Building a Cardiac Palliative Care Program: A Qualitative Study of the Experiences of Ten Program Leaders From Across the United States.

CONTEXT: Palliative care is guideline-recommended for patients with advanced heart failure (HF). However, studies on how cardiac palliative care is provided in the United States are lacking. OBJECTIVES: To study how cardiac palliative care programs provide services, and to identify challenges and facilitators they encountered in program development. METHODS: In this qualitative descriptive study, we used purposive and snowball sampling approaches to identify cardiac palliative care program leaders across the United States, administered a survey and conducted semi-structured interviews. Interview transcripts were coded and evaluated using thematic analysis. RESULTS: While cardiac palliative care programs vary in their organizational setup, they all provide comprehensive interdisciplinary palliative care services, ideally across the care continuum. They predominantly serve HF patients who are evaluated for advanced therapies or have complex needs. The challenges which cardiac palliative care programs face include reaching those cardiac patients who need palliative care the most and collaborating with cardiologists who do not see value added from palliative care for their patients. Facilitators of cardiac palliative care program development include building personal relationships with cardiology providers, proactively assessing local institution needs, and tailoring palliative care services to meet patient and provider needs. CONCLUSION: Cardiac palliative care programs vary in their organizational setup but provide similar services and face similar challenges. The challenges and facilitators we identified can inform the development of future cardiac palliative care programs.

Derivation of algal acute to chronic ratios for use in chemical toxicity extrapolations.

Algal toxicity studies are required by regulatory agencies for a variety of purposes including classification and labeling and environmental risk assessment of chemicals. Algae are also frequently the most sensitive taxonomic group tested. Acute to chronic ratios (ACRs) have been challenging to derive for algal species because of the complexities of the underlying experimental data including: a lack of universally agreed upon algal inhibition endpoints; evolution of experimental designs over time and by different standardization authorities; and differing statistical approaches (e.g., regression versus hypothesis-based effect concentrations). Experimental data for developing globally accepted algal ACRs have been limited because of data availability, and in most regulatory frameworks an ACR of 10 is used regardless of species, chemical type or mode of action. Acute and chronic toxicity (inhibition) data on 17 algal species and 442 chemicals were compiled from the EnviroTox database (https://envirotoxdatabase.org/) and a proprietary database of algal toxicity records. Information was probed for growth rate, yield, and final cell density endpoints focusing primarily on studies of 72 and 96 h duration. Comparisons of acute and chronic data based on either single (e.g., growth rate) and multiple (e.g., growth rate, final cell density) endpoints were used to assess acute and chronic relationships. Linear regressions of various model permutations were used to compute ACRs for multiple combinations of taxa, chemicals, and endpoints, and showed that ACRs for algae were consistently around 4 (ranging from 2.43 to 5.62). An ACR of 4 for algal toxicity is proposed as an alternative to a default value of 10, and recommendations for consideration and additional research and development are provided.

Mode of Action Classifications in the EnviroTox Database: Development and Implementation of a Consensus MOA Classification.

Multiple mode of action (MOA) frameworks have been developed in aquatic ecotoxicology, mainly based on fish toxicity. These frameworks provide information on a key determinant of chemical toxicity, but the MOA categories and level of specificity remain unique to each of the classification schemes. The present study aimed to develop a consensus MOA assignment within EnviroTox, a curated in vivo aquatic toxicity database, based on the following MOA classification schemes: Verhaar (modified) framework, Assessment Tool for Evaluating Risk, Toxicity Estimation Software Tool, and OASIS. The MOA classifications from each scheme were first collapsed into one of 3 categories: non-specifically acting (i.e., narcosis), specifically acting, or nonclassifiable. Consensus rules were developed based on the degree of concordance among the 4 individual MOA classifications to attribute a consensus MOA to each chemical. A confidence rank was also assigned to the consensus MOA classification based on the degree of consensus. Overall, 40% of the chemicals were classified as narcotics, 17% as specifically acting, and 43% as unclassified. Sixty percent of chemicals had a medium to high consensus MOA assignment. When compared to empirical acute toxicity data, the general trend of specifically acting chemicals being more toxic is clearly observed for both fish and invertebrates but not for algae. EnviroTox is the first approach to establishing a high-level consensus across 4 computationally and structurally distinct MOA classification schemes. This consensus MOA classification provides both a transparent understanding of the variation between MOA classification schemes and an added certainty of the MOA assignment. In terms of regulatory relevance, a reliable understanding of MOA can provide information that can be useful for the prioritization (ranking) and risk assessment of chemicals. Environ Toxicol Chem 2019;38:2294-2304. © 2019 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals, Inc. on behalf of SETAC.

Evolution and Conceptual Foundations of Nonhospice Palliative Care.

The term nonhospice palliative care was developed to describe and differentiate palliative care that is delivered prior to the end of life. The purpose of this article is to better define and clarify this concept using Rodgers's evolutionary concept analysis method. Attributes of nonhospice palliative care include (a) patient- and family-centered care, (b) holistic care, (c) interdisciplinary team, (d) early intervention, (e) quality of life-enhancing, (f) advanced care planning, (g) any age of the patient, (h) at any stage in illness, (i) care coordination, (j) concurrent curative treatment options, and (k) provided by primary and specialist providers. Nonhospice palliative care antecedents are serious illness, education, and access to services; consequences include benefits for the patient, family, provider, and health care system. Offering a clearly defined concept may allow for changes in health care to improve access to these services.

Creation of a Curated Aquatic Toxicology Database: EnviroTox.

Flexible, rapid, and predictive approaches that do not require the use of large numbers of vertebrate test animals are needed because the chemical universe remains largely untested for potential hazards. Development of robust new approach methodologies and nontesting approaches requires the use of existing information via curated, integrated data sets. The ecological threshold of toxicological concern (ecoTTC) represents one such new approach methodology that can predict a conservative de minimis toxicity value for chemicals with little or no information available. For the creation of an ecoTTC tool, a large, diverse environmental data set was developed from multiple sources, with harmonization, characterization, and information quality assessment steps to ensure that the information could be effectively organized and mined. The resulting EnviroTox database contains 91 217 aquatic toxicity records representing 1563 species and 4016 unique Chemical Abstracts Service numbers and is a robust, curated database containing high-quality aquatic toxicity studies that are traceable to the original information source. Chemical-specific information is also linked to each record and includes physico-chemical information, chemical descriptors, and mode of action classifications. Toxicity data are associated with the physico-chemical data, mode of action classifications, and curated taxonomic information for the organisms tested. The EnviroTox platform also includes 3 analysis tools: a predicted-no-effect concentration calculator, an ecoTTC distribution tool, and a chemical toxicity distribution tool. Although the EnviroTox database and tools were originally developed to support ecoTTC analysis and development, they have broader applicability to the field of ecological risk assessment. Environ Toxicol Chem 2019;9999:1-12. © 2019 The Authors. Environmental Toxicology and Chemistry published by Wiley Periodicals, Inc. on behalf of SETAC.

Models of non-hospice palliative care: a review.

Palliative care offers patients with a serious illness and their families access to services that can improve quality of life, mood, and symptoms. However, the term palliative care is often confused with end of life or hospice services limiting its application to persons with chronic illnesses who might benefit. Non-hospice palliative care is a term that is emerging to more accurately reflect the broader care model that palliative care represents. The aim of this review was to identify the characteristics of published nonhospice palliative care interventions. We derived our sample predominantly from a recently published systematic review and meta-analysis and selected studies published since the review. Inclusion criteria were: self-described palliative care intervention studies using randomized designs for participants with lifelimiting illnesses aged 18 years or older. These 38 studies fell into 3 broad categories: primary, specialty, and hybrid models. Common challenges among these models include limited education of generalists, limited reimbursement, and limited access in certain areas. However, increasing palliative care usage has also been associated with increased hospice use and appropriate timing of referrals.

Assessing the reliability of ecotoxicological studies: An overview of current needs and approaches.

In general, reliable studies are well designed and well performed, and enough details on study design and performance are reported to assess the study. For hazard and risk assessment in various legal frameworks, many different types of ecotoxicity studies need to be evaluated for reliability. These studies vary in study design, methodology, quality, and level of detail reported (e.g., reviews, peer-reviewed research papers, or industry-sponsored studies documented under Good Laboratory Practice [GLP] guidelines). Regulators have the responsibility to make sound and verifiable decisions and should evaluate each study for reliability in accordance with scientific principles regardless of whether they were conducted in accordance with GLP and/or standardized methods. Thus, a systematic and transparent approach is needed to evaluate studies for reliability. In this paper, 8 different methods for reliability assessment were compared using a number of attributes: categorical versus numerical scoring methods, use of exclusion and critical criteria, weighting of criteria, whether methods are tested with case studies, domain of applicability, bias toward GLP studies, incorporation of standard guidelines in the evaluation method, number of criteria used, type of criteria considered, and availability of guidance material. Finally, some considerations are given on how to choose a suitable method for assessing reliability of ecotoxicity studies. Integr Environ Assess Manag 2017;13:640-651. © 2016 The Authors. Integrated Environmental Assessment and Management published by Wiley Periodicals, Inc. on behalf of Society of Environmental Toxicology & Chemistry (SETAC).

Dyspnea Management of Hospice Patients.

Up to 70% of hospice patients are reported to experience dyspnea at end of life. Despite the high prevalence of this burdensome symptom, there is little in the literature to guide effective treatment. Assessment of subjective symptoms and objective signs as well as physical, psychospiritual, sociocultural, or environmental barriers is critical to an effective plan of care. The purpose of the article is to review the current literature on assessment and management of dyspnea in hospice patients and provide implications for hospice clinicians.

Evaluation and comparison of the relationship between NOEC and EC10 or EC20 values in chronic Daphnia toxicity testing.

Hypothesis-based no-effect-concentration (NOEC) and regression-based x% effect concentration (ECx) values are common statistical approaches used to summarize ecotoxicological effects. Controversy over the NOEC model has prompted a movement toward discontinuation of the NOEC in favor of ECx, but the best x% effect surrogate for NOEC has not yet been determined. Historically, 10% and 20% effect concentrations (EC10 and EC20) have been treated as NOEC analogs. Given these measurements' importance to ecotoxicology, further understanding of the relationships between NOEC and EC10 or EC20 is crucial. In the present study, a metadataset of daphnid chronic toxicity tests was compiled to analyze the strength and significance of NOEC:EC10 and NOEC:EC20 relationships. The impact of endpoint (e.g., mortality, reproduction) and test condition parameters (e.g., pH, temperature) on NOEC:EC10 and NOEC:EC20 was evaluated. Mortality endpoints were most sensitive 51% of the time, with growth and reproductive endpoints constituting the remainder, underscoring the value of using multiple endpoints to evaluate toxic effects rather than relying on reproduction as the a priori most sensitive endpoint. When test condition parameters were less restricted (e.g., pH, hardness), the NOEC:EC20 association was more robust, suggesting that variability introduced by test implementation increased variability in ECx calculation. The analysis revealed that, overall, EC10 was a more suitable analog than EC20 for NOEC. Recommendations include refinement and reporting of the test parameters pH and hardness to minimize variability in ECx calculation.

Stepwise Information-Filtering Tool (SIFT): A method for using risk assessment metadata in a nontraditional way.

Tools exist to evaluate large ecotoxicity databases for risk assessment purposes, but these tools are less useful for alternative analytical purposes. In the present study, the authors developed the Stepwise Information-Filtering Tool (SIFT), a strategic method to select relevant, reliable data from a large ecotoxicity database; demonstrated utility in a case study of chronic toxicity data for statistical endpoint comparison purposes; and evaluated SIFT by comparison with 2 existing data evaluation methods.

A molecular method for assessing the effects of potential contaminants on the rate of zebrafish (Danio rerio) development.

Monitoring expression of the developmentally regulated genes shh, sox2, and tnnt1 by reverse transcriptase polymerase chain reaction (RT-PCR) allows determination of the rate of embryogenesis in zebrafish (Danio rerio) embryos without direct visual observation. The utility of combining this approach and morphological methods during toxicity studies was demonstrated with embryos developing at either 28.5 °C or 24.5 °C and with embryos exposed to sublethal doses of silver nanoparticles.

Consistency of morphological endpoints used to assess developmental timing in zebrafish (Danio rerio) across a temperature gradient.

Zebrafish (Danio rerio) are model organisms for testing developmental toxicity at the morphological level. In this study, influence of temperature (24.5-28.5°C) and silver nanoparticles on developmental staging, ear-eye distance, and ratio of ear-eye distance to inner ear diameter was investigated. As temperature decreased, all endpoints showed developmental delay, with differences between endpoints in amount and type of delay measured. Differences in developmental delay patterns were observed, with rate delays increasing over time when staging endpoints were utilized and rates remaining constant when using ear-eye measurements. Integrated predictive equations were created to normalize each endpoint for temperature. Influence of image rotation on ear-eye distance accuracy showed that more than 75% eye overlap during analysis is necessary to minimize error. Exposure to silver nanoparticles demonstrated a lack of consistency between developmental endpoints and highlighted the usefulness of a multi-endpoint approach when measuring changes to developmental timing.

The effects of blood pressure on rebleeding when using ExcelArrest™ in a porcine model of lethal femoral injury.

BACKGROUND: Uncontrolled hemorrhage is one of the leading causes of death in both combat and civilian trauma. This study was designed to compare the arterial blood pressures at which rebleeding occurred when a hemostatic agent, ExcelArrest™, was used compared with a standard pressure dressing. MATERIALS AND METHODS: This study was a prospective, experimental, and mixed research design. Swine were assigned to one of two groups: ExcelArrest™ (n=5) or a control consisting of standard pressure dressings (n=5). Investigators generated a complex groin injury. The femoral artery and vein were transected and allowed to bleed for 60 s in each pig. After 60 s, ExcelArrest™ was poured into the wound. The control group underwent the same procedures, but without treatment with the hemostatic agent. After 5 min of direct pressure, a standard pressure dressing was applied. After 30 min, dressings were removed and the systolic blood pressure (SBP) was increased incrementally using intravenous phenylephrine until rebleeding occurred. STATISTICAL ANALYSIS: A multivariate ANOVA and a least significant difference were used to analyze the data. RESULTS: ExcelArrest™ was more effective in preventing rebleeding compared to a standard pressure dressing (P<0.05). The means and standard deviations in mmHg for SBP and mean arterial pressure (MAP) for rebleeding were as follows: ExcelArrest™ (SBP=206.4, SD±11.6; MAP=171.4, SD±12.5); for the control group (SBP=89.40±3.58, MAP=58.60±12.86). CONCLUSIONS: ExcelArrest™ was more effective in preventing rebleeding compared to the standard dressing with elevated blood pressures. There may be protective benefits in using this hemostatic agent against elevated blood pressures provided by ExcelArrest™.

Treating patients with smallpox in the operating room.

Recent events around the world have emphasized the need for health care facilities to prepare to deal with biological threats, including smallpox. At Walter Reed Army Medical Center, Washington, DC, administrators recognized the need for a policy on handling patients with smallpox in the OR and asked a group of students to create a template policy for care of patients with smallpox in need of surgery. This article provides a brief history of smallpox, concerns surrounding smallpox today, and smallpox characteristics with which perioperative personnel should be familiar, as well as a guideline for treating patients in the OR who have smallpox.