemia and lymphoma, aORs of ON were 3.4 (95% CI 2.5 to 4.5), 4.3 (95% CI 2.7 to 7.0) and 5.8 (95% CI 4.3 to 7.8), respectively. Among other chronic conditions, aORs were 3.5 (95% CI 3.0 to 4.1) for connective tissue diseases and 2.3 (95% CI 2.0 to 2.7) for chronic pulmonary diseases. aORs were also increased at 2.8 (95% CI 1.9 to 4.1) and 4.5 (95% CI 2.5 to 8.2) for mild and moderate-to-severe liver disease, respectively, and 4.2 (95% CI 3.4 to 5.2) for renal disease.ConclusionThis large population-based study provides evidence for an increasing ON incidence in the general population and documents an association between several common comorbid conditions and risk of ON.

Objective: To investigate the circumstances under which patients initiate direct questions in oncology consultations. Design: Conversation analysis of 47 consultations between oncologists and patients with cancer. Setting: An oncology clinic at a teaching hospital in the East Midlands. Participants: 16 Oncologists and 67 cancer patients. Outcome measure: Patient initiated direct questions. Results: On the whole patients’ direct questions are designed to seek specific information regarding, the cancer itself, treatment options or their experience of symptoms. When patients do ask direct questions they typically follow the announcement of test results where some reference to the details of those results, is provided. More specifically, there seems to be a relation between showing the patient their scan/X-ray results, patient involvement and patient-initiated direct questions. Higher levels of patient-initiated direct questions were clustered around occasions where doctors provided information and explanations of test results (12 consultations) sometimes with direct reference to scan or X-ray results (7 consultations). Conclusions: This study highlights the importance of careful explanation of diagnostic evidence as a factor contributing to increased patient involvement. More specifically, the findings suggest that, when appropriate, invoking diagnostic evidence (eg, scan or X-ray results) is an effective way of increasing levels of patient question asking. Doctors need to be able to encourage patient question asking to ensure that patients have at their disposal an important means through which they can determine their information needs. Although these results come from a study of oncology consultations, the findings may be transferable to other clinical contexts.