End-of-life care for homeless people: A qualitative analysis exploring the challenges to access and provision of palliative care

BACKGROUND: Being homeless or vulnerably housed is associated with death at a young age, frequently related to medical problems complicated by drug or alcohol dependence. Homeless people experience high symptom burden at the end of life, yet palliative care service use is limited. AIM: To explore the views and experiences of current and formerly homeless people, frontline homelessness staff (from hostels, day centres and outreach teams) and health- and social-care providers, regarding challenges to supporting homeless people with advanced ill health, and to make suggestions for improving care. DESIGN: Thematic analysis of data collected using focus groups and interviews. PARTICIPANTS: Single homeless people ( n = 28), formerly homeless people ( n = 10), health- and social-care providers ( n = 48), hostel staff ( n = 30) and outreach staff ( n = 10). RESULTS: This research documents growing concern that many homeless people are dying in unsupported, unacceptable situations. It highlights the complexities of identifying who is palliative and lack of appropriate places of care for people who are homeless with high support needs, particularly in combination with substance misuse issues. CONCLUSION: Due to the lack of alternatives, homeless people with advanced ill health often remain in hostels. Conflict between the recovery-focused nature of many services and the realities of health and illness for often young homeless people result in a lack of person-centred care. Greater multidisciplinary working, extended in-reach into hostels from health and social services and training for all professional groups along with more access to appropriate supported accommodation are required to improve care for homeless people with advanced ill health

Challenges to discussing palliative care with people experiencing homelessness: a qualitative study

OBJECTIVES: To explore the views and experiences of people who are homeless and those supporting them regarding conversations and approaches to palliative care SETTING: Data were collected between October 2015 and October 2016 in homeless hostels and day centres and with staff from primary and secondary healthcare providers and social care services from three London boroughs. PARTICIPANTS: People experiencing homelessness (n=28), formerly homeless people (n=10), health and social care providers (n=48), hostel staff (n=30) and outreach staff (n=10). METHODS: In this qualitative descriptive study, participants were recruited to interviews and focus groups across three London boroughs. Views and experiences of end-of-life care were explored with people with personal experience of homelessness, health and social care professionals and hostel and outreach staff. Saturation was reached when no new themes emerged from discussions. RESULTS: 28 focus groups and 10 individual interviews were conducted. Participants highlighted that conversations exploring future care preferences and palliative care with people experiencing homelessness are rare. Themes identified as challenges to such conversations included attitudes to death; the recovery focused nature of services for people experiencing homelessness; uncertainty regarding prognosis and place of care; and fear of negative impact. CONCLUSIONS: This research highlights the need for a different approach to supporting people who are homeless and are experiencing advanced ill health, one that incorporates uncertainty and promotes well-being, dignity and choice. We propose parallel planning and mapping as a way of working with uncertainty. We acknowledge that these approaches will not always be straightforward, nor will they be suitable for everyone, yet moving the focus of conversations about the future away from death and dying, towards the present and the future may facilitate conversations and enable the wishes of people who are homeless to be known and explored

Research Report: Usefulness of investigating error profiles in diagnosis of naming impairments

peer-reviewedBackground: Word-retrieval difficulties are commonly experienced by people with aphasia (PwA) and also by typically ageing persons. Differentiation between true naming impairments and naming difficulties found in healthy persons may, therefore, be challenging. Aims: To investigate the extent to which the Maltese adaptation of the Boston Naming Test (BNT) can identify people with lexical retrieval difficulties and to differentiate them from people with unimpaired word finding. Methods & Procedures: Naming performance of a group of PwA was compared with the performance of a control group. Performance on theMaltese adaptation of the BNT was investigated in terms of scores, range of scores and error profiles of the two groups. Outcomes & Results: All PwA scored below the mean score of the controls, indicating that persons who scored above the mean score may be considered as unimpaired. However, a number of the controls obtained very low scores that overlapped with the scores obtained by the PwA. This indicated that scores alone cannot be used to differentiate between impaired and unimpaired people. Some types of errors were only produced by people with impaired naming, and did not appear at all in error profiles of unimpaired individuals. Conclusions & Implications: Mild–moderate anomic impairments may be missed if naming impairment is assessed and diagnosed using a cut-off score. In order to differentiate between people with impaired and unimpaired naming, it is necessary to look at error profiles, apart from the number of errors, as the presence of atypical errors may be an important indicator of naming impairments

Malaria in pregnancy.

Recently, there has been a resurgence of malaria in densely populated areas of the United States secondary to human migration from endemic areas where factors such as cessation of vector control, vector resistance to insecticides, disease resistance to drugs, environmental changes, political instability, and indifference, have played a role for malaria becoming an overwhelming infection of these tropical underdeveloped countries. It is important for health care providers of gravida to be alert of the disease and its effects on pregnancy

A common short-term memory retrieval rate may describe many cognitive procedures

We examine the relationship between response speed and the number of items in short-term memory (STM) in four different paradigms and find evidence for a similar high-speed processing rate of about 25–30 items per second (∼35–40 ms/item). We propose that the similarity of the processing rates across paradigms reflects the operation of a very basic covert memory process, high-speed retrieval, that is involved in both the search for information in STM and the reactivation or refreshing of information that keeps it in STM. We link this process to a specific pattern of rhythmic, repetitive neural activity in the brain (gamma oscillations). This proposal generates ideas for research and calls for an integrative approach that combines neuroscientific measures with behavioral cognitive techniques

Re-playing Maimonides’ Codes: Designing Games to Teach Religious Legal Systems

Lost & Found is a game series, created at the Initiative for Religion, Culture, and Policy at the Rochester Institute of Technology MAGIC Center.1 The series teaches medieval religious legal systems. This article uses the first two games of the series as a case study to explore a particular set of processes to conceive, design, and develop games for learning. It includes the background leading to the author\u27s work in games and teaching religion, and the specific context for the Lost & Found series. It discusses the rationale behind working to teach religious legal systems more broadly, then discuss the hermeneutics influencing the approach to understanding the legal systems being modeled, and closes with a discussion of the kind of teaching and learning involved in the design of the games and early stage data on the public play of the games

Teaching the Three E’s of Sustainability Through Service‐Learning in a Professional Program

Using seven established course design principles for effective service‐learning, this chapter discusses the lessons learned in teaching the three E’s of sustainability: environmental; economic; and (social) equity, in a professional program at an American Midwestern public university.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/154652/1/tl20374_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/154652/2/tl20374.pd

When should tests for unexpected antibodies be done during pregnancy?

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/87118/1/j.1537-2995.2011.03212.x.pd

Acute Kidney Injury in Patients with Systemic Sclerosis Participating in Hematopoietic Cell Transplantation Trials in the United States

Recipients of hematopoietic cell transplantation may be at risk for developing acute kidney injury (AKI), and this risk may be increased in patients who undergo transplantation for severe systemic sclerosis (SSc) due to underlying scleroderma renal disease. AKI after transplantation can increase treatment-related mortality. To better define these risks, we analyzed 91 patients with SSc who were enrolled in 3 clinical trials in the United States of autologous or allogeneic hematopoietic cell transplantation (HCT). Eleven (12%) of the 91 patients with SSc in these studies (8 undergoing autologous HCT, 1 undergoing allogeneic HCT, 1 pretransplantation, 1 given i.v. cyclophosphamide on a transplantation trial) experienced AKI, of whom 8 required dialysis and/or therapeutic plasma exchange. AKI injury in the 9 HCT recipients developed a median of 35 days (range, 0-90 days) after transplantation. Ten of 11 patients with AKI received angiotensin-converting enzyme inhibitor (ACE-I) therapy. The etiology of AKI was attributed to scleroderma renal crisis in 6 patients (including 2 with normotensive renal crisis), to AKI of uncertain etiology in 2 patients, and to AKI superimposed on scleroderma kidney disease in 3 patients. Eight of the 11 patients died, one each because of progression of SSc, multiorgan failure, gastrointestinal and pulmonary bleeding, pericardial tamponade and pulmonary complications, diffuse alveolar hemorrhage, pulmonary embolism, graft-versus-host disease, and malignancy. Limiting nephrotoxins, cautious use of corticosteroids, renal shielding during total body irradiation, strict control of blood pressure, and aggressive use of ACE-Is may be of importance in preventing renal complications after HCT for SSc

Gamification of learning deactivates the Default Mode Network

We hypothesised that embedding educational learning in a game would improve learning outcomes, with increased engagement and recruitment of cognitive resources evidenced by increased activation of working memory network (WMN) and deactivation of Default Mode Network (DMN) regions. In an fMRI study, we compared activity during periods of learning in three conditions that were increasingly game-like: Study-only (when periods of learning were followed by an exemplar question together with its correct answer), Self-quizzing (when periods of learning were followed by a multiple choice question in return for a fixed number of points) and Game-based (when, following each period of learning, participants competed with a peer to answer the question for escalating, uncertain rewards). DMN hubs deactivated as conditions became more game-like, alongside greater self-reported engagement and, in the Game-based condition, higher learning scores. These changes did not occur with any detectable increase in WMN activity. Additionally, ventral striatal activation was associated with responding to questions and receiving positive question feedback. Results support the significance of DMN deactivation for educational learning, and are aligned with recent evidence suggesting DMN and WMN activity may not always be anti-correlated