Carbon and Nitrogen Isotope Fractionations During Biotic and Abiotic Transformations of 2,4-Dinitroanisole (DNAN).

2,4-Dinitroanisole (DNAN) is a main constituent in various new insensitive munition formulations. Although DNAN is susceptible to biotic and abiotic transformations, in many environmental instances, transformation mechanisms are difficult to resolve, distinguish, or apportion on the basis solely of analysis of concentrations. We used compound-specific isotope analysis (CSIA) to investigate the characteristic isotope fractionations of the biotic (by three microbial consortia and three pure cultures) and abiotic (by 9,10-anthrahydroquinone-2-sulfonic acid [AHQS]) transformations of DNAN. The correlations of isotope enrichment factors (ΛN/C) for biotic transformations had a range of values from 4.93 ± 0.53 to 12.19 ± 1.23, which is entirely distinct from ΛN/C values reported previously for alkaline hydrolysis, enzymatic hydrolysis, reduction by Fe2+-bearing minerals and iron-oxide-bound Fe2+, and UV-driven phototransformations. The ΛN/C value associated with the abiotic reduction by AHQS was 38.76 ± 2.23, within the range of previously reported values for DNAN reduction by Fe2+-bearing minerals and iron-oxide-bound Fe2+, albeit the mean ΛN/C was lower. These results enhance the database of isotope effects accompanying DNAN transformations under environmentally relevant conditions, allowing better evaluation of the extents of biotic and abiotic transformations of DNAN that occur in soils, groundwaters, surface waters, and the marine environment.

Role of Post-Traumatic Growth in Bereavement Outcomes: An Inquiry of Family Caregivers in Hospice.

Background: Family caregivers (FCGs) encounter several physical, psychosocial, and financial struggles while caring for a dying loved one. After their loved one has passed, FCGs face new difficulties as they transition out of the caregiving role and into bereavement. Recent research has focused on the positive adaptive outcomes of bereavement. Objective: This study examined the relationship between core bereavement experiences and post-traumatic growth (PTG) for bereaved hospice FCGs. Design: This is a quantitative cross-sectional mail-in survey. Settings/Subjects: A total of 395 bereaved FCGs of patients who died while under the care of a comprehensive hospice program were surveyed. Measurements: Demographics were collected. Bereavement experiences were assessed using the core bereavement items, and PTG was assessed using the Posttraumatic Growth Inventory (PTGI). Both surveys are validated measures. Results: Two-tailed bivariate correlations were used to analyze the relationships between bereavement experiences and PTG. Significant positive relationships were found between all bereavement experiences and PTG variables (p = <0.01-0.011, r = 0.134-0.290), except for one variable pairing (grief × new possibilities). Participants who reported more intense bereavement experiences also reported greater PTG, especially in the areas relating to others and appreciation of life. Conclusion: FCGs who undergo more intense bereavement experiences tend to experience greater PTG. This information can be used in the future to develop a more comprehensive understanding of the multifaceted nature of grief and loss.

Pyrogenic Black Carbon Suppresses Microbial Methane Production by Serving as a Terminal Electron Acceptor.

Methane (CH4) is the second most important greenhouse gas, 27 times as potent as CO2 and responsible for >30% of the current anthropogenic warming. Globally, more than half of CH4 is produced microbially through methanogenesis. Pyrogenic black carbon possesses a considerable electron storage capacity (ESC) and can be an electron donor or acceptor for abiotic and microbial redox transformation. Using wood-derived biochar as a model black carbon, we demonstrated that air-oxidized black carbon served as an electron acceptor to support anaerobic oxidation of organic substrates, thereby suppressing CH4 production. Black carbon-respiring bacteria were immediately active and outcompeted methanogens. Significant CH4 did not form until the bioavailable electron-accepting capacity of the biochar was exhausted. An experiment with labeled acetate (13CH3COO-) yielded 1:1 13CH4 and 12CO2 without biochar and predominantly 13CO2 with biochar, indicating that biochar enabled anaerobic acetate oxidation at the expense of methanogenesis. Methanogens were enriched following acetate fermentation but only in the absence of biochar. The electron balance shows that approximately half (∼2.4 mmol/g) of biochar's ESC was utilized by the culture, corresponding to the portion of the ESC > +0.173 V (vs SHE). These results provide a mechanistic basis for quantifying the climate impact of black carbon and developing ESC-based applications to reduce CH4 emissions from biogenic sources.

Thermodynamic Two-Site Surface Reaction Model for Predicting Munition Constituent Reduction Kinetics with Iron (Oxyhydr)oxides.

Iron (oxyhydr)oxides comprise a significant portion of the redox-active fraction of soils and are key reductants for remediation of sites contaminated with munition constituents (MCs). Previous studies of MC reduction kinetics with iron oxides have focused on the concentration of sorbed Fe(II) as a key parameter. To build a reaction kinetic model, it is necessary to predict the concentration of sorbed Fe(II) as a function of system conditions and the redox state. A thermodynamic framework is formulated that includes a generalized double-layer model that utilizes surface acidity and surface complexation reactions to predict sorbed Fe(II) concentrations that are used for fitting MC reduction kinetics. Monodentate- and bidentate Fe(II)-binding sites are used with individual oxide sorption characteristics determined through data fitting. Results with four oxides (goethite, hematite, lepidocrocite, and ferrihydrite) and four nitro compounds (NB, CN-NB, Cl-NB, and NTO) from six separate studies have shown good agreement when comparing observed and predicted surface area-normalized rate constants. While both site types are required to reproduce the experimental redox titration, only the monodentate site concentration controls the MC reaction kinetics. This model represents a significant step toward predicting the timescales of MC degradation in the subsurface.

Linear Free Energy Relationship for Predicting the Rate Constants of Munition Compound Reduction by the Fe(II)-Hematite and Fe(II)-Goethite Redox Couples.

Abiotic reduction by iron minerals is arguably the most important fate process for munition compounds (MCs) in subsurface environments. No model currently exists that can predict the abiotic reduction rates of structurally diverse MCs by iron (oxyhydr)oxides. We performed batch experiments to measure the rate constants for the reduction of three classes of MCs (poly-nitroaromatics, nitramines, and azoles) by hematite or goethite in the presence of aqueous Fe2+. The surface area-normalized reduction rate constant (kSA) depended on the aqueous-phase one-electron reduction potential (EH1) of the MC and the thermodynamic state (i.e., pe and pH) of the iron oxide-Feaq2+ system. A linear free energy relationship (LFER), similar to that reported previously for nitrobenzene, successfully captures all MC reduction rate constants that span 6 orders of magnitude: log(kSA)=(1.12±0.04)[0.53EH159mV-(pH+pe)]+(5.52±0.23). The finding that the rate constants of all the different classes of MCs can be described by a single LFER suggests that these structurally diverse nitro compounds are reduced by iron oxide-Feaq2+ couples through a common mechanism up to the rate-limiting step. Multiple mechanistic implications of the results are discussed. This study expands the applicability of the LFER model for predicting the reduction rates of legacy and emerging MCs and potentially other nitro compounds.

The effectiveness of an unsupervised home-based pulmonary rehabilitation with self-management program in patients with chronic obstructive pulmonary disease.

AIMS: To assess the effectiveness of an unsupervised home-based pulmonary rehabilitation with self-management program in patients with chronic obstructive pulmonary disease (COPD). BACKGROUND: A few recent studies have shown that unsupervised home-based pulmonary rehabilitation can improve the clinical outcome of patients with COPD. More studies are needed to prove its benefits. DESIGN: This study used a quasi-experimental design. METHODS: Seventy-two admitted COPD patients were assigned to experimental group or control group through purposeful sampling. Data were collected from March 2016 to November 2017 in the Thoracic Intensive Care Unit of a Medical Center in Taiwan. The Medical Research Council dyspnea scale, the COPD Self-Efficacy Scale and the Clinical COPD Questionnaire were measured before education and at the first, second and third months after discharge. RESULTS: The Medical Research Council dyspnea scale and COPD Self-Efficacy Scale results in the experimental group were significantly improved compared with the control group in the third month after discharge. The Clinical COPD Questionnaire score continued to improve in both groups in the third month after discharge, and there was no difference between the two groups. CONCLUSION: A short-term unsupervised home-based pulmonary rehabilitation with self- management program had significant benefits for patients with COPD. The long-term effects need to be confirmed.

Electron Transfer Energy and Hydrogen Atom Transfer Energy-Based Linear Free Energy Relationships for Predicting the Rate Constants of Munition Constituent Reduction by Hydroquinones.

No single linear free energy relationship (LFER) exists that can predict reduction rate constants of all munition constituents (MCs). To address this knowledge gap, we measured the reduction rates of MCs and their surrogates including nitroaromatics [NACs; 2,4,6-trinitrotoluene (TNT), 2,4-dinitroanisole (DNAN), 2-amino-4,6-dinitrotoluene (2-A-DNT), 4-amino-2,6-dinitrotoluene (4-A-DNT), and 2,4-dinitrotoluene (DNT)], nitramines [hexahydro-1,3,5-trinitro-1,3,5-triazine (RDX) and nitroguanidine (NQ)], and azoles [3-nitro-1,2,4-triazol-5-one (NTO) and 3,4-dinitropyrazole (DNP)] by three dithionite-reduced quinones (lawsone, AQDS, and AQS). All MCs/NACs were reduced by the hydroquinones except NQ. Hydroquinone and MC speciations were varied by controlling pH, permitting the application of a speciation model to determine second-order rate constants (k) from observed pseudo-first-order rate constants. The intrinsic reactivity of MCs (oxidants) decreased upon deprotonation, while the opposite was true for hydroquinones (reductants). The rate constants spanned ∼6 orders of magnitude in the order NTO ≈ TNT > DNP > DNT ≈ DNAN ≈ 2-A-DNT > DNP- > 4-A-DNT > NTO- > RDX. LFERs developed using density functional theory-calculated electron transfer and hydrogen atom transfer energies and reported one-electron reduction potentials successfully predicted k, suggesting that these structurally diverse MCs/NACs are all reduced by hydroquinones through the same mechanism and rate-limiting step. These results increase the applicability of LFER models for predicting the fate and half-lives of MCs and related nitro compounds in reducing environments.

End-of-Life Dreams and Visions: Initial Guidelines and Recommendations to Support Dreams and Visions at the End of Life.

Background: End-of-life dreams and visions (ELDVs) are a common phenomenon in which dying patients experience dreams/visions often of deceased loved ones before death. Past research has highlighted the need for education and awareness to improve clinical engagement at the bedside in response to ELDVs. Objectives: To explore the perspectives of multidisciplinary hospice care providers who are ELDV subject matter experts. Design/Methods: Semi-structured interviews with 13 multidisciplinary hospice providers were conducted and analyzed using thematic qualitative analysis. Results: Analysis revealed six themes: Normalization, Rapport Building, Active Listening, Individualized Meaning Making, Barriers, and Education. A secondary thematic analysis focused on defining/describing ELDVs and resulted in two themes: Natural Part of Dying and ELDV Properties. Conclusions: Findings identified facilitators and barriers encountered when caring for a patient with ELDVs. Based on this, an initial set of recommendations for meaningful clinical engagement regarding ELDVs and initial operationalized definition has been proposed.

Melanocortin 4 receptor agonism enhances sexual brain processing in women with hypoactive sexual desire disorder.

BACKGROUNDHypoactive sexual desire disorder (HSDD) is characterized by a persistent deficiency of sexual fantasies and desire for sexual activity, causing marked distress and interpersonal difficulty. It is the most prevalent female sexual health problem globally, affecting approximately 10% of women, but has limited treatment options. Melanocortin 4 receptor (MC4R) agonists have emerged as a promising therapy for women with HSDD, through unknown mechanisms. Studying the pathways involved is crucial for our understanding of normal and abnormal sexual behavior.METHODSUsing psychometric, functional neuroimaging, and hormonal analyses, we conducted a randomized, double-blinded, placebo-controlled, crossover clinical study to assess the effects of MC4R agonism compared with placebo on sexual brain processing in 31 premenopausal heterosexual women with HSDD.RESULTSMC4R agonism significantly increased sexual desire for up to 24 hours after administration compared with placebo. During functional neuroimaging, MC4R agonism enhanced cerebellar and supplementary motor area activity and deactivated the secondary somatosensory cortex, specifically in response to visual erotic stimuli, compared with placebo. In addition, MC4R agonism enhanced functional connectivity between the amygdala and the insula during visual erotic stimuli compared with placebo.CONCLUSIONThese data suggest that MC4R agonism enhanced sexual brain processing by reducing self-consciousness, increasing sexual imagery, and sensitizing women with HSDD to erotic stimuli. These findings provide mechanistic insight into the action of MC4R agonism in sexual behavior and are relevant to the ongoing development of HSDD therapies and MC4R agonist development more widely.TRIAL REGISTRATIONClinicalTrials.gov NCT04179734.FUNDINGThis is an investigator-sponsored study funded by AMAG Pharmaceuticals Inc., the Medical Research Council (MRC) (MR/T006242/1), and the National Institute for Health Research (NIHR) (CS-2018-18-ST2-002 and RP-2014-05-001).

Clinician Communication in Hospice: Constructions of Reality Throughout the End-of-Life Process.

The current study examined qualitative data from hospice clinicians' perspectives on language, surrounding end-of-life (EOL), to understand challenges and opportunities for constructing a trajectory of communication leading towards a good death experience. Findings from two focus groups with nine clinicians' and 12 individual interviews, four of which were follow up interviews after the focus groups, were guided by framework analysis and revealed three themes, constructing language choices, roles and responsibilities, and socio-cultural considerations. We used the Opportunity Model for Presence during the End-of-Life Process (OMP-EOLP) to make sense of the findings and discuss implications for language use throughout the EOL process. We argue additional efforts should be made in recognizing the value of presence checks, re-constructing advance care planning, and utilizing different forms of media as an educational tool and connection mechanism for clinicians with patients and families to achieve a timely engagement of EOL conversations for all healthcare participants.

Insights From a Large-Scale Whole-Genome Sequencing Study of Systolic Blood Pressure, Diastolic Blood Pressure, and Hypertension.

BACKGROUND: The availability of whole-genome sequencing data in large studies has enabled the assessment of coding and noncoding variants across the allele frequency spectrum for their associations with blood pressure. METHODS: We conducted a multiancestry whole-genome sequencing analysis of blood pressure among 51 456 Trans-Omics for Precision Medicine and Centers for Common Disease Genomics program participants (stage-1). Stage-2 analyses leveraged array data from UK Biobank (N=383 145), Million Veteran Program (N=318 891), and Reasons for Geographic and Racial Differences in Stroke (N=10 643) participants, along with whole-exome sequencing data from UK Biobank (N=199 631) participants. RESULTS: Two blood pressure signals achieved genome-wide significance in meta-analyses of stage-1 and stage-2 single variant findings (P<5×10-8). Among them, a rare intergenic variant at novel locus, LOC100506274, was associated with lower systolic blood pressure in stage-1 (beta [SE]=-32.6 [6.0]; P=4.99×10-8) but not stage-2 analysis (P=0.11). Furthermore, a novel common variant at the known INSR locus was suggestively associated with diastolic blood pressure in stage-1 (beta [SE]=-0.36 [0.07]; P=4.18×10-7) and attained genome-wide significance in stage-2 (beta [SE]=-0.29 [0.03]; P=7.28×10-23). Nineteen additional signals suggestively associated with blood pressure in meta-analysis of single and aggregate rare variant findings (P<1×10-6 and P<1×10-4, respectively). DISCUSSION: We report one promising but unconfirmed rare variant for blood pressure and, more importantly, contribute insights for future blood pressure sequencing studies. Our findings suggest promise of aggregate analyses to complement single variant analysis strategies and the need for larger, diverse samples, and family studies to enable robust rare variant identification.

Genetic determinants of telomere length from 109,122 ancestrally diverse whole-genome sequences in TOPMed.

Genetic studies on telomere length are important for understanding age-related diseases. Prior GWAS for leukocyte TL have been limited to European and Asian populations. Here, we report the first sequencing-based association study for TL across ancestrally-diverse individuals (European, African, Asian and Hispanic/Latino) from the NHLBI Trans-Omics for Precision Medicine (TOPMed) program. We used whole genome sequencing (WGS) of whole blood for variant genotype calling and the bioinformatic estimation of telomere length in n=109,122 individuals. We identified 59 sentinel variants (p-value <5×10-9) in 36 loci associated with telomere length, including 20 newly associated loci (13 were replicated in external datasets). There was little evidence of effect size heterogeneity across populations. Fine-mapping at OBFC1 indicated the independent signals colocalized with cell-type specific eQTLs for OBFC1 (STN1). Using a multi-variant gene-based approach, we identified two genes newly implicated in telomere length, DCLRE1B (SNM1B) and PARN. In PheWAS, we demonstrated our TL polygenic trait scores (PTS) were associated with increased risk of cancer-related phenotypes.

Modeling the Reduction Kinetics of Munition Compounds by Humic Acids.

Dissolved organic matter (DOM) comprises a sizeable portion of the redox-active constituents in the environment and is an important reductant for the abiotic transformation of nitroaromatic compounds and munition constituents (NACs/MCs). Building a predictive kinetic model for these reactions would require the energies associated with both the reduction of the NACs/MCs and the oxidation of the DOM. The heterogeneous and unknown structure of DOM, however, has prohibited reliable determination of its oxidation energies. To overcome this limitation, humic acids (HAs) were used as model DOM, and their redox moieties were modeled as a collection of quinones of different redox potentials. The reduction and oxidation energies of the NACs/MCs and hydroquinones, respectively, via hydrogen atom transfer (HAT) reactions were then calculated quantum chemically. HAT energies have been used successfully in a linear free energy relationship (LFER) to predict second-order rate constants for NAC reduction by hydroquinones. Furthermore, a linear relationship between the HAT energies and the reduction potentials of quinones was established, which allows estimation of hydroquinone reactivity (i.e., rate constants) from HA redox titration data. A training set of three HAs and two NACs/MCs was used to generate a mean HA redox profile that successfully predicted reduction kinetics in multiple HA/MC systems.

Abiotic reduction of 3-nitro-1,2,4-triazol-5-one (NTO) and other munitions constituents by wood-derived biochar through its rechargeable electron storage capacity.

The environmental fate of 3-nitro-1,2,4-triazol-5-one (NTO) and other insensitive munitions constituents (MCs) is of significant concern due to their high water solubility and mobility relative to legacy MCs. Plant-based biochars have been shown to possess a considerable electron storage capacity (ESC), which enables them to undergo reversible electron transfer reactions. We hypothesized biochar can act as a rechargeable electron donor to effect abiotic reduction of MCs repeatedly through its ESC. To test this hypothesis, MC reduction experiments were performed using wood-derived biochars that were oxidized with dissolved oxygen or reduced with dithionite. Removal of aqueous NTO, an anion at circumneutral pH, by oxidized biochar was minimal and occurred through reversible adsorption. In contrast, NTO removal by reduced biochar was much more pronounced and occurred predominantly through reduction, with concomitant formation of 3-amino-1,2,4-triazol-5-one (ATO). Mass balance and electron recovery with ferricyanide further showed that (1) the amount of NTO reduced to ATO was relatively constant (85-100 µmol per gram of biochar) at pH 6-10; (2) the fraction of biochar ESC reactive toward NTO was ca. 30% of that toward ferricyanide; (3) the NTO-reactive fraction of the ESC was regenerable over multiple redox cycles. We also evaluated biochar transformation of other MCs, including nitroguanidine (NQ), 2,4-dinitroanisole (DNAN), and hexahydro-1,3,5-trinitro-1,3,5-triazine (RDX). While mass and electron balances could not be established due to sorption, DNAN and RDX reduction by reduced biochar was confirmed via detection of multiple reduction products. In contrast, NQ was not reduced under any of the conditions tested. This study is the first demonstration of organic contaminant degradation through biochar's rechargeable ESC. Our results indicate biochar is a regenerable electron storage medium and sorbent that can remove MCs from water through concurrent reduction and sorption, and is thus potentially useful for pollution control and remediation at military facilities.

Changes in Circulating Kisspeptin Levels During Each Trimester in Women With Antenatal Complications.

CONTEXT: Antenatal complications such as hypertensive disorders of pregnancy (HDP), fetal growth restriction (FGR), gestational diabetes (GDM), and preterm birth (PTB) are associated with placental dysfunction. Kisspeptin has emerged as a putative marker of placental function, but limited data exist describing circulating kisspeptin levels across all 3 trimesters in women with antenatal complications. OBJECTIVE: We aimed to assess whether kisspeptin levels are altered in women with antenatal complications. METHODS: Women with antenatal complications (n = 105) and those with uncomplicated pregnancies (n = 265) underwent serial ultrasound scans and blood sampling at the Early Pregnancy Assessment Unit at Hammersmith Hospital, UK, at least once during each trimester (March 2014 to March 2017). The women with antenatal complications (HDP [n = 32], FGR [n = 17], GDM [n = 35], PTB [n = 11], and multiple complications [n=10]) provided 373 blood samples and the controls provided 930 samples. Differences in circulating kisspeptin levels were assessed. RESULTS: Third-trimester kisspeptin levels were higher than controls in HDP but lower in FGR. The odds of HDP adjusted for gestational age, maternal age, ethnicity, BMI, smoking, and parity were increased by 30% (95% CI, 16%-47%; P < 0.0001), and of FGR were reduced by 28% (95% CI, 4-46%; P = 0.025), for every 1 nmol/L increase in plasma kisspeptin. Multiple of gestation-specific median values of kisspeptin were higher in pregnancies affected by PTB (P = 0.014) and lower in those with GDM (P = 0.020), but not significantly on multivariable analysis. CONCLUSION: We delineate changes in circulating kisspeptin levels at different trimesters and evaluate the potential of kisspeptin as a biomarker for antenatal complications.

Treatment of Positive Urine Cultures at End-of-Life and the Effect on Terminal Delirium Management.

Background: The decision to initiate antibiotics in hospice patients that are very near end-of-life is a complex ethical and stewardship decision. Antibiotics may be ordered to improve urinary tract infection-related symptoms, such as delirium. However, infection symptoms may be managed using antipsychotics, antipyretics, antispasmodics, and analgesics instead. Currently, there are no studies that compare symptom management between those who receive antibiotics and those who do not. Methods: A retrospective chart review was conducted for patients admitted to a hospice inpatient unit. Charts were included if the patient was admitted for delirium and had a Palliative Performance Scale score ≤40%, the urine culture was positive for organism growth, and the patient died while in the HIU. Clinical and demographic data was collected. Medication use was tallied for the 5 days prior to the date of death. Results: Sixty-one charts met the inclusion criteria. Thirty-five patients received antibiotics (ABX+) and 26 did not (ABX-). There was no difference in any medication consumption between groups during the 5 days prior to death. The ABX+ group died 8.2 days after obtaining the urine sample vs 6 days (P =0.046). The ABX+ group had more documented urinary tract-specific infection symptoms (66% vs 38%, P =0.042). More than half of antibiotic courses were discontinued prematurely. Conclusion: The results of this study do not show a difference in overall medication consumption between groups, which suggests that antibiotics may not help improve terminal delirium symptoms in those with a suspected urinary tract infection at end-of-life.

Reductive Transformation of 3-Nitro-1,2,4-triazol-5-one (NTO) by Leonardite Humic Acid and Anthraquinone-2,6-disulfonate (AQDS).

3-Nitro-1,2,4-triazol-5-one (NTO) is a major and the most water-soluble constituent in the insensitive munition formulations IMX-101 and IMX-104. While NTO is known to undergo redox reactions in soils, its reaction with soil humic acid has not been evaluated. We studied NTO reduction by anthraquinone-2,6-disulfonate (AQDS) and Leonardite humic acid (LHA) reduced with dithionite. Both LHA and AQDS reduced NTO to 3-amino-1,2,4-triazol-5-one (ATO), stoichiometrically at alkaline pH and partially (50-60%) at pH ≤ 6.5. Due to NTO and hydroquinone speciation, the pseudo-first-order rate constants (kObs) varied by 3 orders of magnitude from pH 1.5 to 12.5 but remained constant from pH 4 to 10. This distinct pH dependency of kObs suggests that NTO reactivity decreases upon deprotonation and offsets the increasing AQDS reactivity with pH. The reduction of NTO by LHA deviated continuously from first-order behavior for >600 h. The extent of reduction increased with pH and LHA electron content, likely due to greater reactivity of and/or accessibility to hydroquinone groups. Only a fraction of the electrons stored in LHA was utilized for NTO reduction. Electron balance analysis and LHA redox potential profile suggest that the physical conformation of LHA kinetically limited NTO access to hydroquinone groups. This study demonstrates the importance of carbonaceous materials in controlling the environmental fate of NTO.

Single Subcutaneous Ketamine Dose Followed by Oral Ketamine for Depression Symptoms in Hospice Patients: A Case Series.

Management of depression symptoms in hospice patients is complicated by the fact that an appropriate trial of antidepressant therapy requires 4-6 weeks and most hospice patients receive hospice services for less than 8 weeks. Intravenously administered ketamine has been shown to produce rapid improvement in depression symptoms but is not an ideal route for hospice patients and oral ketamine appears to have a slower onset of antidepressant activity. We present a case series that illustrates the use of a single subcutaneous dose of ketamine (0.5 mg/kg) followed by daily oral ketamine (0.5 mg/kg daily) therapy to manage depression symptoms in three hospice patients. Clinical improvement of depression symptoms occurred quickly for all patients as measured by the PHQ-4, numeric ratings, and subjective reporting. A single subcutaneous dose of ketamine followed by oral therapy presents itself as an option to quickly reduce depression symptoms in hospice patients that do not also require additional pain management. Combining the use of the subcutaneous and oral routes takes advantage of the possibly faster onset, home administration, and milder side effects than intravenous dosing. Prospective studies are needed to determine which dosing strategy would be the most beneficial for hospice patients.