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Blake MJ, Steer CJ. Chimeric Livers: Interspecies Blastocyst Complementation and Xenotransplantation for End-Stage Liver Disease. Hepat Med 2024; 16:11-29. [PMID: 38379783 PMCID: PMC10878318 DOI: 10.2147/hmer.s440697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Accepted: 02/10/2024] [Indexed: 02/22/2024] Open
Abstract
Orthotopic liver transplantation (OLT) currently serves as the sole definitive treatment for thousands of patients suffering from end-stage liver disease; and the existing supply of donor livers for OLT is drastically outpaced by the increasing demand. To alleviate this significant gap in treatment, several experimental approaches have been devised with the aim of either offering interim support to patients waiting on the transplant list or bioengineering complete livers for OLT by infusing them with fresh hepatic cells. Recently, interspecies blastocyst complementation has emerged as a promising method for generating complete organs in utero over a short timeframe. When coupled with gene editing technology, it has brought about a potentially revolutionary transformation in regenerative medicine. Blastocyst complementation harbors notable potential for generating complete human livers in large animals, which could be used for xenotransplantation in humans, addressing the scarcity of livers for OLT. Nevertheless, substantial experimental and ethical challenges still need to be overcome to produce human livers in larger domestic animals like pigs. This review compiles the current understanding of interspecies blastocyst complementation and outlines future possibilities for liver xenotransplantation in humans.
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Affiliation(s)
- Madelyn J Blake
- Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Clifford J Steer
- Departments of Medicine, and Genetics, Cell Biology and Development, University of Minnesota Medical School, Minneapolis, MN, USA
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2
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Kieffer SF, Tanaka T, Ogilvie AC, Gilbertson-White S, Hagiwara Y. Palliative Care and End-of-Life Outcomes in Patients Considered for Liver Transplantation: A Single-Center Experience in the US Midwest. Am J Hosp Palliat Care 2023; 40:1049-1057. [PMID: 36448659 DOI: 10.1177/10499091221142841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Introduction: Previous research has shown limited palliative care (PC) utilization among patients evaluated for liver transplantation (LT) despite the cohort's significant symptom burden, high frequency of hospitalization and risk of rapid decompensation. Our aim was to evaluate patient characteristics and end-of-life (EOL) outcomes (i.e. ICU utilization, code status, advance care planning) associated with the use of PC services in patients who were evaluated for LT. Methods: We performed a single-center cross-sectional study comprised of 223 deceased patients evaluated for LT between 1/1/2017 and 12/31/2021. We evaluated demographic characteristics and EOL outcomes for differences between patients who received PC consultation and those who did not. EOL outcomes associated with PC use were assessed using logistic and linear regression analysis adjusted for patient demographics. Results: Patients who received PC consultation were younger (mean 57 vs. 61; P = 0.048), had higher Model for end-stage Liver Disease (MELD) scores (27.5 vs. 22; P = 0.001), higher rates of hepatic encephalopathy (96% vs. 84%, P = 0.005), and were more frequently declined for LT (77% vs. 57%; P = 0.008). Patients who received PC services were less likely to die in the ICU (OR = 0.07 [0.02-0.18]) and were more likely to have documented advance care planning (OR = 3.16 [1.47-6.97]), family meetings (OR = 6.58 [2.72-17.08]), and goals-of-care discussions (OR = 14.83 [4.39-69.29]). Conclusion: For patients being evaluated for LT, PC utilization differed based on demographics, disease complications and severity, and transplant status. Those who received PC services had higher quality EOL care planning and fewer ICU admissions.
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Affiliation(s)
- Sawyer F Kieffer
- Carver College of Medicine, University of Iowa, Iowa City, IA, USA
- Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Tomohiro Tanaka
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Iowa, Iowa City, IA, USA
| | - Amy C Ogilvie
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, IA, USA
| | | | - Yuya Hagiwara
- Division of General Internal Medicine, Department of Medicine, University of Iowa, Iowa City, IA, USA
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3
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Juvet TM, Bornet MA, Desbiens JF, Tapp D, Roos P. "Do Not Protect Us, Train Us."-Swiss Healthcare Students' Attitudes Toward Caring for Terminally Ill Patients. OMEGA-JOURNAL OF DEATH AND DYING 2023; 86:1190-1211. [PMID: 33818156 PMCID: PMC9903000 DOI: 10.1177/00302228211007003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Positive attitudes and a sense of competence toward end-of-life care are the key to adequately support terminally ill patients. This qualitative study aims to explore healthcare students' attitudes toward caring for terminally ill patients. Eleven students from the University of Applied Health Sciences in Switzerland participated in focus groups. Attitudes were overall positive. Most participants felt that supporting dying patients was a way to achieve professional fulfillment. However, most students felt not competent in palliative care and lacking experience. They wanted to receive better training, more specifically in good practices and appropriate behaviors. Our study fills a knowledge gap regarding the opinions and pedagogical needs of healthcare students, and highlights the importance of experiencing end-of-life care during the educational process. We recommend early exposure to terminally ill patients and appropriate attitudes toward death and dying as part of the bachelor's curriculum, accompanied by benevolent guidance from teachers and health professionals.
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Affiliation(s)
- Typhaine Maïko Juvet
- Haute Ecole Arc Santé (HE-Arc Santé), University of Applied Sciences and Arts Western Switzerland (HES-SO), Neuchâtel, Switzerland
| | - Marc-Antoine Bornet
- Lausanne University Hospital (CHUV), University of Lausanne (UNIL), Lausanne, Switzerland
| | | | - Diane Tapp
- Faculty of Nursing, Laval University (ULaval), Québec, Canada
| | - Pauline Roos
- Haute Ecole Arc Santé (HE-Arc Santé), University of Applied Sciences and Arts Western Switzerland (HES-SO), Neuchâtel, Switzerland,Pauline Roos, Haute Ecole Arc Santé (HE-Arc Santé), University of Applied Sciences and Arts Western Switzerland (HES-SO), Route de Moutier 14, 2800 Delémont, Switzerland.
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4
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Kim S, Lee K, Kim C, Choi J, Kim S. How Do We Start Palliative Care for Patients With End-Stage Liver Disease? Gastroenterol Nurs 2022; 45:101-112. [PMID: 34269708 PMCID: PMC8963522 DOI: 10.1097/sga.0000000000000611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 04/30/2021] [Indexed: 11/25/2022] Open
Abstract
Patients with end-stage liver disease undergo repetitive patterns of recovery and deterioration and are burdened with uncertainty. Although quality of life is low in patients with end-stage liver disease and their family members, few studies have been conducted to identify what palliative care should be provided for them. This integrative review aimed to explore palliative care for patients with end-stage liver disease, focusing on the components and outcome measurements for further research. After searching for studies on palliative care for end-stage liver disease published between 1995 and 2017, 12 studies that met the inclusion criteria were analyzed. The common components of palliative care for patients with liver disease were: (a) an interdisciplinary approach, (b) early palliative care, (c) discussion goals of care with patient and family members, (d) symptom management, and (e) psychosocial support. It was reported that patients who were provided palliative care had improved itching, well-being, appetite, anxiety, fatigue, and depression, increased the number of do-not-resuscitate orders, palliative care consultations, and decreased length of stay. These findings could guide the development of palliative care for end-stage liver disease patients.
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Affiliation(s)
- Sookyung Kim
- Correspondence to: Sanghee Kim, PhD, RN, College of Nursing & Mo-Im Kim Nursing Research Institute, Yonsei University, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea ()
| | - Kyunghwa Lee
- Sookyung Kim, PhD, RN, is Postdoctoral Researcher, College of Nursing & Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
- Kyunghwa Lee, PhD, RN, is Assistant Professor, College of Nursing, Konyang University, Daejeon, Republic of Korea
- Changhwan Kim, MSN, RN, is Staff Nurse, Department of Critical Care Nursing, Samsung Medical Center, Seoul, Republic of Korea
- Jahyun Choi, MSN, RN, is Doctoral Student, Department of Nursing, Yonsei University Graduate School, Seoul, Republic of Korea
- Sanghee Kim, PhD, RN, is Associate Professor, College of Nursing & Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
| | - Changhwan Kim
- Sookyung Kim, PhD, RN, is Postdoctoral Researcher, College of Nursing & Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
- Kyunghwa Lee, PhD, RN, is Assistant Professor, College of Nursing, Konyang University, Daejeon, Republic of Korea
- Changhwan Kim, MSN, RN, is Staff Nurse, Department of Critical Care Nursing, Samsung Medical Center, Seoul, Republic of Korea
- Jahyun Choi, MSN, RN, is Doctoral Student, Department of Nursing, Yonsei University Graduate School, Seoul, Republic of Korea
- Sanghee Kim, PhD, RN, is Associate Professor, College of Nursing & Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
| | - Jahyun Choi
- Sookyung Kim, PhD, RN, is Postdoctoral Researcher, College of Nursing & Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
- Kyunghwa Lee, PhD, RN, is Assistant Professor, College of Nursing, Konyang University, Daejeon, Republic of Korea
- Changhwan Kim, MSN, RN, is Staff Nurse, Department of Critical Care Nursing, Samsung Medical Center, Seoul, Republic of Korea
- Jahyun Choi, MSN, RN, is Doctoral Student, Department of Nursing, Yonsei University Graduate School, Seoul, Republic of Korea
- Sanghee Kim, PhD, RN, is Associate Professor, College of Nursing & Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
| | - Sanghee Kim
- Sookyung Kim, PhD, RN, is Postdoctoral Researcher, College of Nursing & Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
- Kyunghwa Lee, PhD, RN, is Assistant Professor, College of Nursing, Konyang University, Daejeon, Republic of Korea
- Changhwan Kim, MSN, RN, is Staff Nurse, Department of Critical Care Nursing, Samsung Medical Center, Seoul, Republic of Korea
- Jahyun Choi, MSN, RN, is Doctoral Student, Department of Nursing, Yonsei University Graduate School, Seoul, Republic of Korea
- Sanghee Kim, PhD, RN, is Associate Professor, College of Nursing & Mo-Im Kim Nursing Research Institute, Yonsei University, Seoul, Republic of Korea
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5
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Diaz-Aragon R, Coard MC, Amirneni S, Faccioli L, Haep N, Malizio MR, Motomura T, Kocas-Kilicarslan ZN, Ostrowska A, Florentino RM, Frau C. Therapeutic Potential of HNF4α in End-stage Liver Disease. Organogenesis 2021; 17:126-135. [PMID: 35114889 DOI: 10.1080/15476278.2021.1994273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
The prevalence of end-stage liver disease (ESLD) in the US is increasing at an alarming rate. It can be caused by several factors; however, one of the most common routes begins with nonalcoholic fatty liver disease (NAFLD). ESLD is diagnosed by the presence of irreversible damage to the liver. Currently, the only definitive treatment for ESLD is orthotopic liver transplantation (OLT). Nevertheless, OLT is limited due to a shortage of donor livers. Several promising alternative treatment options are under investigation. Researchers have focused on the effect of liver-enriched transcription factors (LETFs) on disease progression. Specifically, hepatocyte nuclear factor 4-alpha (HNF4α) has been reported to reset the liver transcription network and possibly play a role in the regression of fibrosis and cirrhosis. In this review, we describe the function of HNF4α, along with its regulation at various levels. In addition, we summarize the role of HNF4α in ESLD and its potential as a therapeutic target in the treatment of ESLD.
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Affiliation(s)
- Ricardo Diaz-Aragon
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael C Coard
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Sriram Amirneni
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Lanuza Faccioli
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Nils Haep
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michelle R Malizio
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Takashi Motomura
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Alina Ostrowska
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.,Pittsburgh Liver Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Rodrigo M Florentino
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Carla Frau
- Department of Pathology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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6
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Lin YJ, Chen RJ, Tang JH, Yu CS, Wu JL, Chen LC, Chang SS. Machine-Learning Monitoring System for Predicting Mortality Among Patients With Noncancer End-Stage Liver Disease: Retrospective Study. JMIR Med Inform 2020; 8:e24305. [PMID: 33124991 PMCID: PMC7665951 DOI: 10.2196/24305] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 09/25/2020] [Accepted: 09/30/2020] [Indexed: 12/22/2022] Open
Abstract
Background Patients with end-stage liver disease (ESLD) have limited treatment options and have a deteriorated quality of life with an uncertain prognosis. Early identification of ESLD patients with a poor prognosis is valuable, especially for palliative care. However, it is difficult to predict ESLD patients that require either acute care or palliative care. Objective We sought to create a machine-learning monitoring system that can predict mortality or classify ESLD patients. Several machine-learning models with visualized graphs, decision trees, ensemble learning, and clustering were assessed. Methods A retrospective cohort study was conducted using electronic medical records of patients from Wan Fang Hospital and Taipei Medical University Hospital. A total of 1214 patients from Wan Fang Hospital were used to establish a dataset for training and 689 patients from Taipei Medical University Hospital were used as a validation set. Results The overall mortality rate of patients in the training set and validation set was 28.3% (257/907) and 22.6% (145/643), respectively. In traditional clinical scoring models, prothrombin time-international normalized ratio, which was significant in the Cox regression (P<.001, hazard ratio 1.288), had a prominent influence on predicting mortality, and the area under the receiver operating characteristic (ROC) curve reached approximately 0.75. In supervised machine-learning models, the concordance statistic of ROC curves reached 0.852 for the random forest model and reached 0.833 for the adaptive boosting model. Blood urea nitrogen, bilirubin, and sodium were regarded as critical factors for predicting mortality. Creatinine, hemoglobin, and albumin were also significant mortality predictors. In unsupervised learning models, hierarchical clustering analysis could accurately group acute death patients and palliative care patients into different clusters from patients in the survival group. Conclusions Medical artificial intelligence has become a cutting-edge tool in clinical medicine, as it has been found to have predictive ability in several diseases. The machine-learning monitoring system developed in this study involves multifaceted analyses, which include various aspects for evaluation and diagnosis. This strength makes the clinical results more objective and reliable. Moreover, the visualized interface in this system offers more intelligible outcomes. Therefore, this machine-learning monitoring system provides a comprehensive approach for assessing patient condition, and may help to classify acute death patients and palliative care patients. Upon further validation and improvement, the system may be used to help physicians in the management of ESLD patients.
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Affiliation(s)
- Yu-Jiun Lin
- Department of Family Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Family Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Ray-Jade Chen
- Department of Surgery, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Division of General Surgery, Department of Surgery, Taipei Medical University Hospital, Taipei, Taiwan
| | - Jui-Hsiang Tang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Cheng-Sheng Yu
- Department of Family Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Family Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Jenny L Wu
- Department of Family Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Family Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Li-Chuan Chen
- Department of Community and Preventive Medicine, Taipei Medical University Hospital, Taipei, Taiwan.,School of Gerontology Health Management, College of Nursing, Taipei Medical University, Taipei, Taiwan
| | - Shy-Shin Chang
- Department of Family Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.,Department of Family Medicine, Taipei Medical University Hospital, Taipei, Taiwan.,Department of Community and Preventive Medicine, Taipei Medical University Hospital, Taipei, Taiwan
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7
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Psychological, Cognitive, and Laboratory Characteristics of End-Stage Liver Disease Patients. HEPATITIS MONTHLY 2020. [DOI: 10.5812/hepatmon.96433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Background: End-Stage Liver Disease (ESLD) causes several clinical and psychological comorbidities. Some accompanying psychiatric disturbances have significant effects on the patients’ quality of life. Objectives: Thus, we aimed to evaluate some psychological characteristics of ESLD patients. Methods: A cross-sectional study was conducted on 91 ESLD patients aged 18 - 70 years. We assessed the patients using the California Verbal Learning Test (CVLT), Fatigue Severity Scale, Epworth Sleepiness Scale, and Hospital Anxiety and Depression Scale. Also, we measured the demographic and some laboratory data of the participants. The data were analyzed by SPSS version 21 software, and P values of less than 0.05 were considered significant. Results: The study included 68 men and 23 women with a mean age of 41.9 ± 13.72 years (range 19 - 68). The mean scores of fatigue (40.6 ± 14.8) and anxiety (12.98 ± 2.76) were more than the normal range. The most significant association was seen between age and CVLT items (attention (P = 0.01), immediate memory (P < 0.001), short delay free recall (0.01), and short delay cued recall (0.03). Conclusions: End-stage liver disease patients had anxiety, fatigue, and memory disorders in addition to their poor clinical conditions. Although the main treatment of ESLD is liver transplantation but the psychological and cognitive problems before transplantation in these patients are prognostic factors for post-operation compliance and follow up.
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8
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Peng JK, Chang HH, Higginson IJ, Gao W. Intensive care utilization in patients with end-stage liver disease: A population-based comparative study of cohorts with and without comorbid hepatocellular carcinoma in taiwan. EClinicalMedicine 2020; 22:100357. [PMID: 32462117 PMCID: PMC7240333 DOI: 10.1016/j.eclinm.2020.100357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND End-of-life intensive care may be futile and can be a cause of distress to both patients and their families. This study aimed to understand the utilization of intensive care and its associated factors in patients with End-stage liver disease (ESLD) during terminal hospitalization. METHODS Population-based retrospective cohort study using the National Health Institute Research Database of Taiwan. All adult patients with ESLD who died during their hospitalization in 2010-2013 were included. FINDINGS Of the 14,247 patients with ESLD, the majority (60·8%) was comorbid with hepatocellular carcinoma (HCC). Patients with ESLD only were younger, more deprived, more alcohol-related, and less likely to receive palliative care prior to terminal hospitalization (6·0% vs 29·2% with HCC). Compared to patients with comorbid HCC, relatively more patients without HCC were admitted to ICU (59·6% vs 22·3%), receiving CPR (11·1% vs 4·3%) and mechanical ventilation (36·3% vs 12·5%) during terminal hospitalization. Etiology of alcoholic hepatitis, esophageal varices, septicemia, pneumonia and respiratory failure, and renal failure were associated with a higher probability of ICU admission (adjusted rate ratio (aRR) range: 1·09-2·09). Prior palliative care was associated with lower probability of ICU admission (aRR range: 0·24-0·38). INTERPRETATION The intensive care utilization by patients with ESLD in their terminal hospitalization was substantial in Taiwan. Those who are not comorbid with HCC need more attention, especially in terms of their palliative care needs, choices regarding intensive care, and their healthcare utilization. FUNDING National Institute of Health Research Health Applied Research Collaboration (ARC) South London.
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Affiliation(s)
- Jen-Kuei Peng
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Address: Bessemer Road, London, SE5 9PJ, United Kingdom
- Department of Family Medicine, National Taiwan University College of Medicine, Address: No.1 Jen-Ai Road, Section 1, Taipei 100, Taiwan
- Department of Family Medicine, National Taiwan University Hospital, Address: No.7, Chung Shan South Road, Taipei 100, Taiwan
- Corresponding author: Tel.: 886-2-928595969
| | - Hao-Hsiang Chang
- Department of Family Medicine, National Taiwan University College of Medicine, Address: No.1 Jen-Ai Road, Section 1, Taipei 100, Taiwan
- Department of Family Medicine, National Taiwan University Hospital, Address: No.7, Chung Shan South Road, Taipei 100, Taiwan
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Address: Bessemer Road, London, SE5 9PJ, United Kingdom
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, Address: Bessemer Road, London, SE5 9PJ, United Kingdom
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Health Care Utilization and Costs for Patients With End-Stage Liver Disease Are Significantly Higher at the End of Life Compared to Those of Other Decedents. Clin Gastroenterol Hepatol 2019; 17:2339-2346.e1. [PMID: 30743007 DOI: 10.1016/j.cgh.2019.01.046] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/23/2019] [Accepted: 01/28/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with end-stage liver disease (ESLD) have progressively complex medical needs. However, little is known about their end-of-life health care utilization or associated costs. We performed a population-based study to evaluate the end-of-life direct utilization and costs for patients with ESLD among health care sectors in the province of Ontario. METHODS We used linked Ontario health administrative databases to conduct a population-based retrospective cohort study of all decedents from April 1, 2010, through March 31, 2013. Patients with ESLD were compared with patients without ESLD with regard to total health care utilization and costs in the last year and last 90 days of life. RESULTS The median age at death was significantly lower for ESLD decedents (65 y; interquartile range, 56-75 y) than for individuals without ESLD (80 y; interquartile range, 68-88 y). The median cost in the last year of life was significantly greater for patients with ESLD ($51,235 vs $44,456 without ESLD) (P < .001). Median ESLD end-of-life care costs also significantly exceeded those associated with 4 of the 5 most resource-intensive chronic conditions ($69,040 for ESLD vs $59,088 for non-ESLD) (P < .001). Cost differences were most pronounced in the final 90 days of life. During this period, patients with ESLD spent 4.7 more days in the hospital (95% CI, 4.3-5.1 d) than patients without ESLD (P < .0001), had significantly higher odds of dying in an institutional setting (odds ratio, 1.8; 95% CI, 1.7-1.9) (P < .0001), and incurred an additional $4201 in costs (95% CI, $3384-$5019; P < .0001). CONCLUSIONS In a population-based study in Canada, we found that patients with ESLD incur significantly higher end-of-life care costs than decedents without ESLD, predominantly owing to increased time in the hospital during the final 90 days of life.
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Place of death and factors associated with hospital death in patients who have died from liver disease in England: a national population-based study. Lancet Gastroenterol Hepatol 2019; 4:52-62. [DOI: 10.1016/s2468-1253(18)30379-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 10/25/2018] [Accepted: 10/26/2018] [Indexed: 12/13/2022]
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11
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Peng JK, Hepgul N, Higginson IJ, Gao W. Symptom prevalence and quality of life of patients with end-stage liver disease: A systematic review and meta-analysis. Palliat Med 2019; 33:24-36. [PMID: 30345878 PMCID: PMC6291907 DOI: 10.1177/0269216318807051] [Citation(s) in RCA: 128] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND: End-stage liver disease is a common cause of morbidity and mortality worldwide, yet little is known about its symptomatology and impact on health-related quality of life. AIM: To describe symptom prevalence and health-related quality of life of patients with end-stage liver disease to improve care. DESIGN: Systematic review. DATA SOURCES: We searched eight electronic databases from January 1980 to June 2018 for studies investigating symptom prevalence or health-related quality of life of adult patients with end-stage liver disease. No language restrictions were applied. Meta-analyses were performed where appropriate. RESULTS: We included 80 studies: 35 assessing symptom prevalence, 41 assessing health-related quality of life, and 4 both. The instruments assessing symptoms varied across studies. The most frequently reported symptoms were as follows: pain (prevalence range 30%–79%), breathlessness (20%–88%), muscle cramps (56%–68%), sleep disturbance (insomnia 26%–77%, daytime sleepiness 29.5%–71%), and psychological symptoms (depression 4.5%–64%, anxiety 14%–45%). Erectile dysfunction was prevalent (53%–93%) in men. The health-related quality of life of patients with end-stage liver disease was significantly impaired when compared to healthy controls or patients with chronic liver disease. Compared with compensated cirrhosis, decompensation led to significant worsening of both components of the 36-Item Short Form Survey although to a larger degree for the Physical Component Summary score (decrease from average 6.4 (95% confidence interval: 4.0–8.8); p < 0.001) than for the Mental Component Summary score (4.5 (95% confidence interval: 2.4–6.6); p < 0.001). CONCLUSION: The symptom prevalence of patients with end-stage liver disease resembled that of patients with other advanced conditions. Given the diversity of symptoms and significantly impaired health-related quality of life, multidisciplinary approach and timely intervention are crucial.
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Affiliation(s)
- Jen-Kuei Peng
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK.,2 Department of Family Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.,3 Department of Family Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Nilay Hepgul
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Irene J Higginson
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
| | - Wei Gao
- 1 Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, King's College London, London, UK
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12
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Demographics, Resource Utilization, and Outcomes of Elderly Patients With Chronic Liver Disease Receiving Hospice Care in the United States. Am J Gastroenterol 2017; 112:1700-1708. [PMID: 29016566 DOI: 10.1038/ajg.2017.290] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Accepted: 08/07/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Hospice offers non-curative symptomatic management to improve patients' quality of life, satisfaction, and resource utilization. Hospice enrollment among patients with chronic liver disease (CLD) is not well studied. The aim of tis tudy is to examine the characteristics of Medicare enrollees with CLD, who were discharged to hospice. METHODS Medicare patients discharged to hospice between 2010 and 2014 were identified in Medicare Inpatient and Hospice Files. CLDs and other co-morbidities were identified by International Classification of Diseases-ninth revision codes. Generalized linear model was used to estimate regression coefficients with P-values. Logistic regression was used to calculate odds ratios and 95% confidence intervals. RESULTS A total of 2,179 CLD patients and 34,986 controls without CLD met the inclusion criteria. Non-alcoholic fatty liver disease, alcoholic liver disease, and hepatitis C virus (HCV) were the most frequent cause of CLD. CLD patients were younger (70 vs. 83 years), more likely to be male (57.7 vs. 39.3%), had longer hospital stay (length of stay, LOS) (19.4 vs. 13.0 days), higher annual charges ($175,000 vs. $109,000), higher 30-day re-hospitalization rates (51.6 vs. 34.2%), and shorter hospice LOS (13.7 vs. 17.7 days) than controls (all P<0.001). Presence of HCV and congestive heart failure were the strongest contributors to increased total annual costs (34% and 31% higher, P<0.001), increased total annual LOS (26% and 43% higher, P<0.001), and increased 30-day readmission risk (2.20 and 2.19 times, respectively). CONCLUSIONS Patients with CLD have longer and costly hospitalizations before hospice enrollment as compared with patients without CLD. It was highly likely that these patients were enrolled relatively late, which could potentially lead to less benefit from hospice.
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Chaudhary N, Lucero C, Villanueva G, Poles M, Gillespie C, Zabar S, Weinshel E. Assessment of Abilities of Gastroenterology Fellows to Provide Information to Patients With Liver Disease. Clin Gastroenterol Hepatol 2017; 15:1095-1123.e3. [PMID: 28111335 DOI: 10.1016/j.cgh.2016.12.037] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Revised: 12/23/2016] [Accepted: 12/29/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patient education is critical in ensuring patient compliance and good health outcomes. Fellows must be able to effectively communicate with their patients, delivering enough information for the patient to understand their medical problem and maximize patient compliance. We created an objective structured clinical examination (OSCE) with 4 liver disease cases to assess fellows' knowledge and ability to inform standardized patients (SPs) about their clinical condition. METHODS We developed 4 cases highlighting different aspects of liver disease and created a 4-station OSCE: hepatitis B, acute hepatitis C, new diagnosis of cirrhosis, and an end-stage cirrhotic nontransplant candidate. The SP with hepatitis B was minimizing the fact that she could not read English. The acute hepatitis C SP was a nursing student who is afraid that having hepatitis C might jeopardize her career. The SP with the new diagnosis of alcoholic cirrhosis needed to stop drinking, and the end-stage liver disease patient had to grapple with his advanced directives. Twelve fellows from 4 GI training programs participated. Our focus was to assess the fellows' knowledge about liver diseases and the Accreditation Council for Graduate Medical Education competencies of health literacy, shared decision making, advanced directives, and goals of care. The goal for the fellows was to communicate effectively with the SPs, and acknowledge that each patient had an emotionally charged issue to overcome. The SPs used a checklist to rate fellows' performance. Faculty and the SPs observed the cases and provided feedback. The fellows were surveyed on their performance regarding the case. RESULTS The majority of fellows were able to successfully summarize findings and discuss a plan with the patient in the new diagnosis of cirrhosis (76.92%) and hepatitis C case (100%), but were less successful in the hepatitis B case (30.77%) and the end-of-life case (41.67%). Overall, a small percentage of fellows reflected that they did a good job (22%-33%), except at the end-of-life case (67%). The fellows' greatest challenge was trying to cover a lot of information in a single outpatient visit. CONCLUSIONS Caring for patients with liver diseases can be complex and time consuming. The patients and fellows' observations were discordant in several areas: for example, the fellows believed they excelled in the end-of-life case, but the SP thought only a small percentage of fellows were able to successfully summarize and discuss the plan. This discrepancy and others highlight important areas of focus in training programs. OSCEs are important to help the fellows facilitate striking the right balance of information delivery and empathy, and this will lead to better patient education, compliance, rapport, and satisfaction.
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Affiliation(s)
- Noami Chaudhary
- Department of Medicine, New York University School of Medicine, New York, NY.
| | - Catherine Lucero
- Department of Gastroenterology, New York University School of Medicine, New York, New York
| | - Gerald Villanueva
- Department of Gastroenterology, New York University School of Medicine, New York, New York
| | - Michael Poles
- Department of Gastroenterology, New York University School of Medicine, New York, New York
| | - Colleen Gillespie
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Sondra Zabar
- Department of Medicine, New York University School of Medicine, New York, NY
| | - Elizabeth Weinshel
- Department of Gastroenterology, New York University School of Medicine, New York, New York
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Quinn S, Campbell V, Sikka K. Sooner rather than later: early hospice intervention in advanced liver disease. ACTA ACUST UNITED AC 2017. [DOI: 10.12968/gasn.2017.15.sup5.s18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Sharon Quinn
- Assistant Director of Care and Clinical Development, St Luke's Hospice, Basildon, Essex
| | | | - Karen Sikka
- Project Support Officer, St Luke's Hospice, Basildon, Essex
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Bailey DE, Hendrix CC, Steinhauser KE, Stechuchak KM, Porter LS, Hudson J, Olsen MK, Muir A, Lowman S, DiMartini A, Salonen LW, Tulsky JA. Randomized trial of an uncertainty self-management telephone intervention for patients awaiting liver transplant. PATIENT EDUCATION AND COUNSELING 2017; 100:509-517. [PMID: 28277289 PMCID: PMC5350046 DOI: 10.1016/j.pec.2016.10.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/04/2016] [Revised: 10/13/2016] [Accepted: 10/18/2016] [Indexed: 05/14/2023]
Abstract
OBJECTIVE We tested an uncertainty self-management telephone intervention (SMI) with patients awaiting liver transplant and their caregivers. METHODS Participants were recruited from four transplant centers and completed questionnaires at baseline, 10, and 12 weeks from baseline (generally two and four weeks after intervention delivery, respectively). Dyads were randomized to either SMI (n=56) or liver disease education (LDE; n=59), both of which involved six weekly telephone sessions. SMI participants were taught coping skills and uncertainty management strategies while LDE participants learned about liver function and how to stay healthy. Outcomes included illness uncertainty, uncertainty management, depression, anxiety, self-efficacy, and quality of life. General linear models were used to test for group differences. RESULTS No differences were found between the SMI and LDE groups for study outcomes. CONCLUSION This trial offers insight regarding design for future interventions that may allow greater flexibility in length of delivery beyond our study's 12-week timeframe. PRACTICE IMPLICATIONS Our study was designed for the time constraints of today's clinical practice setting. This trial is a beginning point to address the unmet needs of these patients and their caregivers as they wait for transplants that could save their lives.
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Affiliation(s)
- Donald E Bailey
- Duke University School of Nursing, Durham NC, USA; Duke Center for the Study of Aging and Human Development, Durham, USA.
| | - Cristina C Hendrix
- Duke University School of Nursing, Durham NC, USA; Durham Veterans Affairs Medical Center Geriatric Research, Education, and Clinical Center, Durham, USA; Duke Center for the Study of Aging and Human Development, Durham, USA.
| | - Karen E Steinhauser
- Division of General Medicine, Department of Medicine, Duke University School of Medicine, Durham, USA; Duke Palliative Care, Duke University Health System, Durham, USA; Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, USA.
| | - Karen M Stechuchak
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, USA.
| | - Laura S Porter
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, USA.
| | - Julie Hudson
- Duke Transplant Center, Duke University School of Medicine, Durham, USA.
| | - Maren K Olsen
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, USA; Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, USA.
| | - Andrew Muir
- Division of Gastroenterology, Department of Medicine, Duke University School of Medicine, Durham, USA.
| | - Sarah Lowman
- Duke Palliative Care, Duke University Health System, Durham, USA.
| | - Andrea DiMartini
- University of Pittsburgh Medical Center, Departments of Psychiatry and Surgery, Starzl Transplant Institute Pittsburgh, USA.
| | - Laurel Williams Salonen
- Organ Transplantation Program, The University of Nebraska Medical Center, 983285 Nebraska Medical Center, Omaha, USA.
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, USA; Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, USA; Center for Palliative Care, Harvard Medical School, Boston, USA.
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Abstract
End-of-life care planning is assuming global significance. While general end-of-life care guidelines apply to diabetes, there are some diabetes-specific issues that need to be considered. These include the usual long trajectory to end-of-life care that enables clinicians and people with diabetes to proactively discuss when to change the focus of care from preventing diabetes complications (tight control) to a palliative approach. Palliative care aims to promote comfort and quality of life and reduce the unnecessary burden of care on individuals and their families. The aim of this paper is to discuss common disease trajectories and their relationship to diabetes care, outline strategies for proactively discussing these issues and suggest indications that palliative care is warranted.
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Affiliation(s)
- Trisha Dunning
- Deakin University and Barwon Health, Kitchener House, C/- The Geelong Hospital, Ryrie Street, PO Box 281, Geelong, Vic, 3220, Australia.
| | - Nicole Duggan
- Deakin University and Barwon Health, Kitchener House, C/- The Geelong Hospital, Ryrie Street, PO Box 281, Geelong, Vic, 3220, Australia
| | - Sally Savage
- Deakin University and Barwon Health, Kitchener House, C/- The Geelong Hospital, Ryrie Street, PO Box 281, Geelong, Vic, 3220, Australia
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Ellington L, Clayton MF, Reblin M, Cloyes K, Beck AC, Harrold JK, Harris P, Casarett D. Interdisciplinary Team Care and Hospice Team Provider Visit Patterns during the Last Week of Life. J Palliat Med 2016; 19:482-7. [PMID: 27104950 DOI: 10.1089/jpm.2015.0198] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Hospice provides intensive end-of-life care to patients and their families delivered by an interdisciplinary team of nurses, aides, chaplains, social workers, and physicians. Significant gaps remain about how team members respond to diverse needs of patients and families, especially in the last week of life. OBJECTIVE The study objective was to describe the frequency of hospice team provider visits in the last week of life, to examine changes in frequency over time, and to identify patient characteristics that were associated with an increase in visit frequency. DESIGN This was a retrospective cohort study using electronic medical record data. SETTING/SUBJECTS From U.S. not-for-profit hospices, 92,250 records were used of patients who died at home or in a nursing home, with a length of stay of at least seven days. MEASUREMENTS Data included basic demographic variables, diagnoses, clinical markers of illness severity, patient functioning, and number of hospice team member visits in the last seven days of life. RESULTS On average the total number of hospice team member visits in the last week of life was 1.36 visits/day. Most were nurse visits, followed by aides, social workers, and chaplains. Visits increased over each day on average across the last week of life. Greater increase in visits was associated with patients who were younger, male, Caucasian, had a spouse caregiver, and shorter lengths of stay. CONCLUSIONS This study provides important information to help hospices align the interdisciplinary team configuration with the timing of team member visits, to better meet the needs of the patients and families they serve.
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Affiliation(s)
- Lee Ellington
- 1 College of Nursing, University of Utah , Salt Lake City, Utah
| | | | - Maija Reblin
- 1 College of Nursing, University of Utah , Salt Lake City, Utah
| | - Kristin Cloyes
- 1 College of Nursing, University of Utah , Salt Lake City, Utah
| | - Anna C Beck
- 2 Huntsman Cancer Institute, School of Medicine, University of Utah , Salt Lake City, Utah
| | | | - Pamela Harris
- 4 Kansas City Hospice and Palliative Care , Overland Park, Kansas
| | - David Casarett
- 5 Perelman School of Medicine, University of Pennsylvania , Philadelphia, Pennsylvania
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Wang H, Luo X, Leighton J. Extracellular Matrix and Integrins in Embryonic Stem Cell Differentiation. BIOCHEMISTRY INSIGHTS 2015; 8:15-21. [PMID: 26462244 PMCID: PMC4589090 DOI: 10.4137/bci.s30377] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 09/02/2015] [Accepted: 09/04/2015] [Indexed: 12/17/2022]
Abstract
Embryonic stem cells (ESCs) are pluripotent cells with great therapeutic potentials. The in vitro differentiation of ESC was designed by recapitulating embryogenesis. Significant progress has been made to improve the in vitro differentiation protocols by toning soluble maintenance factors. However, more robust methods for lineage-specific differentiation and maturation are still under development. Considering the complexity of in vivo embryogenesis environment, extracellular matrix (ECM) cues should be considered besides growth factor cues. ECM proteins bind to cells and act as ligands of integrin receptors on cell surfaces. Here, we summarize the role of the ECM and integrins in the formation of three germ layer progenies. Various ECM–integrin interactions were found, facilitating differentiation toward definitive endoderm, hepatocyte-like cells, pancreatic beta cells, early mesodermal progenitors, cardiomyocytes, neuroectoderm lineages, and epidermal cells, such as keratinocytes and melanocytes. In the future, ECM combinations for the optimal ESC differentiation environment will require substantial study.
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Affiliation(s)
- Han Wang
- Department of Cellular and Structural Biology, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Xie Luo
- Department of Cellular and Structural Biology, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Jake Leighton
- Department of Cellular and Structural Biology, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
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20
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Brisebois AJ, Tandon P. Working with palliative care services. Clin Liver Dis (Hoboken) 2015; 6:37-40. [PMID: 31040984 PMCID: PMC6490645 DOI: 10.1002/cld.493] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Revised: 04/09/2015] [Accepted: 05/14/2015] [Indexed: 02/04/2023] Open
Affiliation(s)
- Amanda J. Brisebois
- Division of Internal Medicine and Division of Palliative CareUniversity of AlbertaEdmontonCanada
| | - Puneeta Tandon
- Division of GastroenterologyUniversity of AlbertaEdmontonCanada
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22
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Abstract
In Thailand, several barriers exist that prevent people with life-limiting illnesses from accessing good-quality palliative care, namely: lack of palliative care providers; lack of training and education for the palliative care workforce; and issues with availability and distribution of opioids. Without palliative care, people suffer needlessly during the last months of their life. This paper gives an analysis of these issues and provides recommendations for clinical practice, research and health policy that may help to alleviate these issues.
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Affiliation(s)
- Panit Krongyuth
- Public Health Nursing Doctoral Student, Mahidol University Bangkok, Thailand
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Fowler A, Freiberger D, Moonan M. Palliative and end-of-life care in pediatric solid organ transplantation. Pediatr Transplant 2015; 19:11-7. [PMID: 25422076 DOI: 10.1111/petr.12387] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/15/2014] [Indexed: 11/30/2022]
Abstract
End-of-life care is a component of palliative care and takes a holistic, individualized approach to patients, focusing on the assessment of quality of life and its maintenance until the end of life, and beyond, for the patient's family. Transplant teams do not always make timely referrals to palliative care teams due to various clinician and perceived family barriers, an important one being the simultaneous, active care plan each patient would have alongside an end-of-life plan. Application of findings and further research specific to the pediatric solid organ population would be of significant benefit to guide transplant teams as to the most effective time to introduce end-of-life care, who to involve in ongoing discussions, and important ethical and cultural considerations to include in care planning. Attention must also be paid to clinician training and support in this challenging area of health care.
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Affiliation(s)
- Amy Fowler
- Freeman Hospital, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
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Laporte P, Vonarx N. Les infirmières et la mort au quotidien : souffrances et enjeux. ACTA ACUST UNITED AC 2015. [DOI: 10.3917/inka.154.0149] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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