Difficulties in navigating the intersection of generalist and specialist palliative care services: A cross-sectional study of bereaved family's experiences of care at home in New Zealand

A generalist–specialist model of palliative care is well established as a framework for the provision of community care in resource-rich countries. However, evidence is lacking regarding how the model is experienced by family carers and the extent to which access to both generalist and specialist palliative care is equitable. A cross-sectional postal survey was undertaken to explore bereaved family's experiences of generalist palliative care and its intersection with hospice services in the last 3 months of life. A modified version of the Views of Informal Carers—Evaluation of Services survey was sent to 4,778 bereaved family. Data were collected between February 2017 and October 2018. Chi-square was utilised to identify factors that impacted on experiences of generalist palliative care; analysis of free text data comprising 45,823 words was undertaken using a directed content analysis approach. Eight hundred and twenty-six questionnaires were returned (response rate = 21%). Seventy per cent of people (n = 579) spent some time at home in the last 3 months prior to death. People who received support from hospice were more likely to receive support from multiple other services. Those who received no community services were less likely to feel supported by their general practitioner, less likely to spend the last 2 days of life or die at home. Feeling supported had a strong association with services working well together, being involved in decision-making and being aware of the poor prognosis. The provision of palliative care is complicated by a lack of integration with specialist palliative care and may be the basis of continuing inequities in the provision of community care at the end of life. The assumption at a policy level that “generalists” are willing and able to play a key role in palliative care provision needs to be further challenged.     

Understanding the Enablers and Barriers to Appropriate Infants and Young Child Feeding Practices in India: A Systematic Review

Despite efforts to promote infant and young child feeding (IYCF) practices, there is no collective review of evidence on IYCF enablers and barriers in India. This review was conducted using 2015 Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. Six computerized bibliographic databases, Scopus, PubMed, PsycINFO, CINAHL, Embase, and Ovid MEDLINE, were searched for published studies on factors associated with IYCF practices in India from 1 January 1993, to 30 April 2020. IYCF practices examined were early initiation of breastfeeding, exclusive breastfeeding, continued breastfeeding at one year, introduction to solid semi-solid or soft foods, minimum dietary diversity, minimum meal frequency, minimum acceptable diet, continued breastfeeding at two years, predominant breastfeeding, and bottle feeding. In total, 6968 articles were retrieved, and 46 studies met the inclusion criteria. The common enablers of IYCF were higher maternal socioeconomic status (SES) and more frequent antenatal care visits (ANC) (≥3). Common barriers to IYCF practices were low SES and less frequent ANC. The review showed that the factors associated with IYCF practices in India are largely modifiable and multi-factorial. Improving IYCF practices would require the adoption of both facilities- and community-based policy interventions at the subnational and national levels in India.     

Investigating the relationship between social care supply and healthcare utilization by older people in England

Since 2010, adult social care spending in England has fallen significantly in real terms whilst demand has risen. Reductions in social care supply may also have impacted demand for NHS services, particularly for those whose care is provided at the interface of the health and care systems. We analyzed a panel dataset of 150 local authorities (councils) to test potential impacts on hospital utilization by people aged 65 and over: emergency admission rates for falls and hip fractures (“front‐door” measures); and extended stays of 7 days or longer; and 21 days or longer (“back‐door” measures). Changes in social care supply were assessed in two ways: gross current expenditure (per capita 65 and over) adjusted by local labor costs and social care workforce (per capita 18 and over). We ran negative binomial models, controlling for deprivation, ethnicity, age, unpaid care, council class, and year effects. To account for potential endogeneity, we ran instrumental variable regressions and dynamic panel models. Sensitivity analysis explored potential effects of funding for integrated care (the Better Care Fund). There was no consistent evidence that councils with higher per capita spend or higher social care staffing rates had lower hospital admission rates or shorter hospital stays.     

Implications for farmers of measures to reduce sugars consumption

ObjectiveTo estimate the impact of reduced consumption of free sugars in line with World Health Organization recommendations, on sugar farmers globally.MethodsUsing multiregion input–output analysis, we estimated the proportional impact on production volumes of a 1% reduction in free sugars consumption by the public. We extracted data on sugar production from the Food and Agriculture Organization of the United Nations database for the top 15 sugar-cane- and beet-producing countries globally, and created a custom multiregion input–output database to assess the proportions of production going to human consumption, drawing on household expenditure surveys and national input–output databases (data valid for years 2000–2015). We also considered the impact on production volumes in relation to countries’ gross domestic product.FindingsA high proportion of current sugar production from these countries goes to human consumption, and would thus be impacted by reduced consumption of sugars. The largest impacts on cane sugar production, and thus on farmers, would likely occur in Brazil, China, India and Thailand and on beet production in Belarus, Germany, Russian Federation and United States of America.ConclusionA global opportunity exists for public health leadership to bring together the health, economic, environmental and agriculture sectors to collaborate and build capacity for promotion of alternative livelihoods for sugar farmers. Lessons regarding strategy and the importance of political economy factors can be learnt from tobacco control measures. Further research to quantify the impact of reductions in sugars consumption would provide useful insights for designing policies to complement and strengthen efforts to improve diets and health.     

High affinity of sigma1-binding sites for sterol isomerization inhibitors: evidence for a pharmacological relationship with the yeast sterol C8–C7 isomerase

1. The sigma-drug binding site of guinea-pig liver is carried by a protein which shares significant amino acid sequence similarities with the yeast sterol C₈–C₇ isomerase (ERG2 protein). Pharmacologically - but not structurally - the sigma₁-site is also related to the emopamil binding protein, the mammalian sterol C₈–C₇ isomerase. We therefore investigated if sterol C₈–C₇ isomerase inhibitors are high affinity ligands for the (+)-[³H]-pentazocine labelled sigma₁-binding site.
2. Among the compounds which bound with high affinity to native hepatic and cerebral as well as to yeast expressed sigma₁-binding sites were the agricultural fungicide fenpropimorph (K_i 0.005 nM), the antihypocholesterinaemic drugs triparanol (K_i 7.0 nM), AY-9944 (K_i 0.46 nM) and MDL28,815 (K_i 0.16 nM), the enantiomers of the ovulation inducer clomiphene (K_i 5.5 and 12 nM, respectively) and the antioestrogene tamoxifen (K_i 26 nM).
3. Except for tamoxifen these affinities are essentially identical with those for the [³H]-ifenprodil labelled sterol C₈–C₇ isomerase of S. cerevisiae. This demonstrates that sigma₁-binding protein and yeast isomerase are not only structurally but also pharmacologically related. Because of its affiliations with yeast and mammalian sterol isomerases we propose that the sigma₁-binding site is localized on a sterol isomerase related protein, involved in postsqualene sterol biosynthesis.

     

HLA-D Antigen Expression and Langerhans' Cell Infiltrates in Thyroid Tumors

Papillary carcinomas (PCs) of thyroid are among the most common but least aggressive human malignancies. The factors explaining the indolence of these tumors are unknown but host-tumor immune interactions may play a role. This study was designed to determine if there is morphologic evidence of these. Frozen tissues collected from 21 PCs, 4 follicular adenomas (FAs), 4 follicular carcinomas (FCs), and 11 nodular hyperplasias (NHs) were stained immunohistochemically for HLA-D antigens, lymphocyte and macrophage markers; results were graded numerically. Paraffin-embedded tumors (35 PCs, 10 FAs, and 10 FCs) were stained for S-100 protein to detect Langerhans' cells (LCs). Diffuse staining for HLA-D antigens and heavy mononuclear infiltrates were found more commonly in PCs compared to follicular neoplasms (FNs) or NHs. No consistent relationship was found between lymphocyte/macrophage infiltrates and expression of HLA-D antigens. The largest number of LCs was in PCs (median 11.8 cells/standard microscopic field [c/smf]), fewer cells were found in FA (3.7 c/smf), and the least in FC (0.05 c/smf). Features of host-tumor interaction including HLA-D expression and infiltrates with lymphocyte macrophages and LC are more strongly expressed in PC than other tumors. This may play a role in explaining their biological behavior.     

Surgical anaesthesia for Caesarean section with a subdural catheter

Purpose

This case report describes a radiologically proven subdural catheter placed in a term parturient, which consistently performed as an epidural catheter for both labour analgesia as well as surgical anaesthesia.

Clinical features

The patient was a 26-yr-old, 52.7 kg, 140 cm healthy woman with a 39 wk intrauterine pregnancy. At initiation of epidural blockade, and for many hours throughout labour, an appropriate volume and concentration of local anaesthetic achieved an appropriate analgesic sensory level (10 ml bupivacaine 0.25%, bilateral T₁₀ sensory level). However, for Caesarean section, while an appropriate volume and concentration of local anaesthetic achieved an appropriate surgical anaesthetic sensory level (15 ml bupivacaine 0.5%, bilateral T₄ sensory level), there was no demonstrable motor blockade (0 on the Bromage scale). The Caesarean section was performed without incident, and without the need for supplemental intravenous opioids or anxiolytics.

Conclusion

We report the case to question the commonly held beliefs of subdural catheter presentation. We questioned the catheter position, and proved its subdural placement, only after larger volumes of higher concentration local anaesthetic did not achieve expected goals. It is possible that a high percentage of epidural catheters may be subdural, unbeknownst to the practitioner.     

Decision-making process in abdominal surgery in the geriatric patient

The high rates of abdominal disorders in a growing population of geriatric patients and the greater willingness of the surgeon to cope with major problems in the elderly are factors contributing to a steady increase in abdominal procedures in this group. Four hundred consecutive major abdominal surgical procedures in patients over 70 years of age were submitted for computer analysis, the purpose of which was to determine the principal factors affecting mortality and morbidity. The etiological profile of abdominal surgery in the elderly was characterized by a high percentage of procedures related to the biliary tract, with the second largest group being those for intestinal obstruction due to benign and malignant conditions. The decision-making process in geriatric surgery is of great importance, requiring consideration of ethical, medico-legal and economic factors in addition to the purely medical ones. Analysis of data presented in this series leads to the following conclusions:

1. There is a declining mortality rate in all elective operations in the elderly, in the absence of widespread malignancy.
2. Timing is all important in abdominal emergencies in the elderly, and early operations are usually more successful than either immediate or delayed operations.
3. Definitive procedures are sometimes both safer and more cost effective than minimal procedures performed under such circumstances.
4. The principal factors leading to high mortality rates are the presence of malignancy, generalized peritonitis, and moderate-to-severe involvement of life-support systems.