Differences in trends in discharge location in a cohort of hospitalized patients with cancer and non-cancer diagnoses receiving specialist palliative care: A retrospective cohort study.

BACKGROUND: Patients with and without cancer are frequently hospitalized, and have specialist palliative care needs. In-hospital mortality can serve as a quality indicator of acute care. Trends in acute care outcomes have not previously been evaluated in patients with confirmed specialist palliative care needs or between diagnostic groups. AIM: To compare trends in discharge location between hospitalized patients with and without cancer who received specialist palliative care. DESIGN: Retrospective cohort study. Association between diagnosis (cancer, non-cancer) and in-hospital mortality was assessed using multivariable logistic regression, controlling for demographic, clinical, and admission-specific information. SETTING/PARTICIPANTS: Patients who received specialist palliative care at an academic tertiary hospital in Toronto, Canada from 2013 to 2019. RESULTS: The cohort comprised 6846 patients, 5024 with and 1822 without cancer. A higher proportion of patients without cancer had a Palliative Performance Scale score <30%, anticipated prognosis of <1 month, and were referred for end-of-life care (all p < 0.001). The adjusted odds of dying in hospital was 1.24-times higher among patients without cancer (95% CI: 1.05-1.46; p = 0.011). Though the proportion of patients without cancer who died in hospital decreased by 8.4% from 2013 to 2019, this proportion (41.2%) remained substantially higher compared to patients with cancer (14.0%) in 2019. CONCLUSIONS: Hospitalized patients without cancer were referred to specialist palliative care at a lower functional status, a poorer anticipated prognosis, and more likely for end-of-life care; and were more likely to die in hospital. Future studies are required to determine whether a proportion of hospital deaths in patients without cancer represent goal-discordant end-of-life care.

Improving timely transfers from acute care to the local palliative care unit for patients at the end of life.

BACKGROUND: Despite evidence showing that nearly two thirds of the Canadian population prefer to die at home, the majority die in hospital. Honoring a patient's wish for their preferred location of death is an essential component in end-of-life care. Therefore, for those patients admitted to acute care whose choice is to transfer to a palliative care unit for end-of-life care, it is imperative that this occurs in a safe and timely manner. The General Internal Medicine ward at this local tertiary care academic center, did not have a standardized process for transferring patients at the end-of-life to the local palliative care unit. With bed calls made between Monday to Saturday at 8 am, weekday and weekend transfer times ranged between 1 to 6 hours. The aim of this project was to establish a standardized, safe and efficient patient transfer from acute care to the palliative care unit for a daily standard arrival time. METHODS: A multidisciplinary quality improvement team was formed to analyze the transfer process. Several Plan Do Study Act cycles were tested, targeting all steps of the transfer process and turnaround time. An outcome measure aiming for a turnaround time of two hours was set as the target. RESULTS: A total of fourteen patient transfers were included. Average transfer time during the weekday was reduced from a baseline average of 180.2 to 128.3 min. This change was found to be statistically significant and sustained (P<0.003). The average transfer time on weekends remained stable at 234 min. The outcome target of a 10:00 am arrival time to the palliative care unit was achieved 42% of the time. CONCLUSIONS: This project remains on-going and early data is encouraging as it met the targeted transfer time 42% of the time. Fidelity in the process measures helped to meet the targeted turnaround time of two hours for a safe and efficient transfer to the palliative care unit and ensured patients got to their preferred location for end of life care. The goal is to expand this project to other general internal medicine wards across the organization.

Challenges in nursing care for patients with cancer and severe mental illness: A case report.

Patients with severe mental illness often present with more advanced cancer at diagnosis, experience poorer quality of care, receive fewer medical treatments, have higher overall disease mortality, and are less likely to access timely palliative care when compared to patients without severe mental illness. Research findings have shown that early involvement of specialized palliative care services for patients with advanced cancer improves quality of life, increases satisfaction with care, and mitigates depression. This case study will highlight the spectrum of challenges in caring for patients with a severe mental illness and advanced cancer from the perspective of an inpatient palliative care consult team.

Palliative and end-of-life care for the older adult with cancer.

PURPOSE OF REVIEW: Despite established benefits of palliative care in the oncology population, it remains an underutilized resource particularly among older adults. The illness trajectory and needs of an older adult with cancer are unique. The purpose of this paper is to review the current literature on providing comprehensive palliative and end-of-life care for the older adult with cancer. RECENT FINDINGS: Though the difficulties of applying traditional palliative care principles in the older patients with cancer have been discussed, this review reveals a clear gap in the literature in discussing the provision of comprehensive palliative and end-of-life care in this population. Very few articles have been published in this domain with even fewer published within the past 18 months. SUMMARY: As such, this article reviews key aspects of palliative and geriatric medicine that need to be considered and integrated in order to provide comprehensive palliative care to the older adult with cancer. This includes a discussion of proper pain and symptoms assessment, performance status assessment, advance care planning, and end-of-life care while considering the nuances of geriatric syndromes.

Minding the gap: access to palliative care and the homeless.

BACKGROUND: With an ever increasing number of individuals living with chronic and terminal illnesses, palliative care as an emerging field is poised for unprecedented expansion. Today's rising recognition of its key role in patients' illnesses has led to increased interest in access to palliative care. It is known that homelessness as a social determinant of health has been associated with decreased access to health resources in spite of poorer health outcomes and some would argue, higher need. This article aims to discuss the current state of affairs with regards to accessing palliative care for the homeless in Canada. DISCUSSION: Recent review of the literature reveals differential access to palliative care services and outcomes with differing socio-economic status (SES). Notably, individuals of lower SES and in particular, those who are homeless have poorer health outcomes in addition to poor access to quality palliative care. Current palliative care services are ill equipped to care for this vulnerable population and most programs are built upon an infrastructure that is prohibitive for the homeless to access its services. A preliminary review of existing Canadian programs in place to address this gap in access identified a paucity of sporadic palliative care programs across the country with a focus on homeless and vulnerably-housed individuals. It is apparent that there is no unified national strategy to address this gap in access. The changing landscape of the Canadian population calls for an expansion of palliative care as a field and as many have put it, as a right. The right to access quality palliative and end of life care should not be confined to particular population groups. This article calls for the development of a unified national strategy to address this glaring gap in our healthcare provision and advocates for attention to and adoption of policy and processes that would support the homeless populations' right to quality palliative care.

Low pregnancy-associated plasma protein A level in the first trimester.

OBJECTIVE: To review the recent evidence behind the association of low levels (ie, below the fifth percentile) of pregnancy-associated plasma protein A (PAPP-A) with adverse perinatal outcomes and to integrate new findings with the recommendations made by the Society of Obstetricians and Gynaecologists of Canada in 2008. QUALITY OF EVIDENCE: A review of recently published articles revealed that current evidence is sparse and mixed for the association of low PAPP-A level with small size for gestational age, preterm delivery, hypertensive disorders of pregnancy, and stillbirth. There is limited evidence that suggests an association between low PAPP-A levels and spontaneous pregnancy loss. Recent studies suggest that low PAPP-A levels are associated with abnormal placentation, which might be the root cause of the adverse perinatal outcomes of interest. MAIN MESSAGE: The evidence behind the association of low PAPP-A levels with adverse perinatal outcomes is both lacking and mixed. However, recent data do suggest an association between low PAPP-A levels and abnormal placentation. This emerging topic currently lacks strong evidence-based guidelines, yet has potential important implications for perinatal outcomes. Collaboration with obstetric specialists regarding pregnant women who have low PAPP-A levels in the context of normal first-trimester aneuploidy screening results might aid clinical decision making about pregnancy and placental surveillance. CONCLUSION: While the clinical meaning of a low PAPP-A level detected in the context of normal fetal aneuploidy screening remains under debate, pregnant patients with such results should be counseled that at present no strong evidence exists to justify an ongoing ultrasound surveillance program.

Generation and dissociation of oxygen- and chloride-bridged iron(III) and manganese(III) tetraphenylporphyrin dimer ions in the gas phase.

Electrospray ionization mass spectrometry (ESI/MS) has allowed the discovery of novel dimer ions emerging from solutions of metalloporphyrin salts and their investigation by collision-induced dissociation (CID) with N(2) molecules. ESI mass spectra have been recorded for the formation of the oxygen or chloride-bridged dimer ions [(FeTPP)(2)OH](+), [(MnTPP)(2)OH](+), [(FeTPP)(2)Cl](+) and [(MnTPP)(2)Cl](+) derived from various solutions of FeTPPCl and MnTPPCl salts. The CID of [(FeTPP)(2)OH](+) proceeds mainly by neutral loss of (FeTPP)OH to form [FeTPP](+) and, to a minor extent, to form the charge-reversed products. The CID of [(MnTPP)(2)OH](+) exhibits exclusively the product ion [MnTPP](+) by loss of neutral (MnTPP)OH. [(FeTPP)(2)Cl](+) and [(MnTPP)(2)Cl](+) dissociate by loss of (Fe/MnTPP)Cl to give rise to [Fe/MnTPP](+). [(FeTPP)(2)O](+) and [(FeTPP)(2)OH](+) were generated from a solution of the dimer, (FeTPP)(2)O. Dissociation of [(FeTPP)(2)O](+) yields two product ions, [FeTPP](+) and [(FeTPP)O](+), with higher onsets compared to the equivalent fragments formed from [(FeTPP)(2)OH](+).

High-content functional screen to identify proteins that correct F508del-CFTR function.

Cystic Fibrosis is caused by mutations in CFTR, with a deletion of a phenylalanine at position 508 (F508del-CFTR) representing the most common mutation. The F508del-CFTR protein exhibits a trafficking defect and is retained in the endoplasmic reticulum. Here we describe the development of a high-content screen based on a functional assay to identify proteins that correct the F508del-CFTR defect. Using a HEK293 MSR GripTite cell line that stably expresses F508del-CFTR, we individually co-expressed approximately 450 unique proteins fused to the Cl(-)-sensitive YFP(H148Q/I152L) mutant. We then tested correction of F508del-CFTR function by the CI(-)/l(-) exchange method following stimulation with forskolin/IBMX/genistein, using quantitative recordings in multiple individual cells with a high-content (high-throughput) Cellomics KSR imaging system. Using this approach, we identified several known and novel proteins that corrected F508del-CFTR function, including STAT1, Endothelin 1, HspA4, SAPK substrate protein 1, AP2M1, LGALS3/galectin-3, Trk-fused gene, Caveolin 2, PAP/REG3alpha, and others. The ability of these correctors to rescue F508del-CFTR trafficking was then validated by demonstrating their enhancement of maturation (appearance of band C) and by cell surface expression of F508del-CFTR bearing HA tag at the ectodomain using confocal microscopy and flow cytometry. These data demonstrate the utility of high-content analyses for identifying proteins that correct mutant CFTR and discover new proteins that stimulate this correction. This assay can also be utilized for RNAi screens to identify inhibitory proteins that block correction of F508del-CFTR, small molecule, and peptide screens.

Electron transfer and ligand addition to atomic mercury cations in the gas phase: kinetic and equilibrium studies at 295 k.

Results are reported for experimental measurements of the room-temperature chemical reactions between ground-state Hg*+ ions and 16 important environmental and biological gases: SF6, CO, CO2, N2O, D2O, CH4, CH3F, O2, CH3Cl, OCS, CS2, NH3, C6F6, NO2, NO*, and C6H6. The inductively coupled plasma/selected-ion flow tube tandem mass spectrometer used for these measurements has provided both rate and equilibrium constants. Efficient electron transfer (>19%) is observed with CS2, NH3, C6F6, NO2, NO*, and C6H6, molecular addition occurs with D2O, CH4, CH3F, CH3Cl, and OCS, and SF6, CO, CO2, N2O, and O2 showed no measurable reactivity with Hg*+. Theory is used to explore the stabilities and structures of both the observed and unobserved molecular adducts of Hg*+, and reasonable agreement is obtained with experimental observations, given the uncertainties of the theory and experiments. A correlation is reported between the Hg*+ and proton affinities of the ligands investigated. Solvation of Hg*+ with formic acid was observed to increase the rate of electron transfer from NO* by more than 20%.