Integrating lived experiences of out-of-hours health services for people with palliative and end-of-life care needs with national datasets for people dying in Scotland in 2016: A mixed methods, multi-stage design.

BACKGROUND: Unscheduled care is used increasingly during the last year of life by people known to have significant palliative care needs. AIM: To document the frequency and patterns of use of unscheduled healthcare by people in their last year of life and understand the experiences and perspectives of patients, families and professionals about accessing unscheduled care out-of-hours. DESIGN: A mixed methods, multi-stage study integrating a retrospective cohort analysis of unscheduled healthcare service use in the last year of life for all people dying in Scotland in 2016 with qualitative data from three regions involving service users, bereaved carers and general practitioners. SETTING: Three contrasting Scottish Health Board regions and national datasets for the whole of Scotland. RESULTS: People who died in Scotland in 2016 (n = 56,407) had 472,360 unscheduled contacts with one of five services: telephone advice, primary care, ambulance service, emergency department and emergency hospital admission. These formed 206,841 individual continuous unscheduled care pathways: 65% starting out-of-hours. When accessing healthcare out-of-hours, patients and carers prioritised safety and a timely response. Their choice of which service to contact was informed by perceptions and previous experiences of potential delays and whether the outcome might be hospital admission. Professionals found it difficult to practice palliative care in a crisis unless the patient had previously been identified. CONCLUSION: Strengthening unscheduled care in the community, together with patient and public information about how to access these services could prevent hospital admissions of low benefit and enhance community support for people living with advanced illness.

Short-term dietary nitrate supplementation augments cutaneous vasodilatation and reduces mean arterial pressure in healthy humans.

Nitrate supplementation in the form of beetroot juice has been shown to increase nitric oxide (NO) where nitrate can be reduced to nitrite and, subsequently, to NO through both nitric oxide synthase (NOS)-dependent and -independent pathways. We tested the hypothesis that nitrate supplementation would augment the NO component of the cutaneous vasodilatation to local skin heating in young, healthy humans. Participants reported to the lab for pre- and post-supplement local heating protocols. Nitrate supplementation consisted of one shot (70 ml) of beetroot juice (0.45 g nitrate; 5mM) for three days. Six participants were equipped with two microdialysis fibers on the ventral forearm and randomly assigned to lactated Ringer's (control) or continuous infusion of 20mM l-NAME (NOS inhibitor). The control site was subsequently perfused with l-NAME once a plateau in skin blood flow was achieved to quantify NOS-dependent cutaneous vasodilatation. Skin blood flow via laser-Doppler flowmetry (LDF) and mean arterial pressure (MAP) were measured; cutaneous vascular conductance (CVC) was calculated as LDF/MAP and normalized to %CVCmax. Beetroot juice reduced MAP (Pre: 90 ± 1 mmHg vs. Post: 83 ± 1 mmHg) and DBP (Pre: 74 ± 2 mmHg vs. Post: 62 ± 3 mmHg) (P<0.05). The plateau phase of the local heating response at control sites was augmented post-beetroot juice (91 ± 5%CVCmax) compared to pre-beetroot juice (79 ± 2%CVCmax) (P<0.05). There was no difference in the %NOS-dependent vasodilatation from pre- to post-beetroot juice. These data suggest that nitrate supplementation via beetroot juice can reduce MAP and DBP as well as augment NOS-independent vasodilatation to local heating in the cutaneous vasculature of healthy humans.

Augmented reflex cutaneous vasodilatation following short-term dietary nitrate supplementation in humans.

NEW FINDINGS: What is the central question of this study? Nitrate supplementation via beetroot juice has been shown to have several benefits in healthy humans, including reduced blood pressure and increased blood flow to exercising muscle. Whether nitrate supplementation can improve blood flow to the skin in heat-stressed humans has not been investigated. What is the main finding and its importance? Similar to previous studies, we found that nitrate supplementation reduces blood pressure. Nitrate supplementation increased vasodilatation in the skin of heat-stressed humans but did not directly increase skin blood flow. Nitrate supplementation has been shown to increase NO-dependent vasodilatation through both NO synthase (NOS)-dependent and NOS-independent pathways. We hypothesized that nitrate supplementation would augment reflex cutaneous active vasodilatation. Subjects were equipped with two microdialysis fibres on the forearm randomly assigned as control (Ringer solution) or NOS inhibition (20 mm l-NAME). Whole-body heating was performed to raise core temperature by 0.8°C above baseline core temperature. Maximal cutaneous vasodilatation was achieved via 54 mm sodium nitroprusside and local heating to 43°C. Skin blood flow (measured by laser-Doppler flowmetry) and blood pressure were measured. Cutaneous vascular conductance (CVC) was calculated as skin blood flow divided by mean arterial pressure (MAP) and expressed as a percentage of maximal CVC (%CVCmax ). Subjects underwent heat stress before and after nitrate supplementation (3 days of beetroot juice; 5 mm, 0.45 g nitrates per day). During heat stress, MAP was reduced following nitrate supplementation compared with the control conditions (before 88 ± 3 mmHg versus after 78 ± 2 mmHg; P < 0.05); however, resting MAP was not different between conditions (before 88 ± 3 mmHg versus after 83 ± 2 mmHg; P = 0.117). Nitrate supplementation increased plateau CVC at control sites (before 67 ± 2%CVCmax  versus after 80 ± 5%CVCmax ; P = 0.01) but not at l-NAME-treated sites (before 45 ± 4%CVCmax  versus after 40 ± 5%CVCmax ; P = 0.617). There was no change in the calculated percentage of NOS-dependent vasodilatation before and after supplementation (before 59 ± 4% versus after 64 ± 6%; P = 0.577). These data suggest that nitrate supplementation augments CVC and reduces MAP during heat stress.

Endothelial nitric oxide synthase mediates the nitric oxide component of reflex cutaneous vasodilatation during dynamic exercise in humans.

Recent data suggests neuronal nitric oxide synthase (nNOS) mediates the NO component of reflex cutaneous vasodilatation with passive heat stress. We tested the hypothesis that nNOS inhibition would attenuate reflex cutaneous vasodilatation during sustained dynamic exercise in young healthy humans. All subjects first performed an incremental V̇O2, peak test to exhaustion on a custom-built supine cycle ergometer. On a separate day, subjects were instrumented with four intradermal microdialysis fibres on the forearm and each randomly assigned as: (1) lactated Ringer's (control); (2) 20 mm Nω-nitro-l-arginine methyl ester hydrochloride (non-selective NOS inhibitor); (3) 5 mm N-propyl-l-arginine (nNOS inhibitor); and (4) 10 mm N(5)-(1-iminoethyl)-l-ornithine dihydrochloride [endothelial NOS (eNOS) inhibitor]. Following microdialysis placement, subjects performed supine cycling with the experimental arm at heart level at 60% V̇O2, peak for a period sufficient to raise core temperature 0.8°C. At the end of cycling, all microdialysis sites were locally heated to 43°C and sodium nitroprusside was perfused to elicit maximal vasodilatation. Mean arterial pressure, skin blood flow via laser-Doppler flowmetry and core temperature via ingestible telemetric pill were measured continuously; cutaneous vascular conductance (CVC) was calculated as laser-Doppler flowmetry/mean arterial pressure and normalized to maximum. There was no significant difference between control (58 ± 2%CVCmax) and nNOS-inhibited (56 ± 3%CVCmax) sites in response to exercise-induced hyperthermia. The increase in CVC at eNOS-inhibited (41 ± 3%CVCmax) and non-selective NOS-inhibited (40 ± 4%CVCmax) sites were significantly attenuated compared to control and nNOS-inhibited (P < 0.001 all conditions) but there was no difference between eNOS-inhibited and non-selective NOS-inhibited sites. These data suggest eNOS, not nNOS, mediate NO synthesis during reflex cutaneous vasodilatation with sustained dynamic exercise.

Last Aid Training Online: Participants' and Facilitators' Perceptions from a Mixed-Methods Study in Rural Scotland.

(1) Background: Palliative and end-of-life care services are increasingly gaining centre stage in health and social care contexts in the UK and globally. Death and dying need are relational processes. Building personal and community capacity along with resilience is vital to support families and communities to normalise death and dying. Last Aid Training (LAT) is one such innovative educational initiative which teaches the general public about the fundamentals of palliative care and promotes public discussion about death and dying. The Highland Hospice [HH] in Scotland has pioneered delivery of LAT in face-to-face settings since March 2019 and online since March 2020 to accommodate pandemic restrictions. (2) Methods: This study used a mixed-methods approach, combining an online survey with LAT participants followed by individual semi-structured qualitative interviews with both LAT participants and facilitators. The primary aim of this study was to investigate the impacts of LAT for participants at the individual, family, and community levels, as well as explore participant and facilitator experiences and perspectives of LAT in an online environment. (3) Results: Overall, this evaluation demonstrates that provision of foundational death literacy education in social contexts enhances the personal knowledge, skills, and confidence of individual community members and supports the notion that this personal growth could lead to strengthened community action. (4) Conclusions: Findings from this study concluded that there is potential to include LAT as the foundational core training to promote death literacy in communities with further exploration to integrate/align LAT with other national/global end-of-life care frameworks.

Symptoms of depression and delirium assessed serially in palliative-care inpatients.

BACKGROUND: Delirium occurs in approximately 1 in 5 general hospital admissions and up to 85% of patients with terminal illness, but can be difficult to differentiation from other disorders, such as depression. OBJECTIVE: The authors assessed and compared mood states as they relate to onset of delirium. METHOD: Symptoms of depression and delirium were assessed in 100 consecutive palliative-care admissions immediately after admission and 1 week later. RESULTS: Overall, 51% experienced either major depression or delirium. Most patients with syndromal delirium also met criteria for major depressive illness, and 50% of those with depression had delirium or subsyndromal delirium (SSD). Delirium symptoms were less common in patients with major depression than depressive symptoms in patients with delirium or SSD. DISCUSSION: Delirium should be considered in patients with altered mood states, and screening for depression should initially rule out delirium. Sustained alterations in mood may be more frequent in delirium than previously recognized.

Perceptions of the use of a remote monitoring system in patients receiving palliative care at home.

In remote communities, where frequent face-to-face contact with health professionals may be difficult, the ongoing review and management of symptoms--a fundamental part of good palliative care--can be difficult to achieve. Telecare and other developments in information technology are increasingly being sought as a means of addressing shifting population demographics and rising demands on stretched health services, and may help in providing a system which allows patients to report their symptoms as they are happening. This may be one way of enhancing symptom management and improving quality of care at the end of life. A study testing the feasibility of using mobile phone-based technology (Advanced Symptom Management System in Palliative Care (ASyMSp)) to monitor and manage symptoms reported by patients being cared for at home in the advanced stages of their illness was carried out in two rural communities in the north of Scotland. The results of this study show that the system was usable and acceptable to patients and the health professionals who cared for them.

Cutaneous reactive hyperaemia is unaltered by dietary nitrate supplementation in healthy humans.

The purpose of this study was to determine whether nitrate supplementation augments cutaneous reactive hyperaemia. Seven participants were tested pre- and postnitrate supplementation (25 ml beetroot juice); participants consumed one shot per day for 3 days. Participants were instrumented with two microdialysis fibres: control (Ringer's solution) and NO synthase inhibition (20 mM L-NAME). Skin blood flow was measured via laser-Doppler flowmetry (LDF). A blood pressure cuff was placed on the experimental arm and inflated to 250 mmHg for 5 mins to occlude arterial inflow. The cuff was released, and the resultant reactive hyperaemia was measured. Blood pressure was continuously measured via plethysmography from a finger on the non-experimental arm. Cutaneous vascular conductance was calculated (LDF/MAP) and normalized to maximal vasodilatation (%CVCmax ). Only diastolic blood pressure was reduced following nitrate supplementation (71 ± 2 vs. 66 ± 1 mmHg; P<0·05). There was no effect of nitrate supplementation on peak reactive hyperaemia at control (Pre: 52 ± 3 vs. Post: 57 ± 2%CVCmax ) or L-NAME (Pre: 52 ± 2 vs. Post: 59 ± 4%CVCmax ) sites. There was no effect of nitrate supplementation on total reactive hyperaemia at either control (Pre: 4197 ± 943 vs. Post: 4523 ± 1040%CVCmax * sec) or L-NAME (Pre: 5108 ± 997 vs. Post: 5694 ± 1002%CVCmax * sec) sites. These data suggest cutaneous reactive hyperaemia is unaffected by dietary nitrate supplementation in healthy humans.

Hypoactive delirium: assessing the extent of the problem for inpatient specialist palliative care.

Delirium is a common problem and cause of distress among patients with palliative care needs. The focus to date has been on managing the patient with agitated, hyperactive delirium, as these patients are very noticeable within the palliative care setting. This study in two parts shows that palliative care patients with agitated delirium are a minority of the total proportion of those with delirium. Part I: 100 acute admissions to a specialist palliative care unit were assessed and while 29% were found to have delirium, 86% of these had the hypoactive subtype of delirium. We also demonstrated a positive correlation between high ratings on a depression screening tool and delirium severity ratings. Part II: 8 specialist palliative care units took part in a point prevalence study of delirium over a 48-hour period. One hundred and nine patients were assessed and while 29.4% of these inpatients had delirium, 78% of them had the hypoactive subtype. Patients with hypoactive delirium may be much less noticeable or may be misdiagnosed as having depression or fatigue and the results of this study would advocate the routine use of delirium screening tools in all palliative care settings.