bluuebunny/crossref_metadata_2025 huggingface dataset:
Neglected but Important Role of Apolipoprotein E Exchange in Hepatitis C Virus Infection
Authors: Yang Zaili , Wang Xiaoning , Chi Xiumei , Zhao Fanfan , Guo Jinxu , Ma Pengjuan , Zhong Jin , Niu Junqi , Pan Xiaoyu , Long Gang
Published: August 2016

Hepatitis C virus (HCV) is a major cause of chronic liver disease, infecting approximately 170 million people worldwide. HCV assembly is tightly associated with the lipoprotein pathway. Exchangeable apolipoprotein E (apoE) is incorporated on infectious HCV virions and is important for infectious HCV virion morphogenesis and entry. Moreover, the virion apoE level is positively correlated with its ability to escape E2 antibody neutralization. However, the role of apoE exchange in the HCV life cycle is unclear. In this study, the relationship between apoE expression and cell permissiveness to HCV infection was assessed by infecting apoE knockdown and derived apoE rescue cell lines with HCV. Exchange of apoE between lipoproteins and HCV lipoviral particles (LVPs) was evaluated by immunoprecipitation, infectivity testing, and viral genome quantification. Cell and heparin column binding assays were applied to determine the attachment efficiency of LVPs with different levels of incorporated apoE. The results showed that cell permissiveness for HCV infection was determined by exogenous apoE-associated lipoproteins. Furthermore, apoE exchange did occur between HCV LVPs and lipoproteins, which was important to maintain a high apoE level on LVPs. Lipid-free apoE was capable of enhancing HCV infectivity for apoE knockdown cells but not apoE rescue cells. A higher apoE level on LVPs conferred more efficient LVP attachment to both the cell surface and heparin beads. This study revealed that exogenous apoE-incorporating lipoproteins from uninfected hepatocytes safeguarded the apoE level of LVPs for more efficient attachment during HCV infection.

IMPORTANCE
In this study, a neglected but important role of apoE exchange in HCV LVP infectivity after virus assembly and release was identified. The data indicated that apoE expression level in uninfected cells is important for high permissiveness to HCV infection. Secreted apoE-associated lipoprotein specifically enhances infection of HCV LVPs. apoE exchange between HCV LVP and lipoproteins is important to maintain an adequate apoE level on LVPs for their efficient attachment to cell surface. These data defined for the first time an extracellular role of exchangeable apoE in HCV infection and suggested that exchangeable apolipoproteins reach a natural equilibrium between HCV LVPs and lipoprotein particles, which provides a new perspective to the understanding of the heterogeneity of HCV LVPs in composition.
Functional and Structural Characterization of P[19] Rotavirus VP8* Interaction with Histo-blood Group Antigens
Authors: Sun Xiaoman , Li Dandi , Peng Ruchao , Guo Nijun , Jin Miao , Zhou Yongkang , Xie Guangcheng , Pang Lili , Zhang Qing , Qi Jianxun , Duan Zhao-Jun
Published: August 2016

Rotaviruses (RVs) of species A (RVA) are a major causative agent of acute gastroenteritis. Recently, histo-blood group antigens (HBGAs) have been reported to interact with human RVA VP8* proteins. Human P[19] is a rare P genotype of porcine origin that infects humans sporadically. The functional and structural characteristics of P[19] VP8* interaction with HBGAs are unknown. In this study, we expressed and purified the VP8* proteins of human and porcine P[19] RVs. In oligosaccharide and saliva binding assays, P[19] VP8* proteins showed obvious binding to A-, B-, and O-type saliva samples irrespective of the secretor status, implying broad binding patterns. However, they did not display specific binding to any of the oligosaccharides tested. In addition, we solved the structure of human P[19] VP8* at 2.4 Å, which revealed a typical galectin-like fold. The structural alignment demonstrated that P[19] VP8* was most similar to that of P[8], which was consistent with the phylogenetic analysis. Structure superimposition revealed the basis for the lack of binding to the oligosaccharides. Our study indicates that P[19] RVs may bind to other oligosaccharides or ligands and may have the potential to spread widely among humans. Thus, it is necessary to place the prevalence and evolution of P[19] RVs under surveillance.

IMPORTANCE
Human P[19] is a rare P genotype of porcine origin. Based on phylogenetic analysis of VP8* sequences, P[19] was classified in the P[II] genogroup, together with P[4], P[6], and P[8], which have been reported to interact with HBGAs in a genotype-dependent manner. In this study, we explored the functional and structural characteristics of P[19] VP8* interaction with HBGAs. P[19] VP8* showed binding to A-, B-, and O-type saliva samples, as well as saliva of nonsecretors. This implies that P[19] has the potential to spread among humans with a broad binding range. Careful attention should be paid to the evolution and prevalence of P[19] RVs. Furthermore, we solved the structure of P[19] VP8*. Structure superimposition indicated that P[19] may bind to other oligosaccharides or ligands using potential binding sites, suggesting that further investigation of the specific cell attachment factors is warranted.
Control of lithospheric inheritance on neotectonic activity in northwestern Canada?
Authors: Audet Pascal , Sole Christian , Schaeffer Andrew J.
Published: August 2016

Lithospheric inheritance is thought to affect the location and reactivation of tectonic structures through successive cycles of supercontinent formation and dispersal; however, its relation to neotectonic activity remains unclear. In northwestern Canada, abundant seismicity throughout the northern Canadian Cordillera (NCC) is geographically confined by several crustal-scale boundaries, yet its southern extent terminates abruptly along the inferred westward extension of a Late Cretaceous rifted margin boundary called the Liard transfer zone (LTZ). We use seismic data to show that the uppermost mantle beneath the Cordillera exhibits a sharp north-south contrast in fabric across the LTZ. South of the LTZ, fast axes of seismic wave propagation align closely with the lithospheric mantle fabric orientation of the adjacent Canadian shield. North of the LTZ, fast axes are reoriented subparallel to the motion of the Pacific plate and follow the strike of the large dextral strike-slip Tintina and Denali faults. We attribute changes in anisotropic delay times across the Tintina and Denali faults to localized shear within the lithosphere; this implies that the crust and lithospheric mantle remained mechanically coupled during shearing. We propose that the contrast in uppermost mantle structure across the LTZ reflects a change in the nature and origin of the lithospheric mantle from inherited rifted margin structures, which affects the stability of the lithosphere and limits the extent of seismic activity within the NCC. These results indicate that neotectonic activity in modern Cordilleras is controlled in part by inherited upper mantle structures.
TO INVESTIGATE THE EFFECT OF THE PASTEURISATION PROCESS ON TRACE ELEMENTS IN DONOR BREAST MILK
Authors: Taufek Nor Mohd , Cartwright David , Hewavitharana Amitha , Koorts Pieter , McConachy Helen , Shaw Nick , Whitfield Karen , Davies Mark
Published: August 2016

Aim

To investigate the effect of the pasteurisation process on trace elements in donor breast milk.

Method

Premature infants often receive donor breast milk when the mother is unable to produce sufficient breast milk. It is widely accepted that donor milk has considerable advantages over formula milk.1 The Royal Brisbane and Women's Hospital (RBWH) has a milk bank that receives milk donated by women which undergoes a pasteurisation process.2 This study investigated the effect of pasteurisation on a range of trace elements in donor milk.

A total of 14 participants who donated to the milk bank were recruited in this study. A 2 ml sample was collected pre- and post- pasteurisation, and frozen at −80 °C. Post-natal age of the milk was documented. Inductively-coupled plasma mass-spectrometry was used to analyse the following trace elements – zinc (Zn), copper (Cu), selenium (Se), manganese (Mn), iodine (I), iron (Fe), molybdenum (Mo) and bromine (Br). The study received ethical approval from RBWH and The University of Queensland Ethics Committee.

Results

No significant difference was found between the levels of any of the trace elements tested pre- and post-pasteurisation. The following p-values were calculated – Zn (0.82), Cu (0.80), Se (0.97), Mn (0.63), I (0.99), Fe (0.05), Mo (0.41), Br (0.59). The following ranges in mcg/L of trace elements were calculated – Zn (365.4–5460.0), Cu (157.6–820.5), Se (10.6–23.7), Mn (0.55–3.24), I (66.4–215.3), Fe (101.5–473.1), Mo (0.20–5.45), Br (704.9–3379.0). Spearman's rank correlation analysis showed significant correlations between post-natal age of milk and trace elements – Zn (ρ=−0.578), Se (ρ=−0.627). Fe (ρ=−0.704), and Mo (ρ=−0.534). No significant correlation was found for Cu, Mn, I, and Br.

Conclusion

This study found that the pasteurisation process had minimal effect on trace element levels in donor breast milk. However, it was noted that there was a correlation between post-natal age of donor milk and Zn, Se, Fe and Mo. Further work is needed to establish factors that may influence levels of trace elements in donor milk such as post-natal age.
THE APPROPRIATENESS OF USING AVERAGE DISPLACEMENT VALUES FOR PAEDIATRIC INTRAVENOUS DRUG ADMINISTRATIONS
Authors: Lo Alice , Christiansen Nanna , Bhatti Husnain
Published: August 2016

Aim

To determine the impact of displacement values on doses in paediatric patients when using parenteral. To assess the option of using average displacement values (DV) in the preparation of parenteral medicines.

Method

Over 500 Medusa1 monographs were analysed and 42 medicines were identified with a displacement value not indicated as negligible. The following were calculated: the percentage difference in dose if the DV was not taken into account for each drug and brand, the range of percent differences where there was more than one brand for each strength and the percentage difference in dose incurred if an average DV was used.

Results

The 42 drugs were separated into 3 groups. The first group of 27 drugs had DVs causing less than 5% dose variation for all brands. The second group of 7 drugs had DVs resulting in more than 5% dose variation. The third group of 8 drugs had wider variations i.e. including drugs where the different brands had DVs both below and above 5% (2 to 27.9%) in dose variations for varying brands of a drug and strength.

A total of 64 preparations had less than 5% dose variation. For these the DVs could potentially be disregarded as it is unlikely to have a significant clinical effect. However there are other sources of errors when administering parenteral medications (e.g. dose rounding on prescribing, inaccuracy when preparing and drawing up the dose) and this may further contribute to cumulative dosing inaccuracies. An alternative option would be to provide an average DV for each drug and vial strength. Due to the use of an average DV under or over dosing can occur depending on the preparation. However if this method was used the dose difference is only 0.31% on average (0.47–0.98%), significantly less if the DV was ignored.

For the second group of preparations with dose differences greater than 5% (5–18%), the DV should not be ignored as it can be clinically significant. However where there is more than one manufacturer available for a particular strength of drug the range in difference of the dose variation was small (0.7–4.1%). When an average displacement value was attributed this resulted in a maximum dose difference of 2.5% (0–2.5%). For the third group there are varying differences in the range of dose variation. Where the range is small and an average was assigned the average range in dose variation was 0.30% (0–4.6%). However there are preparations that the range was too wide for an average to be safely used (2.8–9.5%).

Conclusion

For the majority of drugs an average DV can be used safely. Using average DVs would simplify the preparation process for nurses and reduce the risk of them inadvertently using the wrong displacement value.
DEVELOPMENT OF A ONCE DAILY GENTAMICIN REGIMEN FOR PAEDIATRIC SURGERY PATIENTS
Authors: Kasuji Sumayya , Gadaria Prady
Published: August 2016

Aim

Intravenous gentamicin is given as a 5 day course to paediatric patients who have undergone abdominal surgery. There was an impression that the multiple daily dosing regimen in use at the time (2.5 mg/kg three times a day) did not provide therapeutic levels in this patient cohort therefore the aim was to develop a dosing regimen that did.

Method

A retrospective audit of pre- and post-dose gentamicin levels in patients on a multiple daily dose regimen was undertaken. Data was gathered using a microbiology database and children aged between 1 month and 16 years who had gentamicin prophylaxis following abdominal surgery between January 2005 and January 2010 were included. Following on from the initial audit a once daily gentamicin dosing regimen was introduced for all patients who met the inclusion criteria: child aged over 1 month of age without ascites, cystic fibrosis, endocarditis, major burns or significant renal impairment and not pregnant. The once daily dose chosen was based on BNF-c guidance and an administration guideline was incorporated into a prescription chart. A survey of 7 hospitals and a literature review was conducted to determine when gentamicin levels were monitored. Once the regimen had been in place for 12 months a prospective audit of trough levels was undertaken.

Results

Multiple day dosing.

336 children were reviewed, of these 35 had incomplete data and were excluded. Data was analysed from 301 children, 207 (68.7%) had a post dose below the recommended therapeutic range (5–10 mg/L) and the dose was increased by 10%. 132/207 of this subset had a second post dose measured and 99/132 (75%) were still below the therapeutic range. Overall, only 31.2% of children had gentamicin levels within the therapeutic range during the course of treatment.

The Hartford nomogram has not been validated for use in children therefore it cannot it be applied to this patient cohort. The literature review and survey of practice revealed that with once daily dosing a peak gentamicin level does not need to be measured, as it is assumed that with a 7 mg/kg dose the pharmacodynamic goal of achieving a peak to minimum inhibitory concentration ratio greater than 104 will be achieved.1 2 Therefore, it is routine practice to only measure the trough level 1.

Once daily dosing

Thirty patients were audited after the introduction of the once daily regimen and 100% of patients had a trough level of ≤1 mg/L.

Conclusion

A once daily gentamicin regimen of 7 mg/kg was found to achieve therapeutic levels in paediatric surgery patients who met the inclusion criteria when administered in accordance with the local prescription chart. A further audit is planned to determine if the new dosage regimen affects the clinical outcome.
MEDICINES RECONCILIATION FOR PAEDIATRIC PATIENTS ON ADMISSION AND DISCHARGE
Authors: Moss Maria , Bilbul Celine , Crook Jo
Published: August 2016

Introduction

National guidance from National Institute for Health and Clinical Excellence (NICE), National Patient Safety Agency (NPSA), World Health Organization and the Royal Pharmaceutical Society has long highlighted the importance of accurate and timely medicines reconciliation (MR) in reducing medication errors for patients upon transfer of care setting.1
–
4 Current guidance for MR excludes children <16 years of age, where widespread use of off-label and unlicensed formulations puts this group of patients at a higher risk.

Aim

To quantitatively assess the level of MR for paediatric inpatients on admission and discharge and to ascertain whether Discharge Summary (DSUM) information is sent to the GP in a timely manner.

Method

▸ Data was collected retrospectively over a two week period for paediatric take home prescriptions.

▸ An electronic prescribing system was used to complete a data collection form, documenting their MR process and timeframe on admission and discharge.

▸ The information was recorded onto an online template of the data collection form using Qualtrics software to prepare a Microsoft Excel file for data analysis.

Results

65 paediatric patients on four wards were audited.

▸ Standard 1: 32/65 (49.2%) of patients had their drug history (DH) documented within 24 hrs of admission.

▸ Standard 2: 39/65 (60.0%) of patients had their medicines reconciled by a pharmacist within 72 hrs of admission.

▸ Standard 3: 46/65 (70.8%) of patients had their medicines reconciled by a pharmacist and/or doctor at discharge.

▸ Standard 4: 57/65 (87.7%) of patients had their DSUM sent to the GP within 24 hrs of discharge.

Conclusion

None of the four standards were met, emphasising the need to develop better MR practice. The following conclusions were identified:

▸ A need for more MMTs at ward level to conduct accurate DHs within a timely manner.

▸ MR on admission and discharge suffers out-of-hours (OOH), thus supporting plans for seven-day working.

▸ A combined effort between different members of the multidisciplinary team is paramount to ensure accurate MR.

▸ Doctors need to have the resources available OOH to allow them to prioritise completion of DSUMs in a timely manner to optimise accurate MR communication with GPs.

▸ It is evident that anecdotally MR is done to a higher level; however a possible lack of pharmacist understanding on the MR process and its documentation may have contributed to this audit's standards not being met.
DOES MORE SPECIALIST PHARMACIST TIME IN A CLINICAL AREA EQUAL MORE ACTIVITY?
Authors: Isaac Rhian , Gerrard Astrid , Bazaz Kevin
Published: August 2016

Background

Following a medication safety initiative proposed by the PICU Safety Strategy group a pilot was set up to extend the presence of a PICU trained pharmacist in the clinical area.

One of the main safety initiatives was to assess whether increased pharmacist exposure decreased drug omission of time critical medicines, which was highlighted from incident reporting patterns on PICU.

Aim

To assess what impact extending a pharmacist with specific PICU training would have on the medicines management of the PICU patients.

Method

The pilot involved attendance on the afternoon ward round, review of all new admissions and follow up of priority patients as highlighted by the “day” PICU pharmacists. The pilot “late” PICU pharmacist was resident in the hospital, on PICU, for an hour longer than the pharmacy opening hours. A rota of

A basic data collection form was set up on Microsoft Excel. Data collected included start and finish times of the ward round, time leaving PICU, clinical interventions made, queries by staff on PICU and outside of PICU, supplies made, drug omissions prevented, number of times the presence on the unit prevented need to call in the on call pharmacist and interpretation of drug assays reported after pharmacy hours. Follow up of specific medicines management issues highlighted by the “day” pharmacists as requiring action prior to following day pharmacy visit were recorded.

Results

During the 74 days data were collected there was 395 drug related queries by PICU staff (252 by nursing staff, 143 by prescribers). The “late” PICU pharmacist was contacted for advice regarding non-PICU patients by the on call or dispensary pharmacist on 7 occasions and 11 times from clinical staff outside of PICU.

The “late” pharmacist intervened on 412 prescriptions, some of the interventions arose from the 260 follow up reviews requested by the “day” pharmacists. Of the 236 drug assays reported after pharmacy hours, 126 required intervention by pharmacist.

Omission of time critical medicines was prevented on 17 occasions following 79 supplies of non-stock medicines. Calling out the on-call pharmacist was circumvented 11 times.

Conclusion

The Safety Strategy teams’ request for increased access to a “late” PICU pharmacist resulted in a number of clinical interventions, appropriate dosing advice on late-in-day reported drugs assays and prevention of delays in medicines, including time critical drugs. Benefits of the specialist pharmacist being on-site to the pharmacy service included less need to access the on call pharmacist for either advice or supplies of medicines. During a pharmacy 7 day working review these data were used to secure the increased clinical pharmacy service to PICU.
USE OF PILL GLIDE TO ENCOURAGE TRANSITION FROM LIQUID TO SOLID DOSAGE FORMULATIONS
Authors: Gaskell Ceri
Published: August 2016

Situation

Patient I is a 15 year old female with ornithine transcarbamylase deficiency prescribed L-arginine 1.5 g three times daily and sodium benzoate 4.2 g three times daily. By taking her medication and controlling her diet she is able to lead a normal life and does well at school. However she struggles with the palatability of her medication and has not been able to transition to solid dosage forms. She has therefore been stabilised on an unlicensed sodium benzoate liquid and has L-arginine capsules which she takes by opening and dispersing the contents in water. This creates problems for the patient because the volume of sodium benzoate liquid that she needs is very large. This means it has been difficult to come to collect supplies from our pharmacy due to the volume that needs to be carried and transported in one go, and also makes going away on holiday difficult. In addition, the liquid version is more expensive than other options so being able to convert to tablets would be a cost saving measure.

Background

Previous attempts to encourage her to take tablets and alternative options such as licensed sodium phenylbutyrate granules have failed. A recommendation was therefore made by the pharmacist to try using Pill Glide swallowing spray as an aid to help her learn to swallow sodium benzoate tablets, in conjunction with nurse-led teaching. Pill Glide is a flavoured spray that helps patients swallow tablets and capsules more easily. It comes in a number of flavours that patients can choose from and can be used for as long as it is beneficial.

Outcome

Patient I found the spray useful in helping her to swallow sodium benzoate tablets and swallow her L-arginine capsules whole and has now successfully transitioned from using sodium benzoate liquid. This has benefitted the patient by reducing the need collect and transport large volumes of liquid, and by helping her to transition to adulthood. Importantly it has also enabled a significant cost saving, with a saving of £367/month by switching her from liquid sodium benzoate to sodium benzoate tablets and Pill Glide.

Lessons learned

Pill Glide is a useful potential option to help patients who struggle to take solid dosage forms. Liquid medicines are usually much more expensive than tablets and capsules, and therefore helping children with chronic conditions to transition to taking tablets and capsules could be an important cost-saving measure. In addition it could improve compliance in taking medicines where there is no liquid form available or where patients find liquid forms unpalatable. The option of Pill Glide has now been rolled out to other specialties such as renal and respiratory patients where there may also be cost savings and patient benefits for those who find transitioning to solid dosage forms difficult.
Heart failure care or palliative care? Patients want and need both
Authors: Brice Mary , Martin Amanda , Hansford Penny , Richardson Heather , George Rob , Murtagh Fliss
Published: August 2016

Introduction

People with advanced heart failure have significant symptom/disease burden. Optimal models of care have not yet been widely tested and evaluated. We aimed to test a novel combined heart failure palliative care service model.

Method

A mixed-method feasibility study, including comparison with an age- and gender-matched cohort receiving specialist palliative care.

Results

27 male and 13 female patients (mean age 84 years, range 60–99) were recruited. Integrated Palliative care Outcome Scale scores, compared with an age- gender- matched specialist palliative care population, demonstrated significantly higher levels of fatigue (mean score 2.6 v 1.9, p = 0.01), poor mobility (2.75 v 1.6, p = 0.00), drowsiness (2.03 v 0.6, p = 0.00), breathlessness (2.2 v 0.9 , p = 0.00), sore/dry mouth (1.4 v 0.6, p = 0.004), depression (1.4 v 0.5, p = 0.002) and not feeling at peace (1.6 v 0.9, p = 0.02). 67% (95% CI: 49–79%) were severely/overwhelmingly affected by poor mobility and 50% (95% CI: 34–65%) were affected by weakness/fatigue in the previous week. In qualitative interviews (8 patients, 6 carers and 2 joint), patients sought heart failure care critical for optimal symptom control, and whilst realistic about the limitations of therapies, wanted parallel support to prepare for and manage future deterioration.

Conclusion

People with advanced heart failure have considerably greater needs than an age-matched palliative care population. They have realistic expectations about interventions available but identify practical support and appropriately skilled healthcare teams as important to their care. Professionals skilled in both heart failure and palliative care interventions in an integrated service model are needed.

References

Hogg KJ, Jenkins SMM. Prognostication or identification of palliative needs in advanced heart failure: where should the focus lie?BMJ2012;98(7):523524

Nordgrena L, Soerensen S. Symptoms experienced in the last six months of life in patients with end-stage heart failure.Eur J Cardiovasc Nurs2003;2(1):213217

Pattenden JF, Mason AR, Lewin RJP. Collaborative palliative care for advanced heart failure: outcomes and costs from the ‘Better Together’ pilot study.BMJ Support Palliat Care2013;3(1):69–76

Selman L, Harding R, Beynon T,et al. Modelling services to meet the palliative care needs of chronic heart failure patients and their patients: current practice in the UK.Palliat Med2007;21(5):385–390
Supporting adults bereaved through advanced illness: development of a core outcome set (COS)
Authors: Cowie Luke , Nelson Annmarie , Morgan Fiona , Byrne Anthony , Pickett Sara , Sivell Stephanie , Fitzgibbon Jim , Harrop Emily
Published: August 2016

Background

A lack of evidence-based guidance on bereavement support (Hudsonet al., 2012) and of consistency in the measures used in clinical practice and research to assess bereavement outcomes (Forteet al., 2004) have been identified. The heterogeneity in outcome measures makes it difficult to assess and benchmark clinical services. It is also challenging to combine and compare research results, and draw robust conclusions on effectiveness to inform clinical practice and service delivery. One step to resolving this situation is to develop a core outcome set (COS). This represents the ‘minimum that should be measured and reported in all clinical trials of a specific condition’ (www.comet-initiative.org).

Aim

This project, funded by Marie Curie, aims to develop a COS that is specific to bereavement in adults following advanced, progressive illness.

Methods

The COS will be developed through a series of distinct methodologies. First, outcomes utilised in the studies identified by systematic review will be mapped into different domains. Second, an expert consensus day will be convened with up to 30 stakeholders to identify any further outcomes and engage in a consensus methodology (Gallagheret al., 1993) designed to identify the most important. Finally, the list of core outcomes will be further refined through an online Delphi survey with items rated over two rounds to reach consensus on which items should be included in the COS.

Results/conclusions

The COS will allow research results to be compared, contrasted and combined, and will have additional benefits for clinical practice and the commissioning of services.

References

Hudson P, Remedios C, Zordan R,et al. Guidelines for the psychosocial and bereavement support of family caregivers of palliative care.J Palliat Med2012;15(6):696–702

Forte A, Hill M, Pazder R, Feudtner C. Bereavement care interventions: a systematic review.BMC Palliat Care2004;3(1):3

Gallagher M, Hares T, Spencer J, Bradshaw C, Webb I. The nominal group technique: a research tool for general practice?Fam Pract1993;10(1):76–81
What support do people with cirrhosis need from liver healthcare professionals in a liver transplant centre?
Authors: Davis Sarah , Low Joseph , Greenslade Lynda , Marshall Aileen , Thorburn Doug , Jones Louise
Published: August 2016

Background and aims

The incidence of liver disease is increasing in the UK; it is now the 3rdcommonest cause of death in those aged under 65. People with cirrhosis often have complex physical problems that require regular comprehensive management. Limited evidence exists on the ways that people with cirrhosis cope with the disease. We aimed to explore their experience to ascertain whether current levels of healthcare support were sufficient.

Methods

Ten people with cirrhosis were recruited from hepatology clinics in one liver transplant centre. In semi-structured qualitative interviews, we explored their understanding of their disease and prognosis; healthcare services received; specific problems encountered; concerns for the future. Interviews were audio-taped and transcribed verbatim. Data were analysed using a Framework approach.

Results

Our sample was 50% male: 5 were on the liver transplant list. Everyone said that the healthcare they received from the hospital was good; staff continuity and relationships with clinicians were seen as important. However, people lacked understanding of their diagnosis, health status and symptoms and wanted more management advice and psychological support. Contacting a member of the clinical team was difficult if problems developed at home, leading to A+E attendance. Limited discussions were held about disease progression and future care if treatment failed.

Conclusions

Symptom burden in people with cirrhosis is high and needs are complex. Active communication from professionals about current disease status and likely progression may enable better understanding and encourage involvement in plans for their future care.

References

Poonja Z, Brisebois A, van Zanten SV,et al. Patients with cirrhosis and denied liver transplants rarely receive adequate palliative care or appropriate management.Clin Gastroenterol Hepatol2014;12(4):692–698

Kimbell B, Boyd K, Kendall M, Iredale J, Murray SA. Managing uncertainty in advanced liver disease: a qualitative, multi-perspective, serial interview study.BMJ Open2015;e009241. doi:10.1136/bmjopen-2015-009241
Facilitating successful implementation of the carer support needs assessment tool (CSNAT) intervention within palliative care
Authors: Diffin Janet , Ewing Gail , Grande Gunn
Published: August 2016

Background

The Carer Support Needs Assessment Tool (CSNAT) intervention identifies and addresses family carer support needs towards end of life.1–3This person-centred approach involves a change in practice from a practitioner- to carer-led assessment process. Numerous policies recommend carers’ needs should be addressed yet there is little guidance on how to achieve this within palliative care. To address this gap and assist a change to a carer-led process, an implementation strategy for the CSNAT intervention was developed, of which facilitation is key.

Aims

investigate components of facilitation associated with successful implementation of the CSNAT intervention across 36 palliative care services.

Methods

Qualitative: Interviews three and six months post-CSNAT implementation with 38 practitioners acting as CSNAT ‘champion’ (internal facilitation) in 32 services. Researcher field notes collected from teleconference support sessions with ‘champions’ (external facilitation).

Results

Successful implementation of the CSNAT intervention was associated with: a teamwork approach to facilitation; the ‘lead champion’ having a leadership role in the service e.g. team manager; presenting a clear rationale why a change in practice was needed; reviewing progress and making changes to overcome identified barriers; ‘champions’ having good communication skills and authority to make changes. Aspects of context which constrained facilitation included the need to establish a new carer record, and organisational changes e.g. budget cuts, and a culture focused on the patient. Management support assisted with facilitation efforts.

Conclusions

Establishing a team of practitioners to lead facilitation of the CSNAT intervention and regularly review implementation progress, is recommended to help ensure implementation success.

References

Ewing G, Brundle C, Payne S, Grande G. The Carer Support Needs Assessment Tool (CSNAT) for use in palliative and end-of-life care at home: A validation study.J Pain Symptom Manage2013;46(3):395–405

Ewing G, Grande G. Development of a Carer Support Needs Assessment Tool (CSNAT) for end-of-life care practice at home: A qualitative study.Palliat Med2013;27(3):244–256

Ewing G, Austin L, Diffin J, Grande G. The Carer Support Needs Assessment Tool: A person centred approach to carer assessment and support.Br J Community Nurs2015;20(12):580–584
How current UK research addresses out of hours palliative care
Authors: Fordham Florence Todd , McMillan Stevie , Best Sabine , Candy Bridget , Thakrar Sanjay , Noble Bill
Published: August 2016

Introduction

In 2015 the Palliative and end of life care Priority Setting Partnership (PeolcPSP), facilitated by the James Lind Alliance, published a top-ten list of unanswered questions relating to palliative and end-of-life care research. These were ranked in accordance with responses from people in the last years of life, current/bereaved carers and professionals working with people at the end-of-life.

The highest ranked question was: “What are the best ways of providing palliative care outside of working hours to avoid crises and help patients stay in their place of choice? This includes symptom management, counselling and advice, GP visits and 24-hour support, for patients, carers and families.”

Aim

This project presents how current research in the UK is addressing this question.

Methods

Through a grant mapping process, links have been identified between the PSP questions and current research, using the UK Clinical Research Collaboration’s (UKCRC) Health Research Classification System dataset, providing a snapshot of 2014 data. These links have been coded from weak to interventional.

Results

This grant mapping process highlights that although out of hours care is ranked most important by carers and health care professionals, it receives very little research attention. In 2014, no current research proposed an intervention to address the question, and only four grants representing 0.03% of health research spend directly addressed out of hours palliative care. They were funded by the Department of Health and Marie Curie.

Conclusion

This work highlights the need for future research funding to focus on out of hours palliative care.
Enabling successful hospital discharge to home at end of life: can a carer support needs assessment tool (CSNAT) help improve support for family carers?
Authors: Ewing Gail , Austin Lynn , Gibson Debra , Grande Gunn
Published: August 2016

Introduction

Successful hospital discharge and prevention of readmission often depend on carers’ ability to support patients.

Aim

To investigate how carers are supported during patient discharge from acute care towards end of life (EOL) and suitability of using a Carer Support Needs Assessment Tool (CSNAT) to improve this support.

Methods

Qualitative design: focus groups (FGs) with 40 practitioners supporting patient discharge from three English acute hospital trusts; interviews with 22 carers of patients discharged. 14 practitioners and 5 carers joined two final workshops. FGs/interviews/workshops explored current discharge processes and potential value of using CSNAT. Thematic framework analysis was conducted.

Results

Both practitioners and carers viewed CSNAT as highly relevant in supporting carers at discharge. Discharge processes were heavily focussed on patients: carers were consulted but about patients’ needs; there was no systematic approach to supporting carers. CSNAT was identified as a means of facilitating much needed EOL conversations which often were absent, enabling carers to articulate concerns, and managing carers’ expectations of their caregiving role at EOL and support available (or not) in the community. However, palliative care discharges were complex: from many different wards involving different practitioners. No single professional group was identified as best placed to support carers. Feasibility issues included skills, confidence and time for carer assessment and support. A two stage process using CSNAT earlier in hospital admission, then as a carer-held record to manage transition to home were seen as ways forward.

Conclusion

CSNAT shows good potential to enhance carer support at hospital discharge and play a role in preventing readmissions towards EOL.

References

Ewing G, Brundle C, Payne S, Grande G. The Carer Support Needs Assessment Tool (CSNAT) for use in palliative and end-of-life care at home: A validation study.J Pain Symptom Manage2013;46:395–405

Ewing G, Grande GE. Development of a Carer Support Needs Assessment Tool (CSNAT) for end of life care practice at home: a qualitative study.Palliat Med2013;27:244–256
End of life care for people with alcohol and other drug problems: an exploratory study
Authors: Galvani  , Tetley Josie , Haigh Carol , Webb Lucy , Yarwood Gemma , Ashby Jo , Witham  , Peacock Marian , Wright Samantha , Templeton Lorna , Duncan Fiona
Published: August 2016

Introduction

The problematic use of substances is linked to many forms of chronic and life threatening conditions, the majority of which affect people in later life. In part as a consequence of population ageing and with evidence suggesting that older people’s substance use is increasing, this complex and heterogeneous group is growing. Thus greater numbers will require palliative care and present new challenges to end of life services. This study explores the nature and extent of these changes and the needs of service users and providers.

Aim(s) and method(s)

There are five strands to the study; evidence for practice: an international review via a Rapid Evidence Assessment (REA), establishing what is known about prevalence and incidence via a secondary analysis of qualitative and quantitative datasets, exploration of the experiences of people with chronic or terminal illness and a similarly for the experiences of family members and carers, and professionals’ perspectives collected via key informant interviews.

Results

The study began in May 2016 and we will have preliminary findings for presentation from the REA, the quantitative dataset analysis, and the secondary analysis of carer/family study data by October 2016.

Conclusion(s)

This is a key and under-researched area of palliative and end of life care, and an area which we already know results in considerable challenges for both end of life service providers and also for substance use services. Little is known about what may already be in place and still less about the composition and scale of the relevant populations.

References

Galvani S, Hutchinson A, Dance C. Identifying and assessing substance use: findings from a national survey of social work and social care professionals.Br J Social Work2014;44(7):1895–1913

Harling M, Overy C, Beckham G,et al. Addressing negative attitudes toward substance use in nursing: A peer-led approach in nurse education.Drugs Alcohol Today2006;62):38–41

Reisfield GM, Paulian GD, Wilson GR. Substance use disorders in the palliative care patient.J Palliat Med2009;12(5):475

Wadd S, Papadopoulos C. Drinking behaviour and alcohol-related harm amongst older adults: analysis of existing UK datasets.BMC Res Notes2014;7(1):741
Can high fidelity simulation be used to teach communication skills regarding death and dying? A qualitative study
Authors: Hawkins Amy
Published: August 2016

Aims

To explore medical students’ experiences of communicating with patients and relatives about death and dying and their responses to communication skills training using high-fidelity simulation.

Methods

This qualitative study was carried out at a hospital in the south of England with seven final year medical students. Tutorials were developed using high-fidelity simulation to teach communication skills in discussing cardiopulmonary resuscitation. Scenarios involved a simulated ward environment, a high fidelity mannequin and an actor as the patient’s relative. The scenarios were observed through a video link by other students and a facilitator. Data was collected through joint interviews which were audio recorded and transcribed verbatim, then analysed using framework analysis.

Results

Students reported few opportunities to observe consultations regarding end of life issues or to interact with dying patients and their relatives. Barriers reported included healthcare professionals’ and patients’ attitudes to students observing consultations about death and dying. This led to a lack of confidence and preparedness to have these conversations as junior doctors. Students reported that the high-fidelity simulation scenarios were more realistic than low-fidelity (role-play) scenarios and improved their preparedness to have conversations about death and dying with patients and families.

Conclusions

This study has suggested that students lack confidence and are underprepared to communicate with patients and relatives about death and dying as junior doctors. High fidelity simulation may be a useful tool for communication skills training, but further studies are needed to explore the feasibility and cost-effectiveness of this teaching method.
“I’ll be in a safe place”: a qualitative study of the decisions taken by people with advanced cancer to seek emergency department care
Authors: Henson Lesley A , Higginson Irene J , Daveson Barbara A , Ellis-Smith Clare , Koffman Jonathan , Morgan Myfanwy , Gao Wei ,   on behalf of BuildCARE
Published: August 2016

Objective

To explore the decisions of people with advanced cancer, and their caregivers, to seek emergency department (ED) care, and understand the issues that influence the decision-making process.

Design

Qualitative study incorporating semi-structured patient and caregiver interviews, plus research field notes.

Methods

Between December 2014 and July 2015, semi-structured interviews were conducted with 18 people with advanced cancer, all of whom had recently attended the ED of a large university teaching hospital located in south-east London; and six of their caregivers. Interviews were audio-recorded, transcribed verbatim and analysed using a constant comparative approach. Padgett and Brodsky’s modified version of the “Model of Health Services Use” was used as a framework for the study.1

Results

Issues influencing the decision-making process included: i) Anxiety relating to having a diagnosis of cancer – those with greater anxiety interpreted symptoms as more severe and/or requiring immediate attention; ii) Prior patterns of health-seeking behaviour – at times of crisis participants defaulted to previously used services; iii) Feelings of safety and familiarity with the hospital setting – many felt reassured by the presence of healthcare professionals and monitoring of their condition; and, iv) Difficulties accessing community healthcare services – especially urgently and/or out-of-hours.

Conclusion

These data provide healthcare professionals and policymakers with a greater understanding of how systems of care may be developed to help reduce end-of-life ED visits. In particular, our findings suggest that greater support and education regarding end-of-life symptoms, earlier collaboration between oncology and palliative care and increased access to community healthcare services may help reduce the number of end-of-life ED visits made by people with advanced cancer.

Reference

Padgett DK, Brodsky B.Psychosocial factors influencing nonurgent use of the emergency room – a review of the literature and recommendations for research and improved service delivery.Soc Sci Med1992;35(9):1189–1197
Why do patients with haematological malignancies die in hospital? Qualitative findings from a UK study
Authors: McCaughan Dorothy , Roman Eve , Smith Alex , Howell Debra
Published: August 2016

Introduction

Research suggests most people would prefer to die at home,1yet patients with haematological malignancies (leukaemia, lymphoma, myeloma) die in hospital more often than those with other conditions, and there is little evidence to explain this.2–4

Aim

To explore perceptions about why hospital deaths predominate.

Methods

Qualitative interviews with 46 clinicians who care for blood cancer patients and 10 relatives of deceased patients. Interviews were audio-taped, transcribed and analysed for thematic content. An inductive approach was used to code and classify data, which included: familiarisation with the data; attribution of individual codes; collating codes into themes; and interpretation by seeking meaning, salience and connections.

Results

Hospital deaths are largely determined by the disease characteristics and its trajectory, including: intensive, toxic treatment; propensity for sudden, unexpected deterioration/death; and blurred transitions, where patients “dip up and down”, causing difficulties predicting prognosis and determining when to stop treatment. While haematology staff questioned “the rhetoric that the only good death is a home death’, and recognised that hospital deaths were appropriate and desired by some, others considered home death generally more preferable. Hospital admission/deaths were often precipitated by unrealistic expectations about home death and lack of 24-hour community care to facilitate this.

Conclusion

The complex, unpredictable nature of haematological malignancies biases towards hospital deaths. Provision of high quality, hospital-based end-of-life care is essential to patient/caregiver experiences. While some choose to die in hospital, others dying there may have different preferences. Community services should be adequately resourced to enable patients to make meaningful, deliverable choices about their end-of-life care.

References

House of Commons Health Committee. End of life care: Fifth report of session, 2014–2015. London: The Stationery Office Limited; 2015

National Cancer Intelligence Network. Where do patients with blood cancers die? London: Public Health England; 2010

Howell DA, Roman E, Cox H,et al. Destined to die in hospital? Systematic review and meta-analysis of place of death in haematological malignancy.BMC Palliat Care2010;9(9):1–8

Howell DA, Wang HI, Smith AG,et al. Place of death in haematological malignancy: variations by disease sub-type and time from diagnosis to death.BMC Palliat Care2013;12(42):1–8