Serious Illness Conversation Training for Inpatient Medical Oncology Advanced Practice Providers: A Quality Improvement Project.

Background: Hospitalized advanced cancer patients and their families are inadequately informed about their cancer diagnosis and prognosis, which limits educated and reasonable decision-making for their care and end-of-life planning. Objectives: The primary objective of this evidence-based project was to enhance serious illness conversations (SICs) with advanced cancer patients by providing advanced practice providers (APP) training and to increase the frequency of SIC documentation in the electronic medical record (EMR). Methods: SIC training included a 45-minute Zoom video recording and 30-minute discussion groups. Advanced practice providers' beliefs and self-efficacy were measured pre- and post-training via a survey. Prior training was queried in the pre-survey. Data from APP discussion groups were summarized and themes identified. Serious illness conversation documentation frequency was measured. Pre- and post-survey differences were assessed using Wilcoxon rank sum tests. Findings: 19 inpatient medical oncology nurse practitioners and 6 physician assistants participated. Many reported little formal training yet are engaging in SICs regularly. Scores on both the belief and self-efficacy survey sections were high prior to training and did not significantly change following training. Despite the high pre-survey scores, many of the APPs verbalized the need for more training to improve their confidence and to learn SIC communication skills. Training significantly improved the APP's ability to manage their own emotions and be present. This indicates a trend toward improved APP comfort with SICs. Accessible documentation in the EMR increased with training.

Serious Illness Discussion in Palliative Care-A Case Study Approach in an African American Patient with Cancer.

Medicare's new focus on end-of-life care has driven nurses and other clinicians to re-examine when advanced care planning should begin, and serious illness discussions should be conducted. This article will address barriers to, cultural influences on, framing of, and documentation of serious illness discussions using a case study approach.

Weaponizing COVID-19: How the Pandemic Influenced the Behavior of Those Who Use Violence in Domestic and Family Relationships.

COVID-19 has increased threats to women's safety in Australia and globally. This research is based on a 2020 nationwide survey about the impacts of COVID-19 on domestic and family violence (DFV) services and allied sectors throughout Australia. This study focuses on how perpetrator behaviors-coercion, control, and violence-changed and intensified during the COVID-19 pandemic. Two central themes identified from this qualitative analysis were the increase in complexity and severity of DFV during COVID-19. The analysis highlights how perpetrator behavior reflects the weaponizing of COVID-19 against women and children. The article concludes with a discussion about the theoretical, practice, and policy implications.

The impact of COVID-19 pandemic on Australian domestic and family violence services and their clients.

During the early stages of the COVID-19 pandemic, reports emerged that lockdowns were increasing the prevalence of domestic and family violence (DFV) in Australia and across the world. The lockdowns and restrictions were necessary to contain the pandemic. However, leaders in the domestic family violence sector expressed concerns early during 2020 that these lockdowns would lead to the escalation of domestic and family violence. Calling it a shadow pandemic, the United Nations Secretary-General urged all governments to prioritise the prevention of violence against women in their national response plan for COVID-19. To gain some insight into the Australian context, a Queensland University of Technology (QUT) Centre for Justice research team conducted a nationwide survey to assess the impact of COVID-19 pandemic on DFV services and their clients. Findings based on survey data from 362 participants from the DFV sector, including 1,507 qualitative responses, confirm the concerns raised early in the COVID-19 pandemic. This article provides an overview of the survey results, discusses the findings in the light of national international research and highlights the resources needed to strengthen the DFV sector in the future.

A Scientific Basis for Regulating Deep-Sea Fishing by Depth.

The deep sea is the world's largest ecosystem, with high levels of biodiversity and many species that exhibit life-history characteristics that make them vulnerable to high levels of exploitation. Many fisheries in the deep sea have a track record of being unsustainable. In the northeast Atlantic, there has been a decline in the abundance of commercial fish species since deep-sea fishing commenced in the 1970s. Current management is by effort restrictions and total allowable catch (TAC), but there remain problems with compliance and high levels of bycatch of vulnerable species such as sharks. The European Union is currently considering new legislation to manage deep-sea fisheries, including the introduction of a depth limit to bottom trawling. However, there is little evidence to suggest an appropriate depth limit. Here we use survey data to show that biodiversity of the demersal fish community, the ratio of discarded to commercial biomass, and the ratio of Elasmobranchii (sharks and rays) to commercial biomass significantly increases between 600 and 800 m depth while commercial value decreases. These results suggest that limiting bottom trawling to a maximum depth of 600 m could be an effective management strategy that would fit the needs of European legislations such as the Common Fisheries Policy (EC no. 1380/2013) and the Marine Strategy Framework Directive (2008/56/EC).

Cytochrome P450 2D6 phenotyping in an elderly population with dementia and response to galantamine in dementia: a pilot study.

BACKGROUND: The cytochrome P450 (CYP) 2D6 enzyme is involved in the metabolism of many drugs used by the elderly population. Variations in its activity can lead to altered drug response. However, few studies on the activity of this enzyme system have enrolled the elderly population. OBJECTIVE: The goal of this pilot study was to assess the feasibility of in vivo phenotyping of CYP2D6 in an elderly population with dementia and to determine if part of the variability in response to treatment with galantamine is attributable to CYP2D6 phenotype. METHODS: Patients with dementia attending geriatric clinics and receiving galantamine treatment for at least 6 months were enrolled in this case-control study. CYP2D6 phenotype was determined by analysis of the urinary concentrations of the probe drug dextromethorphan and its primary metabolite dextrorphan after ingestion of 30 mg of dextromethorphan. Patients were classified as robust responders to galantamine if their cognitive testing, as measured by using scores on the Mini-Mental State Examination or Alzheimer's Disease Assessment Scale-Cognitive subscale, had not changed or had improved after 6 months of treatment. RESULTS: Forty-three patients (23 men, 20 women; mean age, 78.4 years; 98% white) underwent phenotyping. The mean number of concomitantly prescribed medications was 5.7, and 16 patients (37%) were receiving other CYP2D6 substrate or inhibitor drugs. The distribution of CYP2D6 phenotype was similar to that seen in other white populations. There was no correlation between the phenotypic metabolic ratio and age, the number of routinely taken medications, whether patients were receiving other prescribed substrate or inhibitor drugs of CYP2D6 (P = 0.63), or whether they were a robust responder (P = 0.47). CONCLUSIONS: Urinary assays of CYP2D6 phenotype are technically feasible in older individuals with dementia who are taking multiple medications, and may be a useful clinical tool in this population. However, the study was unable to make inferences about an association between CYP2D6 phenotype and galantamine responsiveness.

A novel model of HPV infection in meshed human foreskin grafts.

The present study describes a novel meshing procedure that provided successful low-risk papillomavirus propagation and reproducible wart induction in human foreskin xenografts. The initial HPV6 and/or 11 inocula were collected from clinically excised human wart tissues and confirmed to be free of HPV16, 18 and 31 by PCR analysis. Human foreskin grafts were collected from a circumcision clinic, and pre-inoculated with HPV virions by scarification. Meshing was carried out with a Zimmer Skin Grafter Mesher. Grafts were cut to appropriate size (1cm x 1cm or 5mm x 5mm) for cutaneous or subcutaneous grafting to NIH-nu-bg-xid mice under halothane anesthesia. Cutaneous xenografts were dressed with antibiotics and protective band-aids for 3 weeks. In the paralleled experiment using the same viral stock containing both HPV6 and 11, and matched grafts, no visible papillomas were observed in non-meshed cutaneous xenografts (n = 4 up to 6 months). In comparison, six of eight cutaneous xenografts treated with the meshing procedure formed visible papillomas within 4 months. This high frequency of distinct papilloma induction over the surface of meshed xenografts were reproduced in subsequent experiments with viral stocks containing both HPV11 and 6 (8 out of 10 grafts), or with a single-type HPV11 inoculum (80-100%). In contrast, an initial viral stock of single-type HPV6 provided lower frequency and more delayed papilloma induction. Serial passage of HPV6 in the meshed xenograft appeared to improve both the induction frequency and growth rate up to the 3rd generation. Histology, in situ hybridization, and immunohistochemical analysis revealed similarity of xenograft warts to those observed in the clinic. The highly reproducible papilloma induction rate and successful viral stock propagation associated with the meshing procedure provide a novel feature in the HPV xenograft model.

Levels of cigarette availability and exposure in black and white women and efficient smokers.

Purposes of this investigation were to examine differences in smoke exposure and smoking topography across three smoking conditions: usual number of cigarettes, restricted (50%) and increased (167%) simulating restricted and unrestricted cigarette availability. A repeated-measures counterbalanced design with a sample of 25 women (13 African Americans; 12 Caucasians) was implemented with a 6-day inpatient protocol conducted in the General Clinical Research Center (GCRC). There were significantly larger percentage increases in carbon monoxide (CO) postcigarette in the restricted condition compared to usual and increased condition. Women with baseline cotinine/cigarette ratios >20 ng/ml/cigarette, considered efficient smokers, had significantly higher CO increases postcigarette at baseline than participants with lower cotinine/cigarette ratios, yet increased this exposure further during the restricted condition. Efficient smokers had significantly higher nicotine boost in the restricted condition compared to less efficient smokers. Differences by ethnicity were also noted with significantly higher CO percentage increases pre- to postcigarette in African Americans across all conditions, compared to Caucasians. Levels of smoke exposure postcigarette in persons who reduce cigarettes per day in response to restricted cigarette availability may be substantial.

Estimating the prevalence of renal insufficiency in seniors requiring long-term care.

BACKGROUND: Renal function declines with age, but little is known about the extent of renal insufficiency among the institutionalized elderly. The objective of this study was to estimate the prevalence of low glomerular filtration rate (GFR) in a large sample of elderly adults living in long-term care facilities, and to compare two commonly used methods for estimating GFR. METHODS: A total of 9931 residents aged 65 years and older participated in a retrospective cross-sectional study of 87 long-term care facilities in Ontario. GFR was estimated by the Cockcroft-Gault and Modification of Diet in Renal Disease Study (MDRD) equations. The prevalence of low GFR, using the Cockcroft-Gault equation (<30 mL/min), was compared with the MDRD equation (<30 mL/min/1.73 m2). RESULTS: A total of 17.0% (95% CI 15.6 to 18.5) of men and 14.4% (95% CI 13.6 to 15.3) of women had a serum creatinine concentration above the laboratory reported upper reference limit of normal. The prevalence of both elevated serum creatinine and low GFR were observed to increase with age (P < 0.0001). The Cockcroft-Gault equation produced a consistently lower estimate of GFR than did the MDRD equation, a discrepancy most pronounced in the oldest residents. Among all men, a low GFR was more prevalent using the Cockcroft-Gault (10.3%, 95% CI 9.2 to 11.5) than MDRD (3.5%, 95% CI 2.8 to 4.2) equation, with a similar difference also seen in women (23.3%, 95% CI 22.4 to 24.3 versus 4.0%, 95% CI 3.6 to 4.5, respectively). Of all residents whose Cockcroft-Gault estimated GFR was under 30 mL/min, 14.7% (95% CI 13.2 to 16.3) were found to have GFR greater than 60 mL/min/1.73 m2 according to the MDRD equation. CONCLUSION: Age-associated renal impairment is common among elderly long-term care residents, but there exists a clear discrepancy between the Cockcroft-Gault and MDRD equations in predicting GFR. Consideration should be given to medication dose adjustment, based on a practical estimate of GFR. However clarification is needed about which method, if either, is most valid among the frail elderly. Complex patient and societal issues surrounding advanced care directives, treatments associated with renal insufficiency, and, if and when to initiate dialysis, require further attention.

Renal impairment and medication use among psychogeriatric inpatients.

OBJECTIVES: To determine the prevalence of renal impairment and the dosage appropriateness of several medications for which dosing guidelines in the advent of renal impairment are available. METHOD: The authors assessed the renal function and medication use of 37 psychogeriatric patients (mean age of 75 years) living in a psychiatric hospital. Renal function was determined by serum creatinine (SCr) levels and creatinine clearance (CCr) data using the Cockcroft and Gault equation. RESULTS: Thirteen of 37 patients (35%) were found to have renal impairment according to CCr data but only two patients (6%) were considered impaired according to SCr levels (k=0.19). Of 44 medications for which dosing guidelines were available, only two (5%) were prescribed inappropriately. CONCLUSION: These data suggest that CCr data should be used over SCr levels to determine renal impairment and to support the monitoring of psychogeriatric patients for declines in renal function and required medication adjustments.