Palliative and end of life care in prisons: a mixed-methods rapid review of the literature from 2014–2018

Objectives: To explore current practice in relation to palliative and end of life care in prisons, and to make recommendations for its future provision. Design: A rapid literature review of studies using qualitative, quantitative and mixed-methods, with a narrative synthesis of results. Data sources: Six databases searched between January 2014 to December 2018: ASSIA, CINAHL, Embase, MEDLINE, National Criminal Justice Reference Service Abstracts and Scopus. Eligibility criteria: Primary research articles reporting qualitative or quantitative findings about palliative and end of life care in prisons, published in peer-reviewed, English language journals between January 2014 to December 2018. Participants: Prisoners, prisoners’ families, prison healthcare staff and other prison staff. Data extraction/synthesis: Data extracted included: citation, design, aim, setting, sample/population, methods and key findings. Data were analysed thematically then subject to a narrative synthesis in order to answer the research questions. Quality appraisal: Two researchers independently appraised articles using the Qualsyst tool, by Kmet et al (2004). Aggregate summary quality scores are included with findings. Articles were not excluded based on quality appraisal. Results: 23 articles were included (16 qualitative, 6 quantitative, 1 mixed methods). Top three findings (by prevalence) were: fostering relationships with people both inside and outside of prison is important to prisoners with palliative and end of life care needs, inmate hospice volunteers are able to build and maintain close relationships with the prisoners they care for and the conflicting priorities of care and custody can have a negative impact on the delivery of palliative and end of life care in prisons. Conclusions: The key findings are: relationships are important to prisoners at the end of life, inmate hospice volunteers can build close bonds with the prisoners in their care and the prison environment and regime conflicts with best practices in palliative and end of life care. Directions for future research are also identified

Caring, sharing, preparing and declaring: how do hospices support prisons to provide palliative and end of life care? A qualitative descriptive study using telephone interviews

Background: Older adults in prison have complex healthcare needs, and many will need palliative care before their sentence ends. Compared with prison-based hospices, little is known about the role played by community-based hospices in providing palliative care to people in prison Aim: To describe the roles Scottish hospices have adopted to support prisons to provide palliative care, and to discuss the international relevance of these findings in addressing the knowledge gap around community hospices supporting people in prison. Design: A qualitative descriptive study using semi-structured telephone interviews. Setting/participants: Representatives from all Scottish adult hospices were invited to take part in a short telephone interview and all (N = 17) participated. Results: Four roles were identified: caring, sharing, preparing and declaring. Most hospices employed different combinations of roles. Five (30%) hospices were engaged in caring (providing direct care at the prison or the hospice). Eleven (65%) hospices were engaged in sharing (supporting the prison by sharing knowledge and expertise). Eleven (65%) hospices were engaged in preparing (making preparations to support prisons). All seventeen hospices were described as declaring (expressing a willingness to engage with prisons to provide care). Conclusions: There are differences and similarities in the way countries provide palliative care to people in prison: many are similar to Scotland in that they do not operate prison-based hospices. Variations exist in the level of support hospices provide. Ensuring that all people in prison have equitable access to palliative care will require close collaboration between prisons and hospices on a national level

A mixed-methods systematic review of nurse-led interventions for people with multimorbidity

Aims: To identify types of nurse-led interventions for multimorbidity and which outcomes are positively affected by them. Design: Mixed-methods systematic review following the Joanna Briggs Institute (JBI) methods for convergent-integrated reviews. PROSPERO ID: CRD42020197956. Data Sources: Cochrane CENTRAL, CINAHL, Embase and MEDLINE were searched in October 2020. Grey literature sources included OpenGrey, the Journal of Multimorbidity and Comorbidity and reference mining. Review Methods: English-language reports of nurse-led interventions for people with multimorbidity were included based on author consensus. Two reviewers performed independent quality appraisal using JBI tools. Data were extracted and synthesized using a pre-existing taxonomy of interventions and core outcome set. Results: Twenty studies were included, with a median summary quality score of 77.5%. Interventions were mostly case-management or transitional care interventions, with nurses in advanced practice, support to self-manage conditions, and an emphasis on continuity of care featuring frequently. Patient-centred outcomes such as quality of healthcare and health-related quality of life were mostly improved, with mixed effects on healthcare utilization, costs, mortality and other outcomes. Conclusion: Interventions such as case management are agreeable to patients and transitional care interventions may have a small positive impact on healthcare utilization. Interventions include long-term patient management or short-term interventions targeted at high-risk junctures. These interventions feature nurses in advanced practice developing care plans in partnership with patients, to simplify and improve the quality of care both in the long and short-term. Impact: This is the first mixed-methods review which includes all types of nurse-led interventions for multimorbidity and does not focus on specific comorbidities or elderly/frail populations. Using adapted consensus-developed frameworks for interventions and outcomes, we have identified the common features of interventions and their overall typology. We suggest these interventions are of value to patients and healthcare systems but require localization and granular evaluation of their components to maximize potential benefits

Multimorbidity, disease count, mortality and emergency care use in persons attending the emergency department: a cross-sectional data-linkage study

Background: Multimorbidity (two or more concurrent chronic conditions) is associated with poorer health outcomes and increased healthcare utilisation in primary care and general populations. Less is known about the prevalence of multimorbidity in emergency department attenders, or its association with poor outcomes in this population. Aim: This study sought to explore the relationship between multimorbidity, mortality and health-care utilisation in a large urban cohort of persons attending emergency departments. Methods: Validated algorithms for the identification of 28 chronic conditions from ICD-10 codes were deployed on a cross-sectional sample of patients attending emergency departments in Glasgow, Scotland between April 2019 and March 2020. Analysis was conducted on complete cases (n=63,328) and compared with results from data with imputed missing values (n=75,723). Models adjusted for age, sex, deprivation and ethnicity were fitted to test for the association between (i) multimorbidity, (ii) complex multimorbidity, (iii) disease count and the following outcomes: admission to hospital, reattendance at 30 and 90 days, and death during admission. Results: Multimorbidity, complex multimorbidity and disease count were significantly associated with hospital admission and emergency department reattendance. Those with 1-3 conditions were at increased risk of inpatient mortality. Conclusion: This study further evidences the impact of multimorbidity and disease burden on health-care use, and mortality to a lesser extent. Deployed algorithms were sufficiently sensitive to detect associations, despite limited access (21 months) to secondary-care data. This should allow for the construction of more robust models to prospectively identify persons at risk of poor outcomes in similar populations

The STAR trial protocol: a randomised multi-stage phase II/III study of Sunitinib comparing temporary cessation with allowing continuation, at the time of maximal radiological response, in the first-line treatment of locally advanced/ metastatic Renal Can

Abstract Background: Over recent years a number of novel therapies have shown promise in advanced renal cell carcinoma (RCC). Internationally the standard of care of first-line therapy is sunitinib™, after a clear survival benefit was demonstrated over interferon-α. Convention dictates that sunitinib is continued until evidence of disease progression, assuming tolerability, although there is no evidence that this approach is superior to intermittent periods of treatment. The purpose of the STAR trial is to compare the standard treatment strategy (conventional continuation strategy, CCS) with a novel drug free interval strategy (DFIS) which includes planned treatment breaks

Genetic mechanisms of critical illness in COVID-19.

Host-mediated lung inflammation is present1, and drives mortality2, in the critical illness caused by coronavirus disease 2019 (COVID-19). Host genetic variants associated with critical illness may identify mechanistic targets for therapeutic development3. Here we report the results of the GenOMICC (Genetics Of Mortality In Critical Care) genome-wide association study in 2,244 critically ill patients with COVID-19 from 208 UK intensive care units. We have identified and replicated the following new genome-wide significant associations: on chromosome 12q24.13 (rs10735079, P = 1.65 × 10-8) in a gene cluster that encodes antiviral restriction enzyme activators (OAS1, OAS2 and OAS3); on chromosome 19p13.2 (rs74956615, P = 2.3 × 10-8) near the gene that encodes tyrosine kinase 2 (TYK2); on chromosome 19p13.3 (rs2109069, P = 3.98 ×  10-12) within the gene that encodes dipeptidyl peptidase 9 (DPP9); and on chromosome 21q22.1 (rs2236757, P = 4.99 × 10-8) in the interferon receptor gene IFNAR2. We identified potential targets for repurposing of licensed medications: using Mendelian randomization, we found evidence that low expression of IFNAR2, or high expression of TYK2, are associated with life-threatening disease; and transcriptome-wide association in lung tissue revealed that high expression of the monocyte-macrophage chemotactic receptor CCR2 is associated with severe COVID-19. Our results identify robust genetic signals relating to key host antiviral defence mechanisms and mediators of inflammatory organ damage in COVID-19. Both mechanisms may be amenable to targeted treatment with existing drugs. However, large-scale randomized clinical trials will be essential before any change to clinical practice

Exploring differential diagnosis decision support systems for trainee advanced practitioners in primary care

Background: In primary care, advanced practitioners from nursing and allied health professions are increasingly deployed to assess, diagnose and manage patients. Differential diagnosis decision support systems may assist trainee advanced practitioners with developing their diagnostic decision-making skills. Aim: To identify which differential diagnosis decision support systems are available to primary care clinicians; review the literature regarding these systems; and identify their positive and negative aspects from the perspective of trainee advanced practitioners in primary care. Method: Market research and a literature review were conducted to identify and explore available systems. In an earlier, larger study, focus groups had been conducted with GPs, advanced practitioners and members of the public. The findings from the focus groups are reported here from the perspective of trainee advanced practitioners. Findings: Four commercially available systems were identified – DXplain, Isabel, PEPID and VisualDx – and explored in terms of accuracy, speed and time efficiency, user feedback, use in education, and use in primary care. Focus group participants expressed the views that such systems could guide and confirm diagnostic decisions, but also raised concerns about their potential to stifle decision-making and inhibit critical thinking. Conclusion: In principle, trainee advanced practitioners are open to using differential diagnosis decision support systems, not necessarily to provide them with the knowledge they do not possess but rather to support and reassure them as they adapt to their new roles

Improving entity disambiguation with a vector space semantic tagger

This note describes a few suggestions for improving entity disambiguation using a vector-based semantic tagger, trained using the Skipgram model. The suggestions include assuming non uniform distributions for the probability distribution of the entity, different ways of building vectors for the document, and using a neural network architecture. We exemplify the suggestions on a running example: the disambiguation of entity Boston, which may be referring to the famous city in Massachusetts US, or a town in Lincolnshire UK, or as we will see in the examples below, a few other places in the US and UK

Caring for people in prison with palliative and end-of-life care needs

Purpose of review: The prison population is growing and ageing, and many people will die from natural causes while incarcerated. This article provides a contemporary review of key issues related to palliative and end-of-life care in prisons. Recent findings: Few countries have integrated prison hospices. Palliative care needs may go unrecognised in prison. Older offenders may not trust the prison to care for them and may benefit from segregation. Cancer remains a major cause of death. Training staff remains a priority, and technology can help facilitate this. The coronavirus disease 2019 (COVID-19) had a significant impact on prisons, less is known about its impact on palliative care. Compassionate release is underutilised, and the issue of medically assisted dying adds complexity to decisions around end-of-life care. Peer carers can provide reliable symptom assessment. Family members are often absent when someone dies in prison. Summary: Palliative and end-of-life care in prisons requires a joined-up approach, and staff must understand the challenges of both this and custodial care in general. The relational network both inside and outside of the prison should be involved, and when possible and appropriate, we should consider alternatives to dying whilst incarcerated, such as compassionate release

Clinical decision tools for the assessment of acceptance of chronic pain: a scoping review protocol

The overall aim of the scoping review is to identify and inventory tools that have been used for adults with chronic pain in the healthcare context which describe a rationale to guide decisions about healthcare and to gain an understanding of what may be learned from this that would be useful to future research