Developing a national implementation strategy to accelerate uptake of evidence-based family caregiver support in U.S. cancer centers

OBJECTIVE

Characterize key factors and training needs of U.S. cancer centers in implementing family caregiver support services.

METHODS

Sequential explanatory mixed methods design consisting of: (1) a national survey of clinicians and administrators from Commission-on-Cancer-accredited cancer centers (N = 238) on factors and training needed for establishing new caregiver programs and (2) qualitative interviews with a subsample of survey respondents (N = 30) to elicit feedback on survey findings and the outline of an implementation strategy to facilitate implementation of evidence-based family caregiver support (the Caregiver Support Accelerator). Survey data was tabulated using descriptive statistics and transcribed interviews were analyzed using thematic analysis.

RESULTS

Top factors for developing new caregiver programs were that the program be: consistent with the cancer center's mission and strategic plan (87%), supported by clinic leadership (86.5%) and providers and staff (85.7%), and low cost or cost effective (84.9%). Top training needs were how to: train staff to implement programs (72.3%), obtain program materials (63.0%), and evaluate program outcomes (62.6%). Only 3.8% reported that no training was needed. Qualitative interviews yielded four main themes: (1) gaining leadership, clinician, and staff buy-in and support is essential; (2) cost and clinician burden are major factors to program implementation; (3) training should help with adapting and marketing programs to local context and culture; and (4) the Accelerator strategy is comprehensive and would benefit from key organizational partnerships and policy standards.

CONCLUSION

Findings will be used to inform and refine the Accelerator implementation strategy to facilitate the adoption and growth of evidence-based cancer caregiver support in U.S. cancer centers.

Availability of Family Caregiver Programs in US Cancer Centers

Importance

Family caregivers provide the majority of health care to the 18 million patients with cancer in the US. Yet despite providing complex medical and nursing care, a large proportion of caregivers report no formal support or training. In recognition of this gap, many interventions to support cancer caregivers have been developed and tested over the past 2 decades. However, there are few system-level data on whether US cancer centers have adopted and implemented these interventions.

Objective

To describe and characterize the availability of family caregiver support programs in US cancer centers.

Design, Setting, and Participants

This cross-sectional national survey study was conducted between September 1, 2021, and April 30, 2023. Participants comprised clinical and administrative staff of Commission on Cancer-accredited US cancer centers. Data analysis was performed in May and June 2023.

Main Outcomes and Measures

Survey questions about the availability of 11 types of family caregiver programs (eg, peer mentoring, education classes, and psychosocial programs) were developed after literature review, assessment of similar program evaluation surveys, and discussions among a 13-member national expert advisory committee. Family caregiver programs were defined as structured, planned, and coordinated groups of activities and procedures aimed at specifically supporting family caregivers as part of usual care. Survey responses were tabulated using standard descriptive statistics, including means, proportions, and frequencies.

Results

Of the surveys sent to potential respondents at 971 adult cancer centers, 238 were completed (response rate, 24.5%). After nonresponse weight adjustment, most cancer centers (75.4%) had at least 1 family caregiver program; 24.6% had none. The most common program type was information and referral services (53.6%). Cancer centers with no programs were more likely to have smaller annual outpatient volumes (χ2 = 11.10; P = .011). Few centers had caregiver programs on training in medical and/or nursing tasks (21.7%), caregiver self-care (20.2%), caregiver-specific distress screening (19.3%), peer mentoring (18.9%), and children caregiving for parents (8.3%). Very few programs were developed from published evidence in a journal (8.1%). The top reason why cancer centers selected their programs was community members requesting the program (26.3%); only 12.3% of centers selected their programs based on scientific evidence. Most programs were funded by the cancer center or hospital (58.6%) or by philanthropy (42.4%).

Conclusions and Relevance

In this survey study, most cancer centers had family caregiver programs; however, a quarter had none. Furthermore, the scope of programming was limited and rarely evidence based, with few centers offering caregiving education and training. These findings suggest that implementation strategies are critically needed to foster uptake of evidence-based caregiver interventions.

Accuracy of Selective Enamel Etching: A Computer-assisted Imaging Analysis

OBJECTIVE

To assess the accuracy of selective enamel etching (SEE) in a laboratory setup simulating clinical conditions.

METHODS AND MATERIALS

A model with permanent human teeth was fabricated. It included a first mandibular molar with a mesio-occlusal-distal inlay preparation, a maxillary central incisor, and a canine with a class IV and class V cavity, respectively. Two dentists (with 1 year and 10 years work experience) repeatedly (n=10 per cavity) performed SEE with a custom gel that had identical rheological properties as a commercially available phosphoric acid etchant. An intraoral scanner was used for image acquisition. To assess the accuracy of SEE, special software was used (OraCheck, Cyfex, Zurich, Switzerland). Two independent investigators analyzed baseline scans and scans taken of the cavities while the gel was in place. The statistical analysis comprised t-tests, Pearson correlation, and analysis of variance (α=0.05).

RESULTS

The level of accuracy, whose average values ranged from 61.1% to 87.0%, showed significant differences between teeth, with the highest level observed in the class V cavity, followed by the class II inlay preparation and the class IV cavity (p<0.001). Across the cavities, no significant correlation was observed between the application time and the accuracy of SEE (p=0.07).

CONCLUSION

This laboratory study suggests that inadvertent conditioning of dentin adjacent to enamel may be common during SEE. Investigations involving larger samples of dentists are needed to corroborate this finding.

Diagnostic performance of angiography-derived FFR in patients presenting with NSTE-ACS

Background

Precise non-invasive methods to measure fractional flow reserve (FFR) are actively being explored, aiming to avoid the use of invasive pressure wire and the administration of hyperaemic stimulus. Coronary angiography-derived FFR (FFRangio) has already proved its diagnostic performance in validation studies in the context of stable coronary artery disease. However, its applicability in the context of non-ST-segment elevation acute coronary syndromes (NSTE-ACS) has yet to be established.

Purpose

The study sought to determine the diagnostic performance of FFRangio in patients presenting with NSTE-ACS and evaluate if it could serve as a reliable alternative to invasive FFR.

Methods

This study is a prospective, single-center, single-arm, double-blinded clinical study comparing the FFR calculated by FFRangio to invasive FFR and it represents a sub-study of a protocol evaluating the diagnostic performance of FFR-CT in NSTE-ACS patients, whose design and rationale has been previously published. Invasive FFR was measured in all angiographically intermediate lesions (30%-70% stenoses) in NSTE-ACS patients and was then compared to FFRangio which was measured in the same position, by a blinded operator. The study primary endpoints were the per lesion diagnostic characteristics of FFRangio using invasive FFR as the standard of reference. A value of ≤0.80 was considered as the threshold for a positive result (i.e. functionally significant lesion) for both invasive and FFRangio.

Results

Among the 46 NSTE-ACS patients included in the study according to the inclusion/exclusion criteria, a total of 60 vessels underwent invasive FFR measurement. The mean value of invasive FFR was 0.83±0.3 with 36% being positive. The mean FFRangio was 0.82±0.1 with 36% being positive. FFRangio showed a sensitivity of 95.5%, a specificity of 97.4% and a diagnostic accuracy of 96.7% to detect the functional significance of an angiographically intermediate stenosis. Moreover, it showed similar diagnostic performance across all three coronary arteries. FFRangio values correlated well with invasive FFR measurements (r=0.83, P&lt;0.001) and the Bland–Altman 95% confidence limits were between −0.12 and 0.10.

Conclusions

This study adds to the limited knowledge on the validity of FFRangio in the context of acute coronary syndromes and demonstrates excellent diagnostic performance as well as strong correlation to the invasive FFR for in the setting of NSTE-ACS. It contributes to the growing body of evidence suggesting that FFRangio can precisely calculate FFR in a wide range of clinical situations thus diminishing the risks of an invasive procedure and the use of hyperaemic agent. Since it is non-invasive, simple and cost-effective, the use of FFRangio could be routinely considered to guide treatment decision in angiographically intermediate coronary lesions in the context of NSTE-ACS.

Funding Acknowledgement

Type of funding sources: None.

Consensus-Based Guidance on Opioid Management in Individuals With Advanced Cancer-Related Pain and Opioid Misuse or Use Disorder

Importance

Opioid misuse and opioid use disorder (OUD) are important comorbidities in people with advanced cancer and cancer-related pain, but there is a lack of consensus on treatment.

Objective

To develop consensus among palliative care and addiction specialists on the appropriateness of various opioid management strategies in individuals with advanced cancer-related pain and opioid misuse or OUD.

Design, Setting, and Participants

For this qualitative study, using ExpertLens, an online platform and methodology for conducting modified Delphi panels, between August and October 2020, we conducted 2 modified Delphi panels to understand the perspectives of palliative and addiction clinicians on 3 common clinical scenarios varying by prognosis (weeks to months vs months to years). Of the 129 invited palliative or addiction medicine specialists, 120 participated in at least 1 round. A total of 84 participated in all 3 rounds.

Main Outcomes and Measures

Consensus was investigated for 3 clinical scenarios: (1) a patient with a history of an untreated opioid use disorder, (2) a patient taking more opioid than prescribed, and (3) a patient using nonprescribed benzodiazepines.

Results

Participants were mostly women (47 [62%]), White (94 (78 [65%]), and held MD/DO degrees (115 [96%]). For a patient with untreated OUD, regardless of prognosis, it was deemed appropriate to begin treatment with buprenorphine/naloxone and inappropriate to refer to a methadone clinic. Beginning split-dose methadone was deemed appropriate for patients with shorter prognoses and of uncertain appropriateness for those with longer prognoses. Beginning a full opioid agonist was deemed of uncertain appropriateness for those with a short prognosis and inappropriate for those with a longer prognosis. Regardless of prognosis, for a patient with no medical history of OUD taking more opioids than prescribed, it was deemed appropriate to increase monitoring, inappropriate to taper opioids, and of uncertain appropriateness to increase the patient's opioids or transition to buprenorphine/naloxone. For a patient with a urine drug test positive for non-prescribed benzodiazepines, regardless of prognosis, it was deemed appropriate to increase monitoring, inappropriate to taper opioids and prescribe buprenorphine/naloxone.

Conclusions and Relevance

The findings of this qualitative study provide urgently needed consensus-based guidance for clinicians and highlight critical research and policy gaps.

Expert Panel Consensus on Management of Advanced Cancer-Related Pain in Individuals With Opioid Use Disorder

IMPORTANCE

Opioid use disorder (OUD) is an important comorbidity in individuals with advanced cancer, in whom pain is common. Full-agonist opioid medications are the cornerstone of cancer pain management, but the existing literature does not address how to manage cancer pain in patients with OUD.

OBJECTIVE

To conduct an expert panel to develop consensus on the appropriateness of management of cancer pain in individuals with co-occurring advanced cancer and OUD.

EVIDENCE REVIEW

A 3-round modified Delphi process was completed from August to October 2020 with 2 cases: patient with advanced cancer, pain, and OUD treated with buprenorphine-naloxone or methadone. Participants rated management strategies in round 1, discussed results in round 2, and provided final responses in round 3. ExpertLens, an online approach to conducting modified Delphi panels, was used. Participants were experts in palliative care, addiction, or both, recruited by email from palliative care and addiction-focused professional groups, lists from prior studies, and snowball sampling. Data analysis was performed from November 2020 to July 2021.

FINDINGS

Of 120 experts (median age, 40-49 years), most were White (78 participants [94%]), female (74 participants [62%]), and held MD or DO degrees (115 participants [96%]); 84 (70%) participated in all rounds. For a patient with OUD taking buprenorphine-naloxone, it was deemed appropriate to continue buprenorphine-naloxone with thrice-daily dosing. Continuing buprenorphine-naloxone and adding a full-agonist opioid was deemed to be appropriate for patients with a prognosis of weeks to months and of uncertain appropriateness for patients with a prognosis of months to years. For a patient with OUD taking methadone dispensed at a methadone clinic, it was deemed appropriate to take over prescribing and dose twice or thrice daily. Continuing methadone daily while adding another full-agonist opioid was deemed appropriate for patients with a prognosis of weeks to months and of uncertain appropriateness for those with a prognosis of months to years.

CONCLUSIONS AND RELEVANCE

The findings of this qualitative study provide urgently needed, consensus-based guidance for clinicians and highlight critical research and policy gaps needed to facilitate implementation.

Consensus-based approach to managing opioids, including opioid misuse and opioid use disorder, in patients with serious illness: protocol for a modified Delphi process

INTRODUCTION

Management of opioid misuse and opioid use disorder (OUD) among individuals with serious illness is an important yet understudied issue. Palliative care clinicians caring for individuals with serious illness, many of whom may live for months or years, describe a complex tension between weighing the benefits of opioids, which are considered a cornerstone of pain management in serious illness, and serious opioid-related harms like opioid misuse and OUD. And yet, little literature exists to inform the management of opioid misuse and OUDs among individuals with serious illness. Our objective is to provide evidence-based management guidance to clinicians caring for individuals with serious illness who develop opioid misuse or OUD.

METHODS AND ANALYSIS

We chose a modified Delphi approach, which is appropriate when empirical evidence is lacking and expert input must be used to shape clinical guidance. We sought to recruit 60 clinicians with expertise in palliative care, addiction or both to participate in this study. We created seven patient cases that capture important management challenges in individuals with serious illness prescribed opioid therapy. We used ExpertLens, an online platform for conducting modified Delphi panels. Participants completed three rounds of data collection. In round 1, they rated and commented on the appropriateness of management choices for cases. In round 2, participants reviewed and discussed their own and other participants' round 1 numerical responses and comments. In round 3 (currently ongoing), participants again reviewed rounds 1 and 2, and are allowed to change their final numerical responses. We used ExpertLens to automatically identify whether there is consensus, or disagreement, among responses in panels. Only round 3 responses will be used to assess final consensus and disagreement.

ETHICS AND DISSEMINATION

This project received ethical approval from the University of Pittsburgh's Institutional Review Board (study 19110301) and the RAND Institutional Research Board (study 2020-0142). Guidance from this work will be disseminated through national stakeholder networks to gain buy-in and endorsement. This study will also form the basis of an implementation toolkit for clinicians caring for individuals with serious illness who are at risk of opioid misuse or OUD.

Strain relaxation dynamics of multiferroic orthorhombic manganites

Resonant ultrasound spectroscopy has been used to characterise strain coupling and relaxation behavior associated with magnetic/magnetoelectric phase transitions in GdMnO₃, TbMnO₃and TbMn_0.98Fe_0.02O₃through their influence on elastic/anelastic properties. Acoustic attenuation ahead of the paramagnetic to colinear-sinusoidal incommensurate antiferromagnetic transition at ∼41 K correlates with anomalies in dielectric properties and is interpreted in terms of Debye-like freezing processes. A loss peak at ∼150 K is related to a steep increase in electrical conductivity with a polaron mechanism. The activation energy,E_a, of ≳0.04 eV from a loss peak at ∼80 K is consistent with the existence of a well-defined temperature interval in which the paramagnetic structure is stabilised by local, dynamic correlations of electric and magnetic polarisation that couple with strain and have relaxation times in the vicinity of ∼10^-6s. Comparison with previously published data for Sm_0.6Y_0.4MnO₃confirms that this pattern may be typical for multiferroic orthorhombicRMnO₃perovskites (R= Gd, Tb, Dy). A frequency-dependent loss peak near 10 K observed for TbMnO₃and TbMn_0.98Fe_0.02O₃, but not for GdMnO₃, yieldedE_a⩾ ∼0.002 eV and is interpreted as freezing of some magnetoelastic component of the cycloid structure. Small anomalies in elastic properties associated with the incommensurate and cycloidal magnetic transitions confirm results from thermal expansion data that the magnetic order parameters have weak but significant coupling with strain. Even at strain magnitudes of ∼0.1-1‰, polaron-like strain effects are clearly important in defining the development and evolution of magnetoelectric properties in these materials. Strains associated with the cubic-orthorhombic transition due to the combined Jahn-Teller/octahedral tilting transition in the vicinity of 1500 K are 2-3 orders of magnitude greater. It is inevitable that ferroelastic twin walls due to this transition would have significantly different magnetoelectric properties from homogeneous domains due to magnetoelastic coupling with steep strain gradients.

P3631Impact of manual thrombectomy on microvascular obstruction among STEMI patients

Background

Manual thrombectomy (MT) in ST segment elevation myocardial infarction (STEMI) is not associated with improved outcome and may even be harmful. Microvascular obstruction (MVO) assessed with cardiac magnetic resonance (CMR) imaging is among the strongest outcome predictors after STEMI.

Purpose

We aimed to investigate the impact of MT on MVO occurrence and extent.

Method

Between December 2010 and June 2017, 401 consecutive STEMI patients admitted for primary PCI, and still hospitalized in our tertiary care hospital at day 3 or later, (i.e. not transferred to another hospital) underwent a CMR during the index hospitalization (routine care at our institution during this period). Among them, 383 patients fulfilled the inclusion criteria and were classified into 2 categories (with or without MT) while 18 patients were excluded because of incomplete CMR data. The 2 co-primary endpoints were the occurrence and the extent of MVO, with these latter being analyzed either as a categorical variable (MVO vs. No-MVO) or as a semi-continuous variable (numbers of segments with MVO), respectively.

Results

In total, 188 (49.1%) patients experienced MVO. Both the incidence of MVO and the median number of segments with MVO were significantly higher in the MT group as compared to the no-MT group (59.5% vs 38.9%, respectively p<0.001, Figure 1A) and (0 [0; 2] vs 1.5 [0; 4]; respectively, p<0.001). When stratifying the analysis on coronary thrombus grade (Figures 1B and 1C), similar results were found only in patients with high thrombus burden (43.5% vs 60.7%, respectively, p=0.004). When adjusting for baseline differences between the 2 groups, MT remained a determinant of MVO (OR 1.90 (CI 95% 1.08 to 3.34); p=0.026) in patients with high thrombus grade.

Figure 1

Conclusion

In STEMI patients undergoing primary PCI, MT is associated with the occurrence and the extent of MVO assessed by CMR, especially in patients with a high thrombus grade. This suggests thrombus fragmentation with distal embolization as a potential mechanistic explanation.

Acknowledgement/Funding

None

464Optimal timing of invasive coronary angiography following NSTEMI

Introduction

Current guidelines recommend angiography within 24 hours of hospitalisation for patients with non-ST elevation myocardial infarction (NSTEMI). The recent VERDICT study found that angiography within 12 hours of hospitalisation was associated with improved cardiovascular outcomes among high-risk patients. We aimed to obtain a real-world perspective of the impact of angiography timing on one-year outcomes of patients admitted with NSTEMI.

Methods

Data was obtained from the SPUM-ACS registry, a cohort of consecutive patients hospitalised with acute coronary syndromes in four university hospitals in Switzerland between 2009 and 2017. Patients without a door-to-catheter (DTC) time and those with life-threatening features were excluded. Cox proportional hazards models evaluated the impact of DTC time on the primary endpoint, defined as one-year major adverse cardiovascular events (MACE: cardiovascular mortality, myocardial infarction, stroke), and on one-year all-cause mortality.

Results

Of 2,672 NSTEMI patients, 1,832 met the inclusion criteria. Among them, 1,464 patients underwent angiography within 12 hours of admission (12h group) while 368 patients underwent angiography between 12 and 24 hours (12–24h group). After 2:1 propensity score matching, 736 patients from the 12h group and 368 patients from the 12–24h group were deemed equivalent in terms of main baseline clinical characteristics. Multiple logistic regression identified admission out-of-hours (night or weekend) as the most significant factor associated with delayed angiography. Cox models found no significant association between early angiography and one-year MACE (12h group: n=57 (7.7%) vs. 12–24h group: n=27 (7.3%), HR: 1.050, 95% CI 0.637- 1.733, p=0.847), or one-year all-cause mortality (12h group: n=25 (3.4%) vs. 12–24h group: n=17 (4.6%), HR: 1.514, 95% CI 0.774- 2.962, p=0.225) (Figure 1A). After stratification based on GRACE score (>140 vs. ≤140), there was no significant difference in one-year MACE or one-year all-cause mortality in the 12h group compared with the 12–24h group (p for interaction=0.601 and 0.463, respectively) (Figure 1A + 1B).

Figure 1

Conclusion

In an unselected real-world cohort of NSTEMI patients, angiography within 12 hours of hospitalisation was not associated with improved one-year outcomes when compared with angiography between 12 and 24 hours, even among patients with an elevated GRACE score.

A Fibromyxoid Stromal Response is Associated with Muscle Invasion in Canine Urothelial Carcinoma

Canine urothelial carcinoma (UC) is the most common type of cancer of the lower urinary tract and tends to affect elderly neutered female dogs, with a high predisposition for Scottish terriers. Tumour stroma, inflammation and necrosis are poorly characterized in canine UC and their role as prognostic factors is unknown. The aims of this study were to (1) assess histologically 381 canine UCs, with emphasis on myxoid tumour stroma, inflammation and necrosis and (2) assess possible associations between these features and the available epidemiological data as well as bladder wall muscle invasion. In 103 of 381 (27%) cases, the stroma was mixed collagenous and myxoid (fibromyxoid), which was strongly associated with invasive growth of muscle (P <0.0001). Peritumoural and intratumoural inflammation was present in 308 of 345 (89%) and 287 of 381 (75%) cases, respectively, and was mostly mild and lymphoplasmacytic. One hundred and fifteen of the 381 (30%) cases showed a variable eosinophilic inflammation and 58 of 381 (15%) presented with formations of one or several lymphoid follicles. Twenty-four percent (91 of 381) of cases had tumour necrosis, which was typically mild. In 83 of 91 (91%) cases, the necrosis was comedo-like. Moderate to severe tumour necrosis was associated with the presence of moderate to predominant fibromyxoid tumour stroma (P <0.02). The results of this study indicate that fibromyxoid stroma is common in canine UC and is a strong indicator for invasive growth of muscle, which is consistent with a poor prognosis. Based on histomorphology, tumour necrosis in canine UC is best described as comedonecrosis.

Publisher Correction: Magnetoelectric inversion of domain patterns

Four incorrect figure citations in this Letter have been corrected online.

Paneth and intestinal stem cells preserve their functional integrity during worsening of acute cellular rejection in small bowel transplantation

Graft survival after small bowel transplantation remains impaired due to acute cellular rejection (ACR), the leading cause of graft loss. Although it was shown that the number of enteroendocrine progenitor cells in intestinal crypts was reduced during mild ACR, no results of Paneth and intestinal stem cells localized at the crypt bottom have been shown so far. Therefore, we wanted to elucidate integrity and functionality of the Paneth and stem cells during different degrees of ACR, and to assess whether these cells are the primary targets of the rejection process. We compared biopsies from ITx patients with no, mild, or moderate ACR by immunohistochemistry and quantitative PCR. Our results show that numbers of Paneth and stem cells remain constant in all study groups, whereas the transit-amplifying zone is the most impaired zone during ACR. We detected an unchanged level of antimicrobial peptides in Paneth cells and similar numbers of Ki-67⁺ IL-22R⁺ stem cells revealing cell functionality in moderate ACR samples. We conclude that Paneth and stem cells are not primary target cells during ACR. IL-22R⁺ Ki-67⁺ stem cells might be an interesting target cell population for protection and regeneration of the epithelial monolayer during/after a severe ACR in ITx patients.

Social and clinical determinants of preferences and their achievement at the end of life: prospective cohort study of older adults receiving palliative care in three countries

Background

Achieving choice is proposed as a quality marker. But little is known about what influences preferences especially among older adults. We aimed to determine and compare, across three countries, factors associated with preferences for place of death and treatment, and actual site of death.

Methods

We recruited adults aged ≥65-years from hospital-based multiprofessional palliative care services in London, Dublin, New York, and followed them for >17 months. All services offered consultation on hospital wards, support for existing clinical teams, outpatient services and received funding from their National Health Service and/or relevant Insurance reimbursements. The New York service additionally had 10 inpatient beds. All worked with and referred patients to local hospices. Face-to-face interviews recorded most and least preferred place of death, treatment goal priorities, demographic and clinical information using validated questionnaires. Multivariable and multilevel analyses assessed associated factors.

Results

One hundred and thirty eight older adults (64 London, 59 Dublin, 15 New York) were recruited, 110 died during follow-up. Home was the most preferred place of death (77/138, 56%) followed by inpatient palliative care/hospice units (22%). Hospital was least preferred (35/138, 25%), followed by nursing home (20%) and home (16%); hospice/palliative care unit was rarely least preferred (4%). Most respondents prioritised improving quality of life, either alone (54%), or equal with life extension (39%); few (3%) chose only life extension. There were no significant differences between countries. Main associates with home preference were: cancer diagnosis (OR 3.72, 95% CI 1.40–9.90) and living with someone (OR 2.19, 1.33–3.62). Adults with non-cancer diagnoses were more likely to prefer palliative care units (OR 2.39, 1.14–5.03). Conversely, functional independence (OR 1.05, 1.04–1.06) and valuing quality of life (OR 3.11, 2.89–3.36) were associated with dying at home. There was a mismatch between preferences and achievements – of 85 people who preferred home or a palliative care unit, 19 (25%) achieved their first preference.

Conclusion

Although home is the most common first preference, it is polarising and for 16% it is the least preferred. Inpatient palliative care unit emerges as the second most preferred place, is rarely least preferred, and yet was often not achieved for those who wanted to die there. Factors affecting stated preferences and met preferences differ. Available services, notably community support and palliative care units, require expansion. Contrasting actual place of death with capacity for meeting patient and family needs may be a better quality indicator than simply ‘achieved preferences’.

Electronic supplementary material

The online version of this article (10.1186/s12877-017-0648-4) contains supplementary material, which is available to authorized users.

Functional electronic inversion layers at ferroelectric domain walls

Ferroelectric domain walls hold great promise as functional two-dimensional materials because of their unusual electronic properties. Particularly intriguing are the so-called charged walls where a polarity mismatch causes local, diverging electrostatic potentials requiring charge compensation and hence a change in the electronic structure. These walls can exhibit significantly enhanced conductivity and serve as a circuit path. The development of all-domain-wall devices, however, also requires walls with controllable output to emulate electronic nano-components such as diodes and transistors. Here we demonstrate electric-field control of the electronic transport at ferroelectric domain walls. We reversibly switch from resistive to conductive behaviour at charged walls in semiconducting ErMnO₃. We relate the transition to the formation-and eventual activation-of an inversion layer that acts as the channel for the charge transport. The findings provide new insight into the domain-wall physics in ferroelectrics and foreshadow the possibility to design elementary digital devices for all-domain-wall circuitry.

A rheological model for immersed corrugated elastic plates

The influence of surface imperfections on the propagation of guided waves in an immersed elastic plate can be interpreted by means of a rheological model. The corrugated surface is modeled by a very thin interface, similar to a Jones spring model, which replaces the continuity boundary conditions at the liquid - corrugated solid-plate interface. As the surrounding liquid is considered to be perfect, only one complex stiffness is used for the model of Jones. The selection of the plate guided mode and the test frequency are motivated by the detectability and non-interference with other modes. The spring stiffness is obtained by a best fit procedure, between the analytical solution and the results obtained by the finite elements method (FEM). One way ensuring the agreement of the two approaches, rheological and FEM, is to consider angular resonances provided by the transmission coefficients. Small changes in the parameters of the roughness keep the positions of the angular resonances of the plate practically unchanged, while at the same time large variations of the half width of the transmission coefficient curve is observed. The effect of corrugation parameters on the guided modes in the plate can be predicted by using the rheological model with the deduced spring complex stiffness.

How empowering is hospital care for older people with advanced disease? Barriers and facilitators from a cross-national ethnography in England, Ireland and the USA

Background

patient empowerment, through which patients become self-determining agents with some control over their health and healthcare, is a common theme across health policies globally. Most care for older people is in the acute setting, but there is little evidence to inform the delivery of empowering hospital care.

Objective

we aimed to explore challenges to and facilitators of empowerment among older people with advanced disease in hospital, and the impact of palliative care.

Methods

we conducted an ethnography in six hospitals in England, Ireland and the USA. The ethnography involved: interviews with patients aged ≥65, informal caregivers, specialist palliative care (SPC) staff and other clinicians who cared for older adults with advanced disease, and fieldwork. Data were analysed using directed thematic analysis.

Results

analysis of 91 interviews and 340 h of observational data revealed substantial challenges to empowerment: poor communication and information provision, combined with routinised and fragmented inpatient care, restricted patients' self-efficacy, self-management, choice and decision-making. Information and knowledge were often necessary for empowerment, but not sufficient: empowerment depended on patient-centredness being enacted at an organisational and staff level. SPC facilitated empowerment by prioritising patient-centred care, tailored communication and information provision, and the support of other clinicians.

Conclusions

empowering older people in the acute setting requires changes throughout the health system. Facilitators of empowerment include excellent staff-patient communication, patient-centred, relational care, an organisational focus on patient experience rather than throughput, and appropriate access to SPC. Findings have relevance for many high- and middle-income countries with a growing population of older patients with advanced disease.

Conductivity Contrast and Tunneling Charge Transport in the Vortexlike Ferroelectric Domain Patterns of Multiferroic Hexagonal YMnO_{3}

We deduce the intrinsic conductivity properties of the ferroelectric domain walls around the topologically protected domain vortex cores in multiferroic YMnO_{3}. This is achieved by performing a careful equivalent-circuit analysis of dielectric spectra measured in single-crystalline samples with different vortex densities. The conductivity contrast between the bulk domains and the less conducting domain boundaries is revealed to reach up to a factor of 500 at room temperature, depending on the sample preparation. Tunneling of localized defect charge carriers is the dominant charge-transport process in the domain walls that are depleted of mobile charge carriers. This work demonstrates that, via equivalent-circuit analysis, dielectric spectroscopy can provide valuable information on the intrinsic charge-transport properties of ferroelectric domain walls, which is of high relevance for the design of new domain-wall-based microelectronic devices.

Cortical Activation Resulting from Painless Vibrotactile Dental Stimulation Measured by Functional Magnetic Resonance Imaging (fMRI)

There have been few investigations on hemodynamic responses in the human cortex resulting from dental stimulation. Identification of cortical areas involved in stimulus perception may offer new targets for pain treatment. This initial study aimed at establishing a cortical map of dental representation, based on non-invasive fMRI measurements. Five right-handed subjects were studied. Eight maxillary and 8 mandibular teeth were stimulated after the vibratory perception threshold was determined for each tooth. Suprathreshold stimulation was repeated thrice per session, in a total of three sessions performed on three consecutive days. Statistical inference on cluster level identified increased blood-oxygen-level-dependent signal during vibratory dental stimulation, primarily in the insular cortex bilaterally and in the supplementary motor cortex. No significant brain activation was observed in the somatosensory cortex with this stimulation protocol. These results agree with previous findings obtained from invasive direct electrical cortical stimulation of the human insula.

Palliative Care and Cardiovascular Disease and Stroke: A Policy Statement From the American Heart Association/American Stroke Association

The mission of the American Heart Association/American Stroke Association includes increasing access to high-quality, evidence-based care that improves patient outcomes such as health-related quality of life and is consistent with the patients’ values, preferences, and goals. Awareness of and access to palliative care interventions align with the American Heart Association/American Stroke Association mission. The purposes of this policy statement are to provide background on the importance of palliative care as it pertains to patients with advanced cardiovascular disease and stroke and their families and to make recommendations for policy decisions. Palliative care, defined as patient- and family-centered care that optimizes health-related quality of life by anticipating, preventing, and treating suffering, should be integrated into the care of all patients with advanced cardiovascular disease and stroke early in the disease trajectory. Palliative care focuses on communication, shared decision making about treatment options, advance care planning, and attention to physical, emotional, spiritual, and psychological distress with inclusion of the patient’s family and care system. Our policy recommendations address the following: reimbursement for comprehensive delivery of palliative care services for patients with advanced cardiovascular disease and stroke; strong payer-provider relationships that involve data sharing to identify patients in need of palliative care, identification of better care and payment models, and establishment of quality standards and outcome measurements; healthcare system policies for the provision of comprehensive palliative care services during hospitalization, including goals of care, treatment decisions, needs of family caregivers, and transition to other care settings; and health professional education in palliative care as part of licensure requirements.

Local dynamics of topological magnetic defects in the itinerant helimagnet FeGe

Chiral magnetic interactions induce complex spin textures including helical and conical spin spirals, as well as particle-like objects such as magnetic skyrmions and merons. These spin textures are the basis for innovative device paradigms and give rise to exotic topological phenomena, thus being of interest for both applied and fundamental sciences. Present key questions address the dynamics of the spin system and emergent topological defects. Here we analyse the micromagnetic dynamics in the helimagnetic phase of FeGe. By combining magnetic force microscopy, single-spin magnetometry and Landau–Lifschitz–Gilbert simulations we show that the nanoscale dynamics are governed by the depinning and subsequent motion of magnetic edge dislocations. The motion of these topologically stable objects triggers perturbations that can propagate over mesoscopic length scales. The observation of stochastic instabilities in the micromagnetic structure provides insight to the spatio-temporal dynamics of itinerant helimagnets and topological defects, and discloses open challenges regarding their technological usage.

Topological defects may strongly influence the evolution of a materials' micromagnetic structure whilst their manipulation forms the basis for emerging technological concepts. Here, the authors study the depinning and motion of magnetic edge dislocations in the domain structure of helimagnetic FeGe.

Static Magnetic Proximity Effect in Pt/NiFe2O4 and Pt/Fe Bilayers Investigated by X-Ray Resonant Magnetic Reflectivity

The spin polarization of Pt in Pt/NiFe2O4 and Pt/Fe bilayers is studied by interface-sensitive x-ray resonant magnetic reflectivity to investigate static magnetic proximity effects. The asymmetry ratio of the reflectivity is measured at the Pt L3 absorption edge using circular polarized x-rays for opposite directions of the magnetization at room temperature. The results of the 2% asymmetry ratio for Pt/Fe bilayers are independent of the Pt thickness between 1.8 and 20 nm. By comparison with ab initio calculations, the maximum magnetic moment per spin polarized Pt atom at the interface is determined to be (0.6±0.1)  μB for Pt/Fe. For Pt/NiFe2O4 the asymmetry ratio drops below the sensitivity limit of 0.02  μB per Pt atom. Therefore, we conclude, that the longitudinal spin Seebeck effect recently observed in Pt/NiFe2O4 is not influenced by a proximity induced anomalous Nernst effect.

Structural invariance upon antiferromagnetic ordering in geometrically frustrated swedenborgite, CaBaCo2Fe2O7

Centimetre-sized single crystals of high-quality CaBaCo2Fe2O7were synthesized by the optical floating zone technique. The metal-to-metal stoichiometry and oxygen content were confirmed by spectroscopy and thermal reduction experiments. The hexagonal symmetryP63mc(No. 186) well describes the powder X-ray and neutron diffraction as well as single-crystal neutron diffraction at all measured temperatures. This symmetry is also consistent with optical second harmonic generation data obtained between 10 and 295 K. However, a satisfactory structure description from single-crystal neutron diffraction data needs an oxygen split position. Specific heat, magnetic susceptibility and powder neutron diffraction data indicate a magnetic phase transition atTN= 159 K to an antiferromagnetic ground state, but with a persisting hexagonal symmetry and intrinsic geometric frustration.

Immunological status of isolated lymphoid follicles after intestinal transplantation

Intestinal transplantation (ITx) faces the challenge of grafting a high immunogenic organ, which is certainly one of the major obstacles for intestinal allograft acceptance. The allograft has to guarantee the proper functioning of the mucosal immune machinery under immunosuppressive conditions. Recently, it has been elucidated that isolated lymphoid follicles (ILFs) are an indispensable part of mucosal immunity to maintain IgA synthesis and consequently to control commensal microflora. No data about these follicular structures in the setting of ITx are available so far. Therefore, we addressed the question whether constitution, integrity and function of allograft ILFs are disturbed by immunosuppressive regimen. We compared allograft ILFs from terminal ileum of transplant patients with ILFs from nontransplant patients via flow cytometry, quantitative real-time polymerase chain reaction and immunohistochemistry. We found that host leukocytes rapidly repopulate allograft ILFs and that maintenance immunosuppressive regimen, tacrolimus and corticosteroids, does not affect their cellular integrity and function. However, allograft ILFs revealed a higher maturation state than control samples and IgA positive plasma cells were increased in number in allograft mucosa. Our results open the path for a better understanding of allograft mucosal immunity.

Adaptation of Chloroplast-Ultrastructure and of Chlorophyll- Protein Levels to High-Light and Low-Light Growth Conditions

Adaptation In saturating light radish seedlings grown in high-light growth conditions (90 W · m-2) possess a much higher photosynthetic capacity on a chlorophyll and leaf area basis than the low-light grown plants (10 W · m-2). The higher CO2-fixation rate of HL-plants is due to the presence of HL-chloroplasts which possess a different ultrastructure and also different levels of the individual chlorophyll-carotenoid-proteins than the LL-chloroplasts of LL-seedlings.

1. Ultrastructure: The high-light adapted chloroplasts are characterized by fewer photo­ synthetic membranes per chloroplast section, by low grana stacks (only few thylakoids per granum), a lower stacking degree of thylakoids, a higher proportion of non-appressed membranes (stroma thylakoids + end grana membranes) and a high starch content. The LL-chloroplasts possess no starch, their grana stacks are higher (up to 17 thylakoids per granum) and also significantly broader than that of HL-chloroplasts.

2. Chlorophyll-proteins: The photosynthetic apparatus of HL-chloroplasts contains a larger proportion of chlorophyll a-proteins of photosystem I (CPIa + CPI) and of photosystem II (CPa, the presumable reaction center of PS II) than the LL-chloroplasts which possess a higher proportion of light-harvesting chlorophyll a/b-proteins (LHCP1, LHCP2, LHCP3, LHCPy). The higher levels of LHCPs in LL-plants are associated with a higher ground fluorescence fo and maximum fluorescence fp of the in vivo chlorophyll.

3. Chlorophyll and carotenoid ratios: The chloroplasts of HL-plants possess a higher proportion of chlorophyll a and β-carotene (higher values for the ratios chlorophyll a /b and lower values for a/c and x/c) which reflect the increased level of the chlorophyll a/β-carotene-proteins CPIa, CPI and CPa. The higher level of light-harvesting chlorophyll a/b-xanthophyll-proteins (LHCPs) in LL-plants is also indicated by an increased content of xanthophylls and chlorophyll b as seen from lower a/b and higher x/c and a/c ratios.

4. The results indicate that plants possess the capacity for an ontogenetic adaptation of their photosynthetic apparatus to the incident light intensity. The HL-chloroplasts of HL-plants which contain less antenna chlorophyll, are adapted for a more efficient photosynthetic quantum conversion at light saturation than the LL-chloroplasts with high grana stacks. The correlation between higher levels of light-harvesting chlorophyll a/b-proteins (LHCPs) and a higher stacking degree of thylakoids, and the involvement of LHCPs in stacking is discussed.

Distribution and Effects of Bentazon in Crop Plants and Weeds

The inhibition of photosynthetic CO2-assimilation and of the variable chlorophyll fluorescence as well as uptake and transport of 14C-labelled bentazon and the possibilities for a herbicideinduced shade-type modification of the photosynthetic apparatus were investigated in bentazonsensitive weeds (Galium, Sinapis, Raphanus) and in the tolerant crop plants wheat and maize.

1. In weeds the depression of photosynthetic CO2-assimilation is irreversible, whereas tolerant plants recover due to the metabolization of the active herbicide.

2. A lower rate of uptake and transport of bentazon associated with its fast metabolization is the reason for the tolerance of crop plants towards bentazon.

3. The transport of [14C]bentazon proceeds in the tracheary elements of the xylem. Uptake and transport of bentazon in the weeds are light dependent.

4. The loss of variable fluorescence (Kautsky effect) in the leaves after root application o f bentazon proceeds much faster at high-light than at low light conditions and confirms the light-dependency of the bentazon transport.

5. In the sensitive dicot weeds bentazon not only inhibits photosynthetic electron flow and depresses CO2-fixation but also induces the formation of shade-type chloroplasts which are less efficient in photosynthetic quantum conversion. This bentazon-induced modification of the photosynthetic apparatus (e.g. changes in ultrastructure, pigment ratios, and levels of chloro-phyll-proteins) contributes to the effectiveness of bentazon as a herbicide.

Change of Chloroplast Ultrastructure in Radish Seedlings under the Influence of the Photosystem II-Herbicide Bentazon

The influence of the photosystem II-herbicide bentazon on the ultrastructure of chloroplasts of radish seedlings (Raphanus sativus L.) was investigated with special emphasis on thylakoid development and grana formation.

Bentazon application (10-3 ᴍ) induces the formation of broader and higher grana stacks (grana width: 0.5-0.6 μm; greatest frequency: 3-8 thylakoids per granum) than in the control plants (grana width: 0.3 μm; greatest frequency: 2-4 thylakoids per granum). Furthermore, the amount of chloroplast lamellae is enhanced, as are the stacking degree of thylakoids and the grana area. The chloroplasts of bentazon-treated plants appear to be shorter and thicker than in the controls and show all signs of a shade-type adaptation of the photosynthetic apparatus.

Transverse spin Seebeck effect versus anomalous and planar Nernst effects in Permalloy thin films

Transverse magnetothermoelectric effects are studied in Permalloy thin films grown on MgO and GaAs substrates and compared to those grown on suspended SiN(x) membranes. The transverse voltage along platinum strips patterned on top of the Permalloy films is measured versus the external magnetic field as a function of the angle and temperature gradients. After the identification of the contribution of the planar and anomalous Nernst effects, we find an upper limit for the transverse spin Seebeck effect, which is several orders of magnitude smaller than previously reported.

Observation of coherent helimagnons and gilbert damping in an itinerant magnet

We study the magnetic excitations of itinerant helimagnets by applying time-resolved optical spectroscopy to Fe(0.8)Co(0.2)Si. Optically excited oscillations of the magnetization in the helical state are found to disperse to lower frequency as the applied magnetic field is increased; the fingerprint of collective modes unique to helimagnets, known as helimagnons. The use of time-resolved spectroscopy allows us to address the fundamental magnetic relaxation processes by directly measuring the Gilbert damping, revealing the versatility of spin dynamics in chiral magnets.

Anisotropic conductance at improper ferroelectric domain walls

Transition metal oxides hold great potential for the development of new device paradigms because of the field-tunable functionalities driven by their strong electronic correlations, combined with their earth abundance and environmental friendliness. Recently, the interfaces between transition-metal oxides have revealed striking phenomena, such as insulator-metal transitions, magnetism, magnetoresistance and superconductivity. Such oxide interfaces are usually produced by sophisticated layer-by-layer growth techniques, which can yield high-quality, epitaxial interfaces with almost monolayer control of atomic positions. The resulting interfaces, however, are fixed in space by the arrangement of the atoms. Here we demonstrate a route to overcoming this geometric limitation. We show that the electrical conductance at the interfacial ferroelectric domain walls in hexagonal ErMnO(3) is a continuous function of the domain wall orientation, with a range of an order of magnitude. We explain the observed behaviour using first-principles density functional and phenomenological theories, and relate it to the unexpected stability of head-to-head and tail-to-tail domain walls in ErMnO(3) and related hexagonal manganites. As the domain wall orientation in ferroelectrics is tunable using modest external electric fields, our finding opens a degree of freedom that is not accessible to spatially fixed interfaces.

A SPECT Camera for Combined MRI and SPECT for Small Animals

We describe an MR-compatible SPECT camera for small animals. The SPECT camera system can be inserted into the bore of a state-of-the-art MRI system and allows researchers to acquire tomographic images from a mouse in-vivo with the MRI and the SPECT acquiring simultaneously. The SPECT system provides functional information, while MRI provides anatomical information. Until today it was impossible to operate conventional SPECT inside the MRI because of mutual interference. The new SPECT technology is based on semiconductor radiation sensors (CZT, ASICs), and it fits into conventional high field MRI systems with a minimum 12-cm bore size. The SPECT camera has an MR-compatible multi-pinhole collimator for mice with a ø25-mm field-of-view. For the work reported here we assembled a prototype SPECT camera system and acquired SPECT and MRI data from radioactive sources and resolution phantoms using the camera outside and inside the MRI.

A SPECT Camera for Combined MRI and SPECT for Small Animals

We describe an MR-compatible SPECT camera for small animals. The SPECT camera system can be inserted into the bore of a state-of-the-art MRI system and allows researchers to acquire tomographic images from a mouse in-vivo with the MRI and the SPECT acquiring simultaneously. The SPECT system provides functional information, while MRI provides anatomical information. Until today it was impossible to operate conventional SPECT inside the MRI because of mutual interference. The new SPECT technology is based on semiconductor radiation sensors (CZT, ASICs), and it fits into conventional high field MRI systems with a minimum 12-cm bore size. The SPECT camera has an MR-compatible multi-pinhole collimator for mice with a ø25-mm field-of-view. For the work reported here we assembled a prototype SPECT camera system and acquired SPECT and MRI data from radioactive sources and resolution phantoms using the camera outside and inside the MRI.