Hospital-Based Palliative Care Programs: Perspectives Regarding Conceptualization and Accreditation

Palliative care has been shown to improve symptoms and increase quality of life in people with a life-limiting illness. Despite growth in hospital-based palliative care programs throughout the United States, only 91 hospitals have obtained The Joint Commission’s Advanced Palliative Certification. The purpose of this descriptive study was to identify how programs that do not have The Joint Commission’s Advanced Palliative Care Certification defined and conceptualized palliative care. An additional focus was to identify the barriers these programs perceived or experienced that prevented them from obtaining the advanced palliative care certification. This research program began with an evolutionary concept analysis that identified how palliative care has changed through time. Following this was a review of existing definitions and theories of palliative care. Following a comparison of various standards for palliative care, the Trajectory of Quality Palliative Care Model was developed and used to guide this research study. Hospital-based palliative care programs listed as active on the Center to Advance Palliative Care’s (CAPC) National Palliative Care Registry were eligible. A total of 21 programs across the United States participated. Data collection was completed via phone interviews guided by the Hospital-Based Palliative Care Survey. Definitions of palliative care used by the programs within the data set were inconsistent but did follow components of the definitions used by the CAPC, National Quality Forum (NQF), National Hospice and Palliative Care Organization (NHPCO), and The Joint Commission. Findings also identified perceived barriers to achieving The Joint Commission Advanced Palliative Care Certification: (a) not meeting the seven-days-per-week and on-call criteria, (b) recruitment and retention of staff, (c) allocating funding necessary to reach minimum staffing standards, and (d) hospital staff and consumer misunderstanding about palliative care. Evidence from this study provides a basis upon which further actions can be taken to address barriers to obtaining The Joint Commission’s Advanced Palliative Care Certification. Finally, this research informs potential policy implication shifts related to education and research in palliative care along with workforce training, staffing standards, and financial resources to support high-quality palliative care

Activity of species-specific antibiotics against Crohnʼs disease–associated adherent-invasive Escherichia coli

Background: Crohn's disease (CD) is associated with bacterial dysbiosis that frequently includes colonization by adherent-invasive Escherichia coli (AIEC). AIEC are adept at forming biofilms and are able to invade host cells and stimulate the production of proinflammatory cytokines. The use of traditional antibiotics for the treatment of CD shows limited efficacy. In this study, we investigate the use of species-specific antibiotics termed colicins for treatment of CD-associated AIEC. Methods: Colicin activity was tested against a range of AIEC isolates growing in the planktonic and biofilm mode of growth. Colicins were also tested against AIEC bacteria associated with T84 intestinal epithelial cells and surviving inside RAW264.7 macrophages using adhesion assays and gentamicin protection assay, respectively. Uptake of colicins into eukaryotic cells was visualized using confocal microscopy. The effect of colicin treatment on the production of proinflammatory cytokine tumor necrosis factor alpha by macrophages was assessed by an enzyme-linked immunosorbent assay. Results: Colicins show potent activity against AIEC bacteria growing as biofilms when delivered either as a purified protein or through a colicin-producing bacterial strain. In addition, colicins E1 and E9 are able to kill cell-associated and intracellular AIEC, but do not show toxicity toward macrophage cells or stimulate the production of proinflammatory cytokines. Colicin killing of intracellular bacteria occurs after entry of colicin protein into AIEC-infected macrophage compartments by actin-mediated endocytosis. Conclusions: Our results demonstrate the potential of colicins as highly selective probiotic therapeutics for the eradication of E. coli from the gastrointestinal tract of patients with CD

A Climatology of Tropospheric Zonal-Mean Water Vapor Fields and Fluxes in Isentropic Coordinates

Based on reanalysis data for the years 1980–2001 from the European Centre for Medium-Range Weather Forecasts (ERA-40 data), a climatology of tropospheric zonal-mean water vapor fields and fluxes in isentropic coordinates is presented. In the extratropical free troposphere, eddy fluxes dominate the meridional flux of specific humidity along isentropes. At all levels, isentropic eddy fluxes transport water vapor from the deep Tropics through the subtropics into the extratropics. Isentropic eddy fluxes of specific humidity diverge near the surface and in the tropical and subtropical free troposphere; they converge in the extratropical free troposphere. Isentropic mean advective fluxes of specific humidity play a secondary role in the meridional water vapor transport in the free troposphere; however, they dominate the meridional flux of specific humidity near the surface, where they transport water vapor equatorward and, in the solstice seasons, across the equator. Cross-isentropic mean advective fluxes of specific humidity are especially important in the Hadley circulation, in whose ascending branches they moisten and in whose descending branches they dry the free troposphere. Near the minima of zonal-mean relative humidity in the subtropical free troposphere, the divergence of the cross-isentropic mean advective flux of specific humidity in the descending branches of the Hadley circulation is the dominant divergence in the mean specific humidity balance; it is primarily balanced by convergence of cross-isentropic turbulent fluxes that transport water vapor from the surface upward. Although there are significant isentropic eddy fluxes of specific humidity through the region of the subtropical relative humidity minima, their divergence near the minima is generally small compared with the divergence of cross-isentropic mean advective fluxes, implying that moistening by eddy transport from the Tropics into the region of the minima approximately balances drying by eddy transport into the extratropics. That drying by cross-isentropic mean subsidence near the subtropical relative humidity minima is primarily balanced by moistening by upward turbulent fluxes of specific humidity, likely in convective clouds, suggests cloud dynamics may play a central role in controlling the relative humidity of the subtropical free troposphere

Impaired myogenic tone in mesenteric arteries from overweight rats

abstract: Background Rats fed high fat (HFD) or high sucrose (HSD) diets develop increased adiposity as well as impaired vasodilatory responsiveness stemming from oxidative stress. Moreover, HFD rats become hypertensive compared to either control (Chow) or HSD fed rats, suggesting elevated vascular tone. We hypothesized that rats with increased adiposity and oxidative stress demonstrate augmented pressure-induced vasoconstriction (i.e. myogenic tone) that could account for the hypertensive state. Methods Male Sprague-Dawley rats were fed Chow, HFD or HSD for 6 weeks. The effects of oxidative stress and endogenous nitric oxide on myogenic responses were examined in small mesenteric arteries by exposing the arteries to incremental intraluminal pressure steps in the presence of antioxidants or an inhibitor of nitric oxide synthase, LNNA (100 μM). Results Contrary to the hypothesis, rats fed either HSD or HFD had significantly impaired myogenic responses despite similar vascular morphology and passive diameter responses to increasing pressures. Vascular smooth muscle (VSM) calcium levels were normal in HFD arteries suggesting that diminished calcium sensitivity was responsible for the impaired myogenic response. In contrast, VSM calcium levels were reduced in HSD arteries but were increased with pre-exposure of arteries to the antioxidants tiron (10 mM) and catalase (1200 U/mL), also resulting in enhanced myogenic tone. These findings show that oxidative stress impairs myogenic tone in arteries from HSD rats by decreasing VSM calcium. Similarly, VSM calcium responses were increased in arteries from HFD rats following treatment with tiron and catalase, but this did not result in improved myogenic tone. Nitric oxide is involved in the impaired myogenic response in HFD, but not HSD, rats since inhibition with LNNA resulted in maximal myogenic responses at lower intraluminal pressures and VSM calcium levels, further implicating reduced calcium sensitivity in the impaired response. Conclusion The impaired myogenic responses observed in isolated arteries from HSD and HFD rats are attributed to changes in VSM calcium signaling.The electronic version of this article is the complete one and can be found online at: http://nutritionandmetabolism.biomedcentral.com/articles/10.1186/1743-7075-9-1

LOX/hydrocarbon rocket engine analytical design methodology development and validation. Volume 2: Appendices

This final report includes a discussion of the work accomplished during the period from Dec. 1988 through Nov. 1991. The objective of the program was to assemble existing performance and combustion stability models into a usable design methodology capable of designing and analyzing high-performance and stable LOX/hydrocarbon booster engines. The methodology was then used to design a validation engine. The capabilities and validity of the methodology were demonstrated using this engine in an extensive hot fire test program. The engine used LOX/RP-1 propellants and was tested over a range of mixture ratios, chamber pressures, and acoustic damping device configurations. This volume contains time domain and frequency domain stability plots which indicate the pressure perturbation amplitudes and frequencies from approximately 30 tests of a 50K thrust rocket engine using LOX/RP-1 propellants over a range of chamber pressures from 240 to 1750 psia with mixture ratios of from 1.2 to 7.5. The data is from test configurations which used both bitune and monotune acoustic cavities and from tests with no acoustic cavities. The engine had a length of 14 inches and a contraction ratio of 2.0 using a 7.68 inch diameter injector. The data was taken from both stable and unstable tests. All combustion instabilities were spontaneous in the first tangential mode. Although stability bombs were used and generated overpressures of approximately 20 percent, no tests were driven unstable by the bombs. The stability instrumentation included six high-frequency Kistler transducers in the combustion chamber, a high-frequency Kistler transducer in each propellant manifold, and tri-axial accelerometers. Performance data is presented, both characteristic velocity efficiencies and energy release efficiencies, for those tests of sufficient duration to record steady state values

Development of the Orion Crew Module Static Aerodynamic Database

The Orion aerodynamic database provides force and moment coefficients given the velocity, attitude, configuration, etc. of the Crew Exploration Vehicle (CEV). The database is developed and maintained by the NASA CEV Aerosciences Project team from computational and experimental aerodynamic simulations. The database is used primarily by the Guidance, Navigation, and Control (GNC) team to design vehicle trajectories and assess flight performance. The initial hypersonic re-entry portion of the Crew Module (CM) database was developed in 2006. Updates incorporating additional data and improvements to the database formulation and uncertainty methodologies have been made since then. This paper details the process used to develop the CM database, including nominal values and uncertainties, for Mach numbers greater than 8 and angles of attack between 140deg and 180deg. The primary available data are more than 1000 viscous, reacting gas chemistry computational simulations using both the Laura and Dplr codes, over a range of Mach numbers from 2 to 37 and a range of angles of attack from 147deg to 172deg. Uncertainties were based on grid convergence, laminar-turbulent solution variations, combined altitude and code-to-code variations, and expected heatshield asymmetry. A radial basis function response surface tool, NEAR-RS, was used to fit the coefficient data smoothly in a velocity-angle-of-attack space. The resulting database is presented and includes some data comparisons and a discussion of the predicted variation of trim angle of attack and lift-to-drag ratio. The database provides a variation in trim angle of attack on the order of +/-2deg, and a range in lift-to-drag ratio of +/-0.035 for typical vehicle flight conditions

Comorbidities and Race/Ethnicity Among Adults with Stimulant Use Disorders in Residential Treatment

Comorbid physical and mental health problems are associated with poorer substance abuse treatment outcomes; however, little is known about these conditions among stimulant abusers at treatment entry. This study compared racial and ethnic groups on baseline measures of drug use patterns, comorbid physical and mental health disorders, quality of life, and daily functioning among cocaine and stimulant abusing/dependent patients. Baseline data from a multi-site randomized clinical trial of vigorous exercise as a treatment strategy for a diverse population of stimulant abusers (N = 290) were analyzed. Significant differences between groups were found on drug use characteristics, stimulant use disorders, and comorbid mental and physical health conditions. Findings highlight the importance of integrating health and mental health services into substance abuse treatment and could help identify potential areas for intervention to improve treatment outcomes for racial and ethnic minority groups

Comparison of mechanisms involved in impaired vascular reactivity between high sucrose and high fat diets in rats

<p>Abstract</p> <p>Background</p> <p>To determine the effects of high sucrose diets on vascular reactivity. We hypothesized that similar to high fat diets (HFD), HSD feeding would lead to increased adiposity resulting in inflammation and oxidative stress-mediated impairment of vasodilation.</p> <p>Methods</p> <p>Male Sprague-Dawley rats were fed control chow (Chow), HSD or HFD diets for 6 weeks. The role of inflammation and oxidative stress on impaired vasodilation were assessed in isolated mesenteric arterioles.</p> <p>Results</p> <p>HSD and HFD induced increased adiposity, oxidative stress and inflammation. HFD rats developed fasting hyperglycemia. Both HSD and HFD rats developed impaired glucose tolerance and hyperleptinemia. Nitric oxide (NO)-mediated vasodilation was significantly attenuated in both HSD and HFD rats but was normalized by treatment with antioxidants or anti-inflammatory drugs. Endothelial NO synthase (eNOS) protein expression was not affected by diet. Sensitivity to NO was reduced since NOS inhibition attenuated vasodilation in Chow rats but did not further impair vasodilation in HSD or HFD rats. Likewise, responsiveness to a NO donor was attenuated in both experimental groups.</p> <p>Conclusions</p> <p>Oxidative stress diminishes vasodilatory responsiveness in HSD and HFD rats through ROS-mediated scavenging of NO and decreased smooth muscle sensitivity to NO. Inflammation also plays a significant role in the impaired vasodilation.</p

Very small deletions within the NESP55 gene in pseudohypoparathyroidism type 1b

Pseudohypoparathyroidism (PHP) is caused by reduced expression of genes within the GNAS cluster, resulting in parathormone resistance. The cluster contains multiple imprinted transcripts, including the stimulatory G protein α subunit (Gs-α) and NESP55 transcript preferentially expressed from the maternal allele, and the paternally expressed XLas, A/B and antisense transcripts. PHP1b can be caused by loss of imprinting affecting GNAS A/B alone (associated with STX16 deletion), or the entire GNAS cluster (associated with deletions of NESP55 in a minority of cases). We performed targeted genomic next-generation sequencing (NGS) of the GNAS cluster to seek variants and indels underlying PHP1b. Seven patients were sequenced by hybridisation-based capture and fourteen more by long-range PCR and transposon-mediated insertion and sequencing. A bioinformatic pipeline was developed for variant and indel detection. In one family with two affected siblings, and in a second family with a single affected individual, we detected maternally inherited deletions of 40 and 33 bp, respectively, within the deletion previously reported in rare families with PHP1b. All three affected individuals presented with atypically severe PHP1b; interestingly, the unaffected mother in one family had the detected deletion on her maternally inherited allele. Targeted NGS can reveal sequence changes undetectable by current diagnostic methods. Identification of genetic mutations underlying epigenetic changes can facilitate accurate diagnosis and counselling, and potentially highlight genetic elements critical for normal imprint settin

Immunological and nutritional factors in elderly people in low-level care and their association with mortality

BACKGROUND: This study examines associations between markers of nutritional status and lymphocyte subsets and seeks to determine if lymphocyte profile is predictive of survival in elderly Australians residing in aged care facilities. Aged yet still ambulatory subjects (n = 88, 73% female) living in low-level care and requiring minimal assistance were studied for 143 weeks. At baseline when participants were aged (mean ± SD) 86.0 ± 5.9 years, dietary intake was determined by 3-day weighed food record, body composition was assessed by dual energy X-ray absorptiometry (DXA) and a venous blood sample was taken. RESULTS: At baseline assessment, study participants were consuming nutrient-poor diets and most had symptoms of chronic disease. Although overweight, 40% exhibited sarcopenia. Markers of nutritional status did not relate closely to immune cell numbers (absolute or relative), which on average were within the normal range. Men had lower numbers of CD3(+)CD4(+) cells (CD4(+) T cells), a higher proportion of CD3(−) CD16(±) CD56(±) (natural killer (NK) cells) and a higher ratio of NK: CD4(+) T cells than women (all P < 0.05). The main age-related changes evident were decreased T cells, particularly low CD4(+) T cell counts, and increased numbers of CD19(+) (B-cell) and NK cells. During the 143 week duration of follow-up, about one quarter of the study participants died, with death more likely in men than women (P < 0.01). Poor survival was predicted by the presence of decreased numbers of CD4(+) T cells (hazard ratio (HR) 0.919, P < 0.01) and expanded numbers of NK cells (HR 1.085, P < 0.05) in the blood, and therefore the presence of a high NK: CD4(+) T cell ratio (HR 30.521, P < 0.01). CONCLUSIONS: The NK: CD4(+) T cell ratio may potentially have clinical utility for predicting longevity in elderly populations. Further studies are needed in other elderly populations to confirm this finding