Death from cancer:frequent unscheduled care

Funding: SEEM is funded through a Clinical Academic Fellowship from the Chief Scientist Office (CAF_17_06). Funding for data extraction and storage was through PATCH Scotland and Tayside Oncology Research Foundation Research Grants.OBJECTIVE : To examine the demographic, clinical, and temporal factors associated with cancer decedents being a frequent or very frequent unscheduled care (GP-general practice Out-Of-Hours (GPOOH) and Accident & Emergency (A&E)) attender, in their last year of life. METHODS : Retrospective cohort study, of all 2443 cancer decedents in Tayside, Scotland, over 30- months period up to 06/2015, comparing frequent attenders (5-9 attendances/year) and very frequent attenders (≥10 attendances/year) to infrequent attenders (1-4 attendances/year) and non-attenders. Clinical and demographic datasets were linked to routinely-collected clinical data using the Community Health Index number. Anonymised linked data were analysed in SafeHaven, using binary/multinomial logistic regression, and Generalised Estimating Equations analysis. RESULTS : Frequent attenders were more likely to be older, and have upper gastrointestinal (GI), haematological, breast and ovarian malignancies, and less likely to live in accessible areas or have a late cancer diagnosis. They were more likely to use GPOOH than A&E, less likely to have face-to-face unscheduled care attendances, and less likely to be admitted to hospital following unscheduled care attendance. CONCLUSIONS : Age, cancer type, accessibility and timing of diagnosis relative to death were associated with increased likelihood of being a frequent or very frequent attender at unscheduled care.Publisher PDFPeer reviewe

Community prescribing trends and prevalence in the last year of life, for people who die from cancer

Funding: SM is funded through a Clinical Academic Fellowship (CAF_17_06) from the Chief Scientist Office. PATCH Scotland and Tayside Oncology Research Foundation Research Grants funded data extraction and storage costs. Publication costs were funded by the University of St Andrews.Background People who die from cancer (‘cancer decedents’) may latterly experience unpleasant and distressing symptoms. Prescribing medication for pain and symptom control is essential for good-quality palliative care; however, such provision is variable, difficult to quantify and poorly characterised in current literature. This study aims to characterise trends in prescribing analgesia, non-analgesic palliative care medication and non-palliative medications, to cancer decedents, in their last year of life, and to assess any associations with demographic or clinical factors. Methods This descriptive study, analysed all 181,247 prescriptions issued to a study population of 2443 cancer decedents in Tayside, Scotland (2013–2015), in the last year of life, linking prescribing data to demographic, and cancer registry datasets using the unique patient-identifying Community Health Index (CHI) number. Anonymised linked data were analysed in Safe Haven using chi-squared test for trend, binary logistic regression and Poisson regression in SPSSv25. Results In their last year of life, three in four cancer decedents were prescribed strong opioids. Two-thirds of those prescribed opioids were also prescribed laxatives and/or anti-emetics. Only four in ten cancer decedents were prescribed all medications in the ‘Just in Case’ medication categories and only one in ten was prescribed breakthrough analgesia in the last year of life. The number of prescriptions for analgesia and palliative care drugs increased in the last 12 weeks of life. The number of prescriptions for non-palliative care medications, including anti-hypertensives, statins and bone protection, decreased over the last year, but was still substantial. Cancer decedents who were female, younger, or had lung cancer were more likely to be prescribed strong opioids; however, male cancer decedents had higher odds of being prescribed breakthrough analgesia. Cancer decedents who had late diagnoses had lower odds of being prescribed strong opioids. Conclusions A substantial proportion of cancer decedents were not prescribed strong opioids, breakthrough medication, or medication to alleviate common palliative care symptoms (including ‘Just in Case’ medication). Many patients continued to be prescribed non-palliative care medications in their last days and weeks of life. Age, gender, cancer type and timing of diagnosis affected patients’ odds of being prescribed analgesic and non-analgesic palliative care medication.Publisher PDFPeer reviewe

Current definitions of advanced multimorbidity: a protocol for a scoping review

INTRODUCTION: People living with and dying from multimorbidity are increasing in number, and ensuring quality care for this population is one of the major challenges facing healthcare providers. People with multimorbidity often have a high burden of palliative and end-of-life care needs, though they do not always access specialist palliative care services. A key reason for this is that they are often not identified as being in the last stages of their life by current healthcare providers and systems.This scoping review aims to identify and present the available evidence on how people with multimorbidity are currently included in research, policy and clinical practice.METHODS AND ANALYSIS: Scoping review methodology, based on Arksey and O'Malley's framework, will be undertaken and presented using the Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews. Search terms have been generated using the key themes of 'multimorbidity', 'end of life' and 'palliative care'. Peer-reviewed research will be obtained through systematic searching of Medline, EMBASE, CINAHL, Scopus and PsycINFO. Grey literature will be searched in a systematic manner. Literature containing a definition for adults with multimorbidity in a terminal phase of their illness experience will be included. After screening studies for eligibility, included studies will be described in terms of setting and characteristics as well as using inductive content analysis to highlight the commonalities in definitions.ETHICS AND DISSEMINATION: Ethical approval is not required for this scoping review. The findings of the scoping review will be used internally as part of SPB's PhD thesis at the University of St Andrews through the Multimorbidity Doctoral Training Programme for Health Professionals, which is supported by the Wellcome Trust (223499/Z/21/Z) and published in an open access, peer-reviewed journal for wider dissemination.</p

Hepatic radioembolization from transradial access: initial experience and comparison to transfemoral access

PURPOSE:Despite the growing evidence in the cardiology literature that transradial approach has substantial benefits over transfemoral access, this technique is rarely used during interventions in the systemic circulation. The aim of this study was to evaluate the feasibility of transradial approach for hepatic radioembolization and to compare it with transfemoral approach.METHODS:Sixty-four hepatic radioembolizations performed in 50 patients were included in the study. Thirty-three procedures were performed via radial access in 27 patients, and 31 procedures were performed via femoral access in 23 patients.RESULTS:There was 100% technical success in performing hepatic radioembolization in both groups. The majority (97%) of the patients who underwent transradial radioembolization reported preference for radial artery access. The fluoroscopy time was significantly longer (9.45±5.09 min vs. 5.72±3.67 min, P < 0.01) and the radiation dose was significantly higher (597.8±585.2 mGy vs. 302.8±208.3 mGy, P < 0.01) in the radial group compared with the femoral group. The direct cost savings using radial access versus femoral access is approximately $100/procedure. In addition, there was a one hour (50%) shorter postprocedural stay for patients who underwent the transradial procedure.CONCLUSION:Transradial access is feasible for hepatic radioembolization. The transradial approach is cheaper and offers improved patient comfort. However, it is technically challenging, with longer fluoroscopy times and higher radiation doses. Transradial approach should be considered as a primary choice in patients with low platelet count and/or morbid obesity. Transradial access should be in the procedural repertoire of every interventional radiologist

Four-Hundred-and-Ninety-Million-Year Record of Bacteriogenic Iron Oxide Precipitation at Sea-Floor Hydrothermal Vents

Fe oxide deposits are commonly found at hydrothermal vent sites at mid-ocean ridge and back-arc sea floor spreading centers, seamounts associated with these spreading centers, and intra-plate seamounts, and can cover extensive areas of the seafloor. These deposits can be attributed to several abiogenic processes and commonly contain micron-scale filamentous textures. Some filaments are cylindrical casts of Fe oxyhydroxides formed around bacterial cells and are thus unquestionably biogenic. The filaments have distinctive morphologies very like structures formed by neutrophilic Fe oxidizing bacteria. It is becoming increasingly apparent that Fe oxidizing bacteria have a significant role in the formation of Fe oxide deposits at marine hydrothermal vents. The presence of Fe oxide filaments in Fe oxides is thus of great potential as a biomarker for Fe oxidizing bacteria in modern and ancient marine hydrothermal vent deposits. The ancient analogues of modern deep-sea hydrothermal Fe oxide deposits are jaspers. A number of jaspers, ranging in age from the early Ordovician to late Eocene, contain abundant Fe oxide filamentous textures with a wide variety of morphologies. Some of these filaments are like structures formed by modern Fe oxidizing bacteria. Together with new data from the modern TAG site, we show that there is direct evidence for bacteriogenic Fe oxide precipitation at marine hydrothermal vent sites for at least the last 490 Ma of the Phanerozoic

Diatoms in a sediment core from a flood pulse wetland in Malaysia record strong responses to human impacts and hydro‐climate over the past 150 years

Rapid development and climate change in southeast Asia is placing unprecedented pressures on freshwater ecosystems, but long term records of the ecological consequences are rare. Here we examine one basin of Tasik Chini (Malaysia), a UNESCO?designated flood pulse wetland, where human disturbances (dam installation, iron ore mining, oil palm and rubber cultivation) have escalated since the 1980s. Diatom analysis and organic matter geochemistry (?13Corg and C/N ratios) were applied to a sediment sequence to infer ecological changes in the basin since c. 1900 CE. As the Tasik Chini wetland is a rare ecosystem with an unknown diatom ecology, contemporary diatom habitats (plant surfaces, mud surfaces, rocks, plankton) were sampled from across the lake to help interpret the sedimentary record. Habitat specificity of diatoms was not strongly defined and, although planktonic and benthic groupings were distinctive, there was no difference in assemblages among the benthic habitat surfaces. An increase in the proportion of benthic diatom taxa suggests that a substantial decrease in water level occurred between c. 1938 and 1995 CE, initiated by a decline in rainfall (supported by regional meteorological data), which increased the hydrological isolation of the sub?basin. Changes in the diatom assemblages were most marked after 1995 CE when the Chini dam was installed. After this time both ?13Corg and C/N decreased, suggesting an increase in autochthonous production relative to allochthonous river flood pulse inputs. Oil palm plantations and mining continued to expand after c. 1995 CE and we speculate that inputs of pollutants from these activities may have contributed to the marked ecological change. Together, our work shows that this sub?basin of Tasik Chini has been particularly sensitive to, and impacted by, a combination of human and climatically induced changes due to its hydrologically isolated position

Packed Red Blood Cell Transfusion Associates with Acute Kidney Injury After Transcatheter Aortic Valve Replacement

Background: Acute kidney injury after cardiac surgery significantly associates with morbidity and mortality. Despite not requiring cardiopulmonary bypass, transcatheter aortic valve replacement patients have an incidence of post-procedural acute kidney injury similar to patients who undergo open surgical aortic valve replacement. Packed red blood cell transfusion has been associated with morbidity and mortality after cardiac surgery. We hypothesized that packed red blood cell transfusion independently associates with acute kidney injury after transcatheter aortic valve replacement, after accounting for other risk factors. Methods: This is a single-center retrospective cohort study of 116 patients undergoing transcatheter aortic valve replacement. Post-transcatheter aortic valve replacement acute kidney injury was defined by Kidney Disease: Improving Global Outcomes serum creatinine-based criteria. Univariate comparisons between patients with and without post-transcatheter aortic valve replacement acute kidney injury were made for clinical characteristics. Multivariable logistic regression was used to assess independent association of packed red blood cell transfusion with post-transcatheter aortic valve replacement acute kidney injury (adjusting for pre-procedural renal function and other important clinical parameters). Results: Acute kidney injury occurred in 20 (17.2%) subjects. Total number of packed red blood cells transfused independently associated with post-procedure acute kidney injury (OR = 1.67 per unit, 95% CI 1.13–2.47, P = 0.01) after adjusting for pre-procedure estimated glomerular filtration rate (OR = 0.97 per ml/min/1.73m2, 95% CI 0.94–1.00, P = 0.05), nadir hemoglobin (OR = 0.88 per g/dL increase, CI 0.61–1.27, P = 0.50), and post-procedure maximum number of concurrent inotropes and vasopressors (OR = 2.09 per inotrope or vasopressor, 95% CI 1.19–3.67, P = 0.01). Conclusion: Packed red blood cell transfusion, along with post-procedure use of inotropes and vasopressors, independently associate with acute kidney injury after transcatheter aortic valve replacement. Further studies are needed to elucidate the pathobiology underlying these associations

Broad anti-hepatitis C virus (HCV) antibody responses are associated with improved clinical disease parameters in chronic HCV infection

During hepatitis C virus (HCV) infection broadly neutralizing antibody (bNAb) responses targeting E1E2 envelope glycoproteins are generated in many individuals. It is unclear if these antibodies play a protective or a pathogenic role during chronic infection. In this study, we investigated whether bNAb responses in individuals with chronic infection were associated with differences in clinical presentation. Patient-derived purified serum IgG was used to assess the breadth of HCV E1E2 binding and neutralization activity of HCV pseudoparticles. Two panels were compared, bearing viral envelope proteins representing either an inter-genotype or an intra-genotype (gt) 1 group. We found that HCV viral load was negatively associated with strong cross-genotypic E1E2 binding (P=0.03). Overall we observed only modest correlation between total E1E2 binding and neutralizing ability. The breadth of inter-genotype neutralization did not correlate with any clinical parameters, however, analysis of individuals with gt 1 HCV infection (n=20), using an intra-genotype pseudoparticle panel, found a strong association between neutralization breadth and reduced liver fibrosis (P=0.006). Broad bNAb response in our chronic cohort was associated with a single nucleotide polymorphism (SNP) in the HLA-DQB1 gene (P=0.038) as previously reported in an acute cohort. Furthermore bNAbs in these individuals targeted more than one region of E2 neutralizing epitopes as assessed through cross-competition of patient bNAbs with well-characterized E2 antibodies. We conclude that bNAb responses in chronic gt1 infection are associated with lower rates of fibrosis and host genetics may play a role in the ability to raise such responses. IMPORTANCE: Globally there are 130-150 million people with chronic HCV infection. Typically the disease is progressive and is a major cause of severe liver cirrhosis and hepatocellular carcinoma. While it is known that neutralizing antibodies have a role in spontaneous clearance during acute infection, little is known about their role in chronic infection. In the present work we investigate the antibody response in a cohort of chronically infected individuals and find that a broad neutralizing antibody response is protective, with reduced levels of liver fibrosis and cirrhosis. We also find an association with SNPs in class II HLA genes and the presence of a broad neutralizing response indicating that antigen presentation may be important for production of HCV neutralizing antibodies

Effectiveness of Community versus Hospital Eye Service follow-up for patients with neovascular age-related macular degeneration with quiescent disease (ECHoES): a virtual non-inferiority trial

Objectives: To compare the ability of ophthalmologists versus optometrists to correctly classify retinal lesions due to neovascular age-related macular degeneration (nAMD). Design: Randomised balanced incomplete block trial. Optometrists in the community and ophthalmologists in the Hospital Eye Service classified lesions from vignettes comprising clinical information, colour fundus photographs and optical coherence tomographic images. Participants' classifications were validated against experts' classifications (reference standard). Setting: Internet-based application. Participants: Ophthalmologists with experience in the age-related macular degeneration service; fully qualified optometrists not participating in nAMD shared care. Interventions: The trial emulated a conventional trial comparing optometrists' and ophthalmologists' decision-making, but vignettes, not patients, were assessed. Therefore, there were no interventions and the trial was virtual. Participants received training before assessing vignettes. Main outcome measures: Primary outcome- correct classification of the activity status of a lesion based on a vignette, compared with a reference standard. Secondary outcomes-potentially sight-threatening errors, judgements about specific lesion components and participants' confidence in their decisions. Results: In total, 155 participants registered for the trial; 96 (48 in each group) completed all assessments and formed the analysis population. Optometrists and ophthalmologists achieved 1702/2016 (84.4%) and 1722/2016 (85.4%) correct classifications, respectively (OR 0.91, 95% CI 0.66 to 1.25; p=0.543). Optometrists' decision-making was non-inferior to ophthalmologists' with respect to the prespecified limit of 10% absolute difference (0.298 on the odds scale). Optometrists and ophthalmologists made similar numbers of sight-threatening errors (57/994 (5.7%) vs 62/994 (6.2%), OR 0.93, 95% CI 0.55 to 1.57; p=0.789). Ophthalmologists assessed lesion components as present less often than optometrists and were more confident about their classifications than optometrists. Conclusions: Optometrists' ability to make nAMD retreatment decisions from vignettes is not inferior to ophthalmologists' ability. Shared care with optometrists monitoring quiescent nAMD lesions has the potential to reduce workload in hospitals