Palliative care is not associated with decreased intensity of care: Results of a chart review from a large children's hospital.

BACKGROUND: Palliative care is an important component of pediatric oncology care, especially for children who will not be cured of their disease. However, barriers remain to integration of this service. One barrier is the perception that it indicates "giving up." This study examined if palliative care involvement was associated with a decreased intensity of care at the end of life for children with malignancy at a large academic center with a well-established palliative care program. PROCEDURE: This is a retrospective chart review that measured intensity of care as the number of emergency department visits, hospital days, and intensive care unit days in the last one and three months of life. The data were compared for patients with and without palliative care involvement and with and without hospice involvement. RESULTS: Palliative involvement was not associated with a decrease in the intensity of care in the last three months of life. Hospice care was associated with a decreased intensity of care. These results held true in analyses adjusted for age at death, gender, and type of malignancy. CONCLUSIONS: These data can reassure patients, families, and providers that palliative involvement does not necessitate decreased intensity of care. Patients and families often choose hospice care to decrease the amount of time spent at the hospital and it was associated with meeting that goal.

The burden of migraine on acute and emergency services in a London teaching hospital.

OBJECTIVE: There is a lack of data on the burden of primary headache disorders such as migraine on emergency services. Existing data relies on a coding of "headache", which encompasses both primary and secondary headache of all causes; for example, subarachnoid haemorrhage. Guy's and St Thomas' NHS Trust in London is one of the UK's busiest emergency departments with 150,000 attendances per year. Our aim was to assess the healthcare resource utilisation of primary headaches, in particular migraine, in acute medical services. METHODS: We conducted an audit of all adult presentations to the emergency department of Guy's and St Thomas' Hospitals which were coded as "headache" over the first 6 months of 2018. We reviewed the initial diagnosis at presentation and also at discharge, investigations and outcome. RESULTS: Of 78,273 attendances to the emergency department, there were 976 presentations to the emergency department with "headache" as their primary complaint. "Migraine" was the most frequent of all diagnoses, accounting for 30% of all headache presentations and 25% of headache admissions. We calculated the cost of admitting and investigating migraine as £131,250 over the 6-month period. CONCLUSION: Emergency admissions for migraine represent an avoidable cost and burden for both the hospital and the migraineur. This data informs us about the need to develop better care pathways for migraine in the community and to improve headache education for physicians and patients.

RNase I regulates Escherichia coli 2',3'-cyclic nucleotide monophosphate levels and biofilm formation.

Regulation of nucleotide and nucleoside concentrations is critical for faithful DNA replication, transcription, and translation in all organisms, and has been linked to bacterial biofilm formation. Unusual 2',3'-cyclic nucleotide monophosphates (2',3'-cNMPs) recently were quantified in mammalian systems, and previous reports have linked these nucleotides to cellular stress and damage in eukaryotes, suggesting an intriguing connection with nucleotide/nucleoside pools and/or cyclic nucleotide signaling. This work reports the first quantification of 2',3'-cNMPs in Escherichia coli and demonstrates that 2',3'-cNMP levels in E. coli are generated specifically from RNase I-catalyzed RNA degradation, presumably as part of a previously unidentified nucleotide salvage pathway. Furthermore, RNase I and 2',3'-cNMP levels are demonstrated to play an important role in controlling biofilm formation. This work identifies a physiological role for cytoplasmic RNase I and constitutes the first progress toward elucidating the biological functions of bacterial 2',3'-cNMPs.

Engaging Law Enforcement in Overdose Reversal Initiatives: Authorization and Liability for Naloxone Administration.

Opioid overdose is reversible through the timely administration of naloxone, which has been used by emergency medical services for decades. Law enforcement officers (LEOs) are often the first emergency responders to arrive at an overdose, but they are not typically equipped with naloxone. This is rapidly changing; more than 220 law enforcement agencies in 24 states now carry naloxone. However, rollout in some departments has been hampered by concerns regarding officer and agency liability. We systematically examined the legal risk associated with LEO naloxone administration. LEOs can be authorized to administer naloxone through a variety of mechanisms, and liability risks related to naloxone administration are similar to or lower than those of other activities in which LEOs commonly engage.

Older adults' perceptions of early rehabilitation and recovery after hip fracture surgery: a UK qualitative study.

PURPOSE: To explore older adult's perceptions of early rehabilitation and recovery after hip fracture, as a complement to the UK standards for acute physiotherapy after hip fracture. METHODS: In-depth semi-structured interviews with 15 adults aged 60 years or more in hospital after hip fracture surgery. A thematic analysis approach with interpretation informed by Bury's biographical disruption theoretical framework. RESULTS: Participants voiced the importance of self-determination, professional support, meaningful feedback, and social capital after hip fracture. Collaborative working with staff was required for meeting the UK standards. Participants voiced anxieties about their hip fracture when considered in conjunction with their age and co-existing conditions, anticipating a disruption to their previous physical and social activities. This new, more dependent, life situation was not acceptable to participants. CONCLUSIONS: This study suggests hip fracture alone, was not perceived as a biographical disruption by older adults although it is presented as a potential tipping point in the loss of independence, contributing to the wider disruption of advancing age and co-existing conditions. For successful implementation of the UK standards, goal setting should consider patients in the wider context of their advancing age and co-existing conditions to empower them to define a fresh narrative of self.Implications for rehabilitationHip fracture was perceived as a potential tipping point in the loss of independence, contributing to the wider disruption of advancing age and co-existing conditions.Participants expressed uncertainty over their ability to recover their previous identity in the absence of professional support and/or social capital.Healthcare professionals need to educate and empower older adults to take charge of their own recovery.For successful implementation of the UK standards for acute physiotherapy, there is a need to contextualize goal setting to empower patients to define a fresh narrative of self.

Emergency medical services naloxone access: a national systematic legal review.

OBJECTIVES: Fatal opioid overdose in the United States is at epidemic levels. Naloxone, an effective opioid antidote, is commonly administered by advanced emergency medical services (EMS) personnel in the prehospital setting. While states are rapidly moving to increase access to naloxone for community bystanders, the EMS system remains the primary source for out-of-hospital naloxone access. Many communities have limited advanced EMS response capability and therefore may not have prehospital access to the medication indicated for opioid overdose reversal. The goal of this research was to determine the authority of different levels of EMS personnel to administer naloxone for the reversal of opioid overdose in the United States, Guam, and Puerto Rico. METHODS: The authors systematically reviewed the scope of practice of EMS personnel regarding administration of naloxone for the reversal of opioid overdose. All relevant laws, regulations, and policies from the 50 U. S. states, the District of Columbia, Guam, and Puerto Rico in effect in November 2013 were identified, reviewed, and coded to determine the authority of EMS personnel at four levels (in increasing order of training: emergency medical responders [EMRs], emergency medical technicians [EMTs], intermediate/advanced EMTs, and paramedics) to administer naloxone. Where available, protocols governing route and dose of administration were also identified and analyzed. RESULTS: All 53 jurisdictions license or certify EMS personnel at the paramedic level, and all permit paramedics to administer naloxone. Of the 48 jurisdictions with intermediate-level EMS personnel, all but one authorized those personnel to administer naloxone as of November 2013. Twelve jurisdictions explicitly permitted EMTs and two permitted EMRs to administer naloxone. At least five jurisdictions modified law or policy to expand EMT access to naloxone in 2013. There is wide variation between states regarding EMS naloxone dosing protocol and route of administration. CONCLUSIONS: Naloxone administration is standard for paramedic and intermediate-level EMS personnel, but most states do not allow basic life support (BLS) personnel to administer this medication. Standards consistent with available medical evidence for naloxone administration, dosing, and route of administration should be implemented at each EMS level of certification.