From comfort zone to front-line care: perspectives and reflections of community pharmacists entering home-based palliative care.

BACKGROUND: Palliative care requires a multidisciplinary team to assist patients and their families to obtain good quality care at the end of life. Typically, community pharmacists have fewer opportunities to provide services for patients with palliative care needs than hospital pharmacists. Moreover, home-based palliative care (HBPC) by pharmacists remains low and there is a lack of research regarding HBPC provided by pharmacists. Therefore, this study sought to understand the views and reflections of community pharmacists in the clinical frontline providing palliative home services. METHODS: Purposive sampling was used to recruit six community pharmacists for one-on-one, in-depth, semi-structured interviews and the data were analysed using thematic analysis. RESULTS: Five major themes emerged: [1] Engagement, [2] Challenge, [3] Mission, [4] Career metamorphosis, and [5] Outlook. The pharmacists described how they engaged in HBPC and faced the challenges. They regarded opioid management as a burden. Moreover, some mentioned that reimbursement for palliative home care is low or non-profitable. They suggested building a platform to exchange advice and legislation adjustments so that they could pass on their experiences to less experienced pharmacists in HBPC. CONCLUSIONS: The involvement of pharmacists is crucial to provide better palliative care. Although the present study was small and might not fully represent the whole situation, the findings could still inform future education, training, and policy planning to promote pharmacists' participation in palliative care to generalise community palliative care.

The experiences and needs of nurses providing home-based palliative care: A qualitative meta-synthesis.

Objective(s): We conducted a qualitative meta-synthesis of qualitative studies on nurses' experiences when caring for palliative patients to (1) identify the needs of nurses and (2) describe their experiences to provide more in-depth information. Methods: Qualitative articles published in English from 2000 to 2022 were identified from several databases through a searching strategy. Authors screened through the title, abstract, and full text of relevant studies. Articles were read repeatedly and discussed. The thematic analysis methodology was adopted to analyze the data. Results: Of 967 articles, 22 were included in our review. Notions reflecting community nurses providing palliative home care were clustered into four themes: (1) nature of community-based palliative nursing, (2) teamwork, (3) relationship with patient and family, and (4) resources. Findings also suggest establishing a sound support system, strengthening palliative education, and creating more decisive referral criteria and systems. Conclusions: The growing need for palliative home care has become challenging for community health care systems. Our study summarized various aspects of nurses providing home-based palliative care. The findings provide information for health care and education settings to improve home care systems and recruit more staff to meet the needs.

Community Nurses' Preparations for and Challenges in Providing Palliative Home Care: A Qualitative Study.

Hospitals have played a leading role in providing palliative care in Taiwan as its care model has developed over the past few decades. However, earlier local studies in Taiwan showed that terminal patients prefer to die at home, highlighting the need to promote community-based palliative care instead of hospital-based care. Along with this shift, how community nurses provide palliative home care merits further exploration. This qualitative descriptive study aims to understand (1) how community nurses implement community-based palliative care, (2) what preparations are needed, and (3) what challenges they may face. Purposive sampling was used for recruiting nurses. We conducted one-on-one, in-depth, semi-structured interviews. Interview recordings were transcribed verbatim and analyzed using thematic analysis. Eight community nurses with a range of experience in palliative home care were interviewed. Four major themes emerged: (1) Opportunities, (2) Qualifications, (3) Support, and (4) Commitments. Psychological preparedness, well-developed professional capabilities, external assistance, and peer support motivate community nurses to offer community-based palliative care. As the requests for palliative home care services increase, community nurses play a critical role in palliative home care. Although the sample size is small and the findings retrieved from a small number of experiences might not be generalized to every region, the study results could inform future experience-sharing and workshop sessions to train more nurses for community-based care, expanding service coverage, and providing optimal palliative care.

Predictors and Assessment of Hospice Use for End-Stage Renal Disease Patients in Taiwan.

OBJECTIVES: Hospice and early palliative care are generally considered as an alternative and supportive care to offer symptoms relief and optimize the quality of life among end-stage renal disease (ESRD) patients, but hospice care remains underutilized. This study aimed to examine patient and health system characteristics and develop a patient assessment scale to evaluate ESRD patients for hospice care after the implementation of non-cancer hospice care reimbursement policy in 2009 in Taiwan. METHOD: We conducted a retrospective cohort study using nationwide population-based datasets. Adult long-term dialysis patients between 2009 and 2012 were included. Multivariable logistic regression and the Firth penalized likelihood estimation were used to estimate the likelihood of receiving hospice care. A receiver operating characteristic curve (ROC) analysis and C-statistic were calculated to determine the optimal models for a patient assessment of hospice use. RESULTS: Patients who were older, comorbid with anemia (odds ratio [OR] 3.53, 95% CI 1.43-8.70) or sepsis (OR 1.62, 95% CI 1.08-2.44), with longer dialysis durations, more hospitalizations (OR 4.68, 95% CI 2.56-8.55), or primary provider care with hospice (OR 5.15, 95% CI 2.80-9.45) were more likely to receive hospice care. The total score of the patient assessment scale of hospice care was 0-28 with a cut-off value of 19 based on the results of the receiver operating characteristic curve. CONCLUSION: Given the "Patient Right to Autonomy Act" implemented in Taiwan in 2019 to promote the concept of a "good quality of death", this patient assessment scale may help health professionals target ESRD patients for hospice care and engage in shared decision making and the advance care planning process.

Air Pollution as a Potential Determinant of Rheumatoid Arthritis: A Population-based Cohort Study in Taiwan.

BACKGROUND: Limited studies have explored the relationship between air pollution and rheumatoid arthritis (RA), with the results being somewhat inconsistent. METHODS: This was a retrospective cohort study that included 322,301 subjects aged 30-50 years, selected from the National Health Insurance Research Database in Taiwan, were followed from 2001 to 2010. We used a time-dependent extended Cox model and incorporated time-dependent variables to estimate the associations between the annual mean concentrations of air pollutants with RA, including carbon monoxide (CO), nitrogen dioxide (NO2), ozone (O3), particles with an aerodynamic diameter less than 10 µm (PM10), and sulfur dioxide (SO2), and reported the hazard ratio (HR) and 95% confidence interval (CI). RESULTS: Newly diagnosed RA was positively associated with a 100-ppb increase in CO (adjusted HR = 1.17 [95% CI = 1.16, 1.18]), a 10-ppb increase in NO2 (1.54 [1.45, 1.64]), a 10-ppb increase in O3 (1.37 [1.33, 1.41]), and a 1 ppb in SO2 (1.02 [1.00, 1.04]). There was no association between a 10-µg/m increase in PM10 and RA (1.02 [0.99, 1.05]). CONCLUSIONS: Our finding suggests that O3 and traffic-related air pollutants (CO and NO2) may be positively associated with incident RA. This is an important finding given that many individuals are exposed to similar levels of O3 and NO2 globally.

Symptom severity of patients with advanced cancer in palliative care unit: longitudinal assessments of symptoms improvement.

BACKGROUND: This study assessed the symptom severity of patients with advanced cancer in a palliative care unit and explored the factors associated with symptom improvement. METHODS: This study was conducted in a palliative care unit in Taiwan between October 2004 and December 2009. Symptom intensity was measured by the "Symptom Reporting Form", and graded on a scale of 0 to 4 (0 = none, and 4 = extreme). These measures were assessed on the 1(st), 3(rd), 5(th), and 7(th) Day in the palliative care unit. The study data comprised routine clinical records and patients' demographic data. Generalized estimating equation (GEE) was used to assess the symptom improvement, and investigate the factors associated with the symptom reporting form scores. RESULTS: Among the 824 recruited patients with advanced cancer, pain (78.4%), anorexia (64.4%) and constipation (63.5%) were the most common and severe symptom. After controlling for other factors in the multivariate GEE model, the day of palliative care administration was a significant factor associated with all of the scales, except Days 7 on the dyspnoea and oedema scales and Day 5 on the anxiety scale. In addition, patients aged ≥ 65 years exhibited significantly lower scores on the pain, sleep disturbance, depression, and anxiety scales than did those aged < 65 years. Moreover, female patients exhibited higher scores on the vomiting, anorexia, oedema, depression, and anxiety scales than did male patients. Furthermore, patients with gastrointestinal tract cancer exhibited higher scores on the constipation, vomiting, anorexia, oedema, depression, and anxiety scales and lower scores on the dyspnoea scale than did those with lung cancer. Patients with breast cancer exhibited higher scores on the oedema scale and lower scores on the anxiety scale. Patients with genitourinary cancer exhibited higher scores on the vomiting and oedema scales and lower scores on the dyspnoea scale. Patients with head, neck, and oral cancer exhibited lower scores on the oedema scale alone. CONCLUSION: The symptom severity declined during the first week in the palliative care unit. In addition, differences in sex and primary cancer sites may contribute to varying degrees of symptom improvement.

Liver function tests may be useful tools for advanced cancer patient care: a preliminary single-center result.

Accurate prognostication in advanced cancer may facilitate better palliative care. An objective marker may be more applicable and appropriate than a subjective evaluation by physicians. The aim of this study was to evaluate liver function tests as useful prognostic factors for survival in patients with advanced cancer. We recruited advanced cancer patients from January 2007 to December 2009. Data on age, sex, cancer diagnosis, site of metastases, clinical symptoms, and performance status were collected at the time of admission to the palliative care unit. Analyzed laboratory data were obtained on the Day 1 of admission to the palliative care unit. A total of 522 patients were enrolled; 322 (61.7%) of them were males. The mean age was 60.6 ± 13.2 years. Multiple logistic regression analysis adjusting for age and sex demonstrated aspartate transaminase (AST) > 80 IU/L [odds ratio (OR) = 2.01, p = 0.010] and alanine transaminase > 80 IU/L (OR = 1.89, p = 0.047) were independently significant prognostic factors of death within 14 days. AST > 80 IU/L (OR = 3.67, p = 0.017) and albumin < 3.0 g/dL (OR = 1.98, p = 0.048) were independently significant prognostic factors of death within 6 months. Liver function tests may be useful prognostic factors for patients in the palliative care unit, in addition to being useful for patients with hepatobiliary cancer or liver metastasis. These biochemical tests of liver function with cutoff values can easily be used in palliative care.

Upregulation of brain-derived neurotrophic factor expression in nodose ganglia and the lower brainstem of hypertensive rats.

Hypertension leads to structural and functional changes at baroreceptor synapses in the medial nucleus tractus solitarius (NTS), but the underlying molecular mechanisms remain unknown. Our previous studies show that brain-derived neurotrophic factor (BDNF) is abundantly expressed by rat nodose ganglion (NG) neurons, including baroreceptor afferents and their central terminals in the medial NTS. We hypothesized that hypertension leads to upregulation of BDNF expression in NG neurons. To test this hypothesis, we used two mechanistically distinct models of hypertension, the spontaneously hypertensive rat (SHR) and the deoxycorticosterone acetate (DOCA)-salt rat. Young adult SHRs, whose blood pressure was significantly elevated compared with age-matched Wistar-Kyoto (WKY) control rats, exhibited dramatic upregulation of BDNF mRNA and protein in the NG. BDNF transcripts from exon 4, known to be regulated by activity, and exon 9 (protein-coding region) showed the largest increases. Electrical stimulation of dispersed NG neurons with patterns that mimic baroreceptor activity during blood pressure elevations led to increases in BDNF mRNA that were also mediated through promoter 4. The increase in BDNF content of the NG in vivo was associated with a significant increase in the percentage of BDNF-immunoreactive NG neurons. Moreover, upregulation of BDNF in cell bodies of NG neurons was accompanied by a significant increase in BDNF in the NTS region, the primary central target of NG afferents. A dramatic increase in BDNF in the NG was also detected in DOCA-salt hypertensive rats. Together, our study identifies BDNF as a candidate molecular mediator of activity-dependent changes at baroafferent synapses during hypertension.

Bereaved females are more likely to suffer from mood problems even if they do not meet the criteria for prolonged grief.

PURPOSE: The goal of this study was to describe the gender difference of grief experience and mood distress among caregivers who cared for terminal cancer patients residing in a hospice ward. METHODS: This study recruited 432 caregivers who cared for terminal cancer patients in the hospice ward. Caregivers received telephone interviews 6 months after the patients had died. The Chinese versions of the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and Inventory of Complicated Grief (ICG) developed in 1995 by Prigerson et al. were employed to assess the mood distress and grief status. RESULTS: Total scores of BDI, BAI, and ICG were significantly higher in females. Six out of twenty-one items of BDI, lack of satisfaction, crying spells, sleep disturbance, fatigability, somatic preoccupation, and loss of libido, showed significantly higher scores in females. According to BAI, inability to relax, dizziness, fear of dying, fright, flushed face, and hot/cold sweats were significantly higher in females. After adjustment for potential confounders, the results show that female gender is associated with higher BDI (regression coefficient 3.24, 95% CI: 1.48-4.99), BAI (3.8; 1.11-6.50), and ICG (4.25, 1.09-7.40). Dichotomizing the BDI, BAI, and ICG into severe and nonsevere cases, the results showed that gender only contributes to severe anxiety status (BAI ≥ 36), but not to severe depression (BDI ≥ 29) or to prolonged grief (ICG ≥ 25). CONCLUSIONS: Bereaved females had higher scores for depression and anxiety than males. Female gender is associated with severe anxiety; however, it is not associated with severe depression or prolonged grief.

Nitric oxide regulates BDNF release from nodose ganglion neurons in a pattern-dependent and cGMP-independent manner.

Activity of arterial baroreceptors is modulated by neurohumoral factors, including nitric oxide (NO), released from endothelial cells. Baroreceptor reflex responses can also be modulated by NO signaling in the brainstem nucleus tractus solitarius (NTS), the primary central target of cardiovascular afferents. Our recent studies indicate that brain-derived neurotrophic factor (BDNF) is abundantly expressed by developing and adult baroreceptor afferents in vivo, and released from cultured nodose ganglion (NG) neurons by patterns of baroreceptor activity. Using electrical field stimulation and ELISA in situ, we show that exogenous NO nearly abolishes BDNF release from newborn rat NG neurons in vitro stimulated with single pulses delivered at 6 Hz, but not 2-pulse bursts delivered at the same 6-Hz frequency, that corresponds to a rat heart rate. Application of L-NAME, a specific inhibitor of endogenous NO synthases, does not have any significant effect on activity-dependent BDNF release, but leads to upregulation of BDNF expression in an activity-dependent manner. The latter effect suggests a novel mechanism of homeostatic regulation of activity-dependent BDNF expression with endogenous NO as a key player. The exogenous NO-mediated effect does not involve the cGMP-protein kinase G (PKG) pathway, but is largely inhibited by N-ethylmaleimide and TEMPOL that are known to prevent S-nitrosylation. Together, our current data identify previously unknown mechanisms regulating BDNF availability, and point to NO as a likely regulator of BDNF at baroafferent synapses in the NTS.

Brain-derived neurotrophic factor in arterial baroreceptor pathways: implications for activity-dependent plasticity at baroafferent synapses.

Functional characteristics of the arterial baroreceptor reflex change throughout ontogenesis, including perinatal adjustments of the reflex gain and adult resetting during hypertension. However, the cellular mechanisms that underlie these functional changes are not completely understood. Here, we provide evidence that brain-derived neurotrophic factor (BDNF), a neurotrophin with a well-established role in activity-dependent neuronal plasticity, is abundantly expressed in vivo by a large subset of developing and adult rat baroreceptor afferents. Immunoreactivity to BDNF is present in the cell bodies of baroafferent neurons in the nodose ganglion, their central projections in the solitary tract, and terminal-like structures in the lower brainstem nucleus tractus solitarius. Using ELISA in situ combined with electrical field stimulation, we show that native BDNF is released from cultured newborn nodose ganglion neurons in response to patterns that mimic the in vivo activity of baroreceptor afferents. In particular, high-frequency bursting patterns of baroreceptor firing, which are known to evoke plastic changes at baroreceptor synapses, are significantly more effective at releasing BDNF than tonic patterns of the same average frequency. Together, our study indicates that BDNF expressed by first-order baroreceptor neurons is a likely mediator of both developmental and post-developmental modifications at first-order synapses in arterial baroreceptor pathways.

[Concept analysis of suffering].

Suffering is commonly encountered in nursing and is defined as an individual and subjective experience. It is a complex human response to which there are physical, psychological, social and spiritual aspects. Perception of suffering threatens self-integrity, and induces negative behaviors, such as personal changes in relation to value system, sense of reality, withdrawal, feelings of helplessness, and despair. A great deal of relevant literature explores the influence of suffering, but only a few articles analyze the concept of suffering. The purpose of this article, therefore, is to clarify the concept of suffering. In order to do this, we used the technique of concept analysis described by Chinn and Kramer (1995). It is hoped that the results of the study will enhance nurses' understanding of suffering and that its lessons may be adopted in clinical nursing.

Calcitonin gene-related peptide enhances release of native brain-derived neurotrophic factor from trigeminal ganglion neurons.

Activity-dependent plasticity in nociceptive pathways has been implicated in pathomechanisms of chronic pain syndromes. Calcitonin gene-related peptide (CGRP), which is expressed by trigeminal nociceptors, has recently been identified as a key player in the mechanism of migraine headaches. Here we show that CGRP is coexpressed with brain-derived neurotrophic factor (BDNF) in a large subset of adult rat trigeminal ganglion neurons in vivo. Using ELISA in situ, we show that CGRP (1-1000 nM) potently enhances BDNF release from cultured trigeminal neurons. The effect of CGRP is dose-dependent and abolished by pretreatment with CGRP receptor antagonist, CGRP(8-37). Intriguingly, CGRP-mediated BDNF release, unlike BDNF release evoked by physiological patterns of electrical stimulation, is independent of extracellular calcium. Depletion of intracellular calcium stores with thapsigargin blocks the CGRP-mediated BDNF release. Using transmission electron microscopy, our study also shows that BDNF-immunoreactivity is present in dense core vesicles of unmyelinated axons and axon terminals in the subnucleus caudalis of the spinal trigeminal nucleus, the primary central target of trigeminal nociceptors. Together, these results reveal a previously unknown role for CGRP in regulating BDNF availability, and point to BDNF as a candidate mediator of trigeminal nociceptive plasticity.