Pediatric Palliative Care of a Transgender Adolescent.

A 15-year-old patient with metastatic synovial sarcoma conveyed to his palliative care physician that his dying wish was to start gender-affirming hormone therapy. His medical team was able to identify resources to support both him and his family as they navigated the immense difficulty of a cancer diagnosis and began to understand their child's gender identity. Literature on the care of gender diverse pediatric patients with terminal illness is minimal, but applications from adult literature, and research on supporting gender diverse adolescents more broadly, provided guidance for palliative care, oncology, and gender-affirming care teams. We believe that honoring and supporting the gender identity of adolescents with terminal illness is an essential aspect of end-of-life care. This case report outlines challenges faced by multidisciplinary pediatric team members who provided gender-affirming care for a minor under hospice care and amplifies the need for future research and guidelines pertinent to this patient population.

From static to semi-dynamic in vitro digestion conditions relevant for the older population: starch and protein digestion of cooked lentils.

In the context of adequately feeding the rising older population, lentils have an important potential as sources of (plant-based) protein as well as slowly digestible bio-encapsulated starch and fibre. This study evaluated in vitro digestion of protein and starch in lentils under conditions representing the gastrointestinal tract of older adults. Both static and semi-dynamic simulations were applied to analyze the effect of specific gastrointestinal conditions (healthy versus older adult) on macronutrient digestion patterns. Gastric proteolysis was strongly dependent on applied gastric pH (gradient), leading to a lower extent of protein hydrolysis for simulations relevant for older adults. Fewer and smaller (lower degree of polymerization, DP) bioaccessible peptides were formed during gastric proteolysis under older adult compared to healthy adult conditions. These differences, developed during the in vitro gastric phase, were compensated during small intestinal digestion, yielding similar final proteolysis levels regardless of the applied simulation conditions. In contrast, in the presence of saliva, amylolysis was generally accelerated under older adult conditions. Moreover, the current work highlighted the importance of considering saliva (or salivary amylase) incorporation in simulations where the applied gastric pH (gradient) allows salivary amylase activity. Under both healthy and older adult conditions, in vitro starch hydrolysis bio-encapsulated in cotyledon cells of cooked lentils was attenuated, compared to a white bread reference.

Withholding versus withdrawing treatment: artificial nutrition and hydration as a model.

PURPOSE OF REVIEW: This article explores various cultural perspectives of withholding and withdrawing of life-sustaining treatment utilizing a case involving artificial nutrition and hydration (ANH) to guide ethical discussion. RECENT FINDINGS: In the United States, there is a general consensus in the medical, ethical, and legal communities that the withholding and withdrawing of life-sustaining treatment are morally equivalent at the end of life. Despite this consensus, the withdrawal of treatment is still emotionally difficult, particularly with ANH. Recent literature challenges the evidence base that feeding tubes for people with advanced dementia lead to significant harm. In light of these new findings, we will reconsider end-of-life decision making that concerns ANH to determine whether these new findings undermine previous ethical arguments and to consider how to best educate and support patients and families during the decision-making process. SUMMARY: Despite many believing that there is no ethical, medical, or moral difference between withholding and withdrawing of life-sustaining treatment, there is no denying it is emotionally taxing, particularly withdrawal of ANH. Upholding the patient's values during high-quality shared decision making, facilitating rapport, and utilizing time limited trials will help, even when treatment is considered medically ineffective.