Comparative Analysis of Palliative Care Needs Identified in Inpatient Rehabilitation and Skilled Nursing Facilities by Multidisciplinary Team Members.

OBJECTIVE: Assess access to, need for, and beliefs surrounding specialized palliative care (PC). DESIGN: Observational, comparative analysis needs assessment survey. SETTING: Four inpatient rehabilitation facilities (IRFs) or skilled nursing facilities with long-term care (SNFs/LTC) that provide subacute rehabilitation within 1 tertiary care system. PARTICIPANTS: Allied health professionals, physicians, nursing, case managers, social workers, spiritual care (n=198). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Frequency of patient needs, attitudes about current systems, individual beliefs, and barriers to PC. Confidence in management, communicating, and navigating primary PC competencies among clinical pathway employees. RESULTS: Of 198 respondents, 37% said PC was available at their facility. Those in IRF reported higher frequencies of grief/unmet spiritual needs of patients compared with SNF/LTC (P≤.001). Conversely, SNF/LTC reported higher frequencies of agitation, poor appetite, and end-of-life care (P≤.003). Respondents in SNF/LTC felt more confident managing end-of-life care, explaining what hospice and PC are and appropriateness for referral to each, discussing advance directives, determining appropriate decision-makers, and navigating ethical decisions than in IRFs (P≤.007). SNF/LTC participants reported higher effectiveness of their current system involving PC and ease of hospice transition compared with IRFs (P≤.008). A majority agreed that PC does not take away patient hope, could prevent recurrent hospitalizations, improve symptom management, communication, and patient and family satisfaction. The most common reported barriers to PC consultation were (1) attitudes and beliefs of staff or patients and families, (2) system issues with access, cost, or prognosis communication, and (3) lack of understanding of PC role. CONCLUSIONS: A gap exists in PC access in IRF and SNF/LTC despite patient needs and staff beliefs. Future studies should focus on identifying which patients should be referred to PC in the post-acute setting and what outcomes can be used as a guide to meet the needs of this growing area of practice.

Presenilin influences glycogen synthase kinase-3 ß (GSK-3ß) for kinesin-1 and dynein function during axonal transport.

Within axons, molecular motors transport essential components required for neuronal growth and viability. Although many levels of control and regulation must exist for proper anterograde and retrograde transport of vital proteins, little is known about these mechanisms. We previously showed that presenilin (PS), a gene involved in Alzheimer's disease (AD), influences kinesin-1 and dynein function in vivo. Here, we show that these PS-mediated effects on motor protein function are via a pathway that involves glycogen synthase kinase-3ß (GSK-3ß). PS genetically interacts with GSK-3ß in an activity-dependent manner. Excess of active GSK-3ß perturbed axonal transport by causing axonal blockages, which were enhanced by reduction of kinesin-1 or dynein. These GSK-3ß-mediated axonal defects do not appear to be caused by disruptions or alterations in microtubules (MTs). Excess of non-functional GSK-3ß did not affect axonal transport. Strikingly, GSK-3ß-activity-dependent axonal transport defects were enhanced by reduction of PS. Collectively, our findings suggest that PS and GSK-3ß are required for normal motor protein function. Our observations propose a model, in which PS likely plays a role in regulating GSK-3ß activity during transport. These findings have important implications for our understanding of the complex regulatory machinery that must exist in vivo and how this system is coordinated during the motility of vesicles within axons.

A Call for the Creation of LGBTQ+ Competencies for Hospice and Palliative Medicine (HPM) Fellowship Programs.

CONTEXT: LGBTQ+ people and their families have unique needs, concerns, and issues when navigating serious illness. OBJECTIVES: To develop curricular milestones and an educational framework for hospice and palliative medicine (HPM) fellowship programs to meet the needs of this community. METHODS: A working group has developed a plan for the inclusion of LGBTQ+ competencies in HPM fellowship programs, utilizing input from an AAHPM Special Interest Group (SIG) at a national meeting. DISCUSSION: Learning to provide culturally competent care is essential for all HPM providers. Our group recommends specific clinical training competencies with plans to pilot them in upcoming academic years. Creating curricular recommendations will help guide fellowship programs education in the care of LGBTQ+ patients with serious illness.

Central poststroke pain: A systematic review.

Background Physical, psychological, and/or social impairment can result after a stroke and can be exacerbated by pain. One type of pain after stroke, central poststroke pain, is believed to be due to primary central nervous system mechanisms. Estimated prevalence of central poststroke pain ranges widely from 8% to 55% of stroke patients, suggesting a difficulty in reliably, accurately, and consistently identifying central poststroke pain. This may be due to the absence of a generally accepted definition. Aim We aimed to clarify the role of thalamic strokes and damage to the spinothalamic pathway in central poststroke pain patients. Also, we aimed to gain a current understanding of anatomic substrates, brain imaging, and treatment of central poststroke pain. Summary of review Two independent reviewers identified 10,144 publications. Based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, we extracted data from 23 papers and categorized the articles' aims into four sections: somatosensory deficits, pathway stimulation, clinical trials, and brain imaging. Conclusions Our systematic review suggests that damage to the spinothalamic pathway is associated with central poststroke pain and this link could provide insights into mechanisms and treatment. Moreover, historical connection of strokes in the thalamic region of the brain and central poststroke pain should be reevaluated as many studies noted that strokes in other regions of the brain have high occurrence of central poststroke pain as well.