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Emergency Medicine Palliative Care Access (EMPallA): Protocol for a multicentre randomised controlled trial comparing the effectiveness of specialty outpatient versus nurse-led telephonic palliative care of older adults with advanced illness
Introduction Emergency department (ED)-initiated palliative care has been shown to improve patient-centred outcomes in older adults with serious, life-limiting illnesses. However, the optimal modality for providing such interventions is unknown. This study aims to compare nurse-led telephonic case management to specialty outpatient palliative care for older adults with serious, life-limiting illness on: (1) quality of life in patients; (2) healthcare utilisation; (3) loneliness and symptom burden and (4) caregiver strain, caregiver quality of life and bereavement. Methods and analysis This is a protocol for a pragmatic, multicentre, parallel, two-arm randomised controlled trial in ED patients comparing two established models of palliative care: nurse-led telephonic case management and specialty, outpatient palliative care. We will enrol 1350 patients aged 50+ years and 675 of their caregivers across nine EDs. Eligible patients: (1) have advanced cancer (metastatic solid tumour) or end-stage organ failure (New York Heart Association class III or IV heart failure, end-stage renal disease with glomerular filtration rate /min/m2, or global initiative for chronic obstructive lung disease stage III, IV or oxygen-dependent chronic obstructive pulmonary disease); (2) speak English; (3) are scheduled for ED discharge or observation status; (4) reside locally; (5) have a working telephone and (6) are insured. Patients will be excluded if they: (1) have dementia; (2) have received hospice care or two or more palliative care visits in the last 6 months or (3) reside in a long-term care facility. We will use patient-level block randomisation, stratified by ED site and disease. Effectiveness will be compared by measuring the impact of each intervention on the specified outcomes. The primary outcome will measure change in patient quality of life. Ethics and dissemination Institutional Review Board approval was obtained at all study sites. Trial results will be submitted for publication in a peer-reviewed journal
Retinoid X Receptor and Peroxisome Proliferator-Activated Receptor-Gamma Agonists Cooperate to Inhibit Matrix Metalloproteinase Gene Expression
We recently described the ability of retinoid X receptor (RXR) ligand LG100268 (LG268) to inhibit interleukin-1-beta (IL-1-β)-driven matrix metalloproteinase-1 (MMP-1) and MMP-13 gene expression in SW-1353 chondrosarcoma cells. Other investigators have demonstrated similar effects in chondrocytes treated with rosiglitazone, a ligand for peroxisome proliferator-activated receptor-gamma (PPARγ), for which RXR is an obligate dimerization partner. The goals of this study were to evaluate the inhibition of IL-1--induced expression of MMP-1andMMP-13 by combinatorial treatment with RXR and PPAR ligands and to investigate the molecular mechanisms of this inhibition
Evaluating outcomes from an integrated health service for older patients
Background: Hospital-associated disability is the loss of the ability to complete one activity of daily living (ADL), with this decline occurring between the onset of acute illness and discharge from the hospital. Approximately 30% of patients who are >70 years old and admitted to hospitals are discharged with an ADL disability. Comprehensive geriatric assessment (CGA) models use a multidimensional, interdisciplinary process of diagnosis and treatment with the goal of improving outcomes and decreasing lengths of stay. Methods: A retrospective clinical audit of Ipswich Hospital’s medical records included patients for random selection who were >75 years of age and had an acute admission to the Older Person Evaluation Review and Assessment (OPERA) or general medicine (GM) service from July 2012 to December 2012. Data were collected for the entire admission period on length of stay, comorbidities, allied health visits, functional ability, and delirium and dementia at admission. Results: Of the 267 patients evaluated, 133 were admitted to the OPERA service, and 134 were admitted to the GM service. Patients admitted to the OPERA service were significantly more ill than patients admitted to the GM service as measured by the Charlson Comorbidity Index scores (6.53 - 1.83 vs 6.02 - 1.96, respectively, P¼0.02), Katz Index of Independence in ADL scores (3.77 - 2.22 vs 4.72 - 2.00, respectively,
Educating pharmacists on the risks of strong opioids with descriptive and simulated experience risk formats: A randomized controlled trial
Objectives. High opioid prescription rates in the United States and Europe suggest miscalibrated risk perceptions among those who prescribe, dispense, and take opioids. Findings from cognitive decision science suggest that risk perceptions and behaviors can differ depending on whether people learn about risks by experience or description. This study investigated effects of a descriptive versus an experience-based risk education format on pharmacists’ risk perceptions and counseling behavior in the long-term administration of strong opioids to patients with chronic noncancer pain. Methods. In an exploratory, randomized controlled online trial, 300 German pharmacists were randomly assigned to either a descriptive format (fact box) or a simulated experience format (interactive simulation). Primary Outcome Measures. 1) Objective risk perception, 2) subjective risk perception, and 3) intended and 4) actual counseling behavior. Results. Both risk formats significantly improved pharmacists’ objective risk perception, but pharmacists exposed to the fact box estimated the benefit-harm ratio more accurately than those exposed to the simulation. Both formats proved equally effective in adjusting pharmacists’ subjective risk perception toward a better recognition of opioids’ harms; however, pharmacists receiving the simulation showed a greater change in their actual counseling behavior and higher consistency between their intended and actual counseling than pharmacists receiving the fact box. Conclusion. The simulated experience format was less effective than the descriptive format in improving pharmacists’ objective risk perception, equally effective in motivating pharmacists to counsel patients on less risky treatment alternatives and more effective in changing the reported actual counseling behavior. Implications. These exploratory findings provide important insights into the relevance of the description-experience gap for drug safety and raise questions for future research regarding the specific mechanisms at work
Suppression of mid-infrared plasma resonance due to quantum confinement in delta-doped silicon
The classical Drude model provides an accurate description of the plasma
resonance of three-dimensional materials, but only partially explains
two-dimensional systems where quantum mechanical effects dominate such as
P:-layers - atomically thin sheets of phosphorus dopants in silicon
that induce novel electronic properties beyond traditional doping. Previously
it was shown that P:-layers produce a distinct Drude tail feature in
ellipsometry measurements. However, the ellipsometric spectra could not be
properly fit by modeling the -layer as discrete layer of classical
Drude metal. In particular, even for large broadening corresponding to
extremely short relaxation times, a plasma resonance feature was anticipated
but not evident in the experimental data. In this work, we develop a physically
accurate description of this system, which reveals a general approach to
designing thin films with intentionally suppressed plasma resonances. Our model
takes into account the strong charge density confinement and resulting quantum
mechanical description of a P:-layer. We show that the absence of a
plasma resonance feature results from a combination of two factors: i), the
sharply varying charge density profile due to strong confinement in the
direction of growth; and ii), the effective mass and relaxation time anisotropy
due to valley degeneracy. The plasma resonance reappears when the atoms
composing the -layer are allowed to diffuse out from the plane of the
layer, destroying its well-confined two-dimensional character that is critical
to its novel electronic properties
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