"We are Human too.": The Challenges of Being an End-of-Life Doula

End-of-life (EOL) doulas are emerging professionals who provide an intimate approach to the death process by focusing on the psychological, social, spiritual, and emotional needs of dying individuals. EOL doula work is stressful; it exposes individuals to recurring stressors such as suffering and grief. Trained professionals are needed to help advocate for the dying individual and their families. Despite the growing literature on EOL doulas, information regarding the challenges of being an EOL doula is underrepresented in the literature. This paper is one of the first to address this concept. Twelve in-depth, semi-structured interviews regarding the EOL doula experience were conducted as a part of a larger exploratory study. Three overarching themes emerged from the larger project: motivations to become an EOL doula, roles of an EOL doula, and challenges of an EOL doula. In this article, only challenges of EOL are discussed, along with subsequent subordinate themes.

Axial spondyloarthritis patients have altered mucosal IgA response to oral and fecal microbiota

Axial spondyloarthritis (axSpA) is an inflammatory arthritis involving the spine and the sacroiliac joint with extra-articular manifestations in the eye, gut, and skin. The intestinal microbiota has been implicated as a central environmental component in the pathogenesis of various types of spondyloarthritis including axSpA. Additionally, alterations in the oral microbiota have been shown in various rheumatological conditions, such as rheumatoid arthritis (RA). Therefore, the aim of this study was to investigate whether axSpA patients have an altered immunoglobulin A (IgA) response in the gut and oral microbial communities. We performed 16S rRNA gene (16S) sequencing on IgA positive (IgA⁺) and IgA negative (IgA^-) fractions (IgA-SEQ) from feces (n=17 axSpA; n=14 healthy) and saliva (n=14 axSpA; n=12 healthy), as well as on IgA-unsorted fecal and salivary samples. PICRUSt2 was used to predict microbial metabolic potential in axSpA patients and healthy controls (HCs). IgA-SEQ analyses revealed enrichment of several microbes in the fecal (Akkermansia, Ruminococcaceae, Lachnospira) and salivary (Prevotellaceae, Actinobacillus) microbiome in axSpA patients as compared with HCs. Fecal microbiome from axSpA patients showed a tendency towards increased alpha diversity in IgA⁺ fraction and decreased diversity in IgA^- fraction in comparison with HCs, while the salivary microbiome exhibits a significant decrease in alpha diversity in both IgA⁺ and IgA^- fractions. Increased IgA coating of Clostridiales Family XIII in feces correlated with disease severity. Inferred metagenomic analysis suggests perturbation of metabolites and metabolic pathways for inflammation (oxidative stress, amino acid degradation) and metabolism (propanoate and butanoate) in axSpA patients. Analyses of fecal and salivary microbes from axSpA patients reveal distinct populations of immunoreactive microbes compared to HCs using the IgA-SEQ approach. These bacteria were not identified by comparing their relative abundance alone. Predictive metagenomic analysis revealed perturbation of metabolites/metabolic pathways in axSpA patients. Future studies on these immunoreactive microbes may lead to better understanding of the functional role of IgA in maintaining microbial structure and human health.

"Would you like me to take your hand?": Introduction to End of Life Doulas

End-of-life (EOL) doulas are care providers and companions that offer spiritual, emotional, psychosocial, or psychological care to a person who is dying as well as their family and loved ones (Fukuzawa & Kondo, 2017). However, much like other options for EOL care (e.g., hospice, palliative care), their practice is often underutilized and misunderstood. There is limited research on EOL doulas, including who they are and what they do, leaving an opening for future studies to explore the topic (Krawczyk & Rush, 2020). As part of a larger investigation to gather information on EOL doulas, 12 in-depth, semi-structured interviews were conducted with certified doulas regarding their experiences. Three themes emerged from this project: motivations to become an EOL doula, roles of an EOL doula, and challenges of an EOL doula. In this article, only two themes, motivations to become an EOL doula and roles of an EOL doula are discussed.

The Interplay Between COVID-19 and Spondyloarthritis or Its Treatment

OBJECTIVE

The coronavirus disease 2019 (COVID-19) pandemic has created multiple uncertainties regarding rheumatic diseases or their treatment, with regard to the susceptibility to or severity of the viral disease. We aimed to address these questions as they relate to spondyloarthritis (SpA).

METHODS

We created a longitudinal survey from April 10, 2020, to April 26, 2021. There were 4723 subjects with SpA and 450 household contacts who participated worldwide. Of these, 3064 respondents were from the US and 70.4% of them provided longitudinal data. To control for the duration of potential risk of COVID-19, the rate of contracting the disease was normalized for person-months of exposure.

RESULTS

In an analysis of US subjects who provided longitudinal data, the incident rate ratio for the 159 (out of 2157) subjects who tested positive for COVID-19 was 1.16 compared to the US population as adjusted for age and sex (range 0.997-1.361, P = 0.06). A paired evaluation using patients and household members did not show a statistically significant effect to indicate a predisposition for developing COVID-19 as a result of SpA or its treatment. Our data failed to show that any class of medication commonly used to treat SpA significantly affected the risk of developing COVID-19 or increasing the severity of COVID-19.

CONCLUSION

These data do not exclude a small increased risk of developing COVID-19 as a result of SpA, but the risk, if it exists, is low and not consistently demonstrated. The data should provide reassurance to patients and to rheumatologists about the risk that COVID-19 poses to patients with SpA.

Workshops to Teach State-Tested Nursing Assistants About End-of-Life Care

Given that almost 25 percent of U.S. deaths occur annually in long-term care facilities (U.S. Census Bureau, 2017), it’s imperative that frontline workers are given training and support they need to deliver good, person-centered care at the end of life. Inadequate end-of-life (EOL) care may lead to unrelieved suffering and undignified deaths (Bukki, Neuhaus, Paa, 2016). Furthermore, nursing staffs have knowledge gaps and low confidence regarding end-of-life care and they may underestimate its complexity (Pfister, Markett & Muller, 2013). With the growing population of older adults, improving end-of-life care in long- term care facilities needs to be a priority. This research explored the needs of State Tested Nursing Assistants (STNAs) working in long-term care and their knowledge regarding EOL care. Based on the findings of this research, workshops were developed to better educate the STNAs regarding care of the dying and to enhance the EOL care for long term residents.

Radiologic imaging shows variable accuracy in diagnosing orbital inflammatory disease and assessing its activity

Radiologic orbital imaging provides important information in the diagnosis and management of orbital inflammation. However, the diagnostic value of orbital imaging is not well elucidated. This study aimed to investigate the diagnostic accuracy of orbital imaging to diagnose orbital inflammatory diseases and its ability to detect active inflammation. We collected 75 scans of 52 patients (49 computed tomography (CT) scans; 26 magnetic resonance (MR) imaging scans). Clinical diagnoses included thyroid eye disease (TED) (41 scans, 31 patients), non-specific orbital inflammation (NSOI) (22 scans, 14 patients), sarcoidosis (4 scans, 3 patients), IgG4-related ophthalmic disease (IgG4-ROD) (5 scans, 3 patients), and granulomatosis with polyangiitis (GPA) (3 scans, 1 patient). Two experienced neuroradiologists interpreted the scans, offered a most likely diagnosis, and assessed the activity of inflammation, blinded to clinical findings. The accuracy rate of radiological diagnosis compared to each clinical diagnosis was evaluated. Sensitivity and specificity in detecting active inflammation were analyzed for TED and NSOI. The accuracy rate of radiologic diagnosis was 80.0% for IgG4-ROD, 77.3% for NSOI, and 73.2% for TED. Orbital imaging could not diagnose sarcoidosis. Orbital CT had a sensitivity of 50.0% and a specificity of 75.0% to predict active TED using clinical assessment as the gold standard. The sensitivity/specificity of orbital MR was 83.3/16.7% for the detection of active NSOI. In conclusion, orbital imaging is accurate for the diagnosis of IgG4, NSOI, and TED. Further studies with a large number of cases are needed to confirm this finding, especially with regard to uncommon diseases. Orbital CT showed moderate sensitivity and good specificity for identifying active TED.

RNA-Seq of human whole blood: Evaluation of globin RNA depletion on Ribo-Zero library method

Peripheral blood is a highly accessible biofluid providing a rich source of information about human physiology and health status. However, for studies of the blood transcriptome with RNA sequencing (RNA-Seq) techniques, high levels of hemoglobin mRNAs (hgbRNA) present in blood can occupy valuable sequencing space, impacting detection and quantification of non-hgbRNAs. In this study, we evaluated two methods for preparing ribosomal RNA (rRNA)-depleted sequencing libraries for RNA-Seq of whole blood, one of which is also designed to deplete hgbRNAs. Two experiments were performed: one evaluating library performance across 6 human blood samples and the other examining library reproducibility and performance in a two-subject subset. We find that addition of hgbRNA depletion to the rRNA-depletion protocol for library preparation from blood RNA effectively reduces highly abundant hgbRNA reads; however, it does not result in a statistically significant increase in differentially expressed genes in our patient-control study. Bioinformatic removal of globin gene counts in non-hgbRNA depleted libraries provides improvement in overall performance of these libraries. We conclude that use of a standard ribosomal RNA depletion method for library preparation coupled with bioinformatic removal of globin gene counts is sufficient for reproducible and sensitive measurement of both coding and noncoding RNAs in the blood transcriptome.

Factors Affecting MoO4(2-) Inhibitor Release from Zn2Al Based Layered Double Hydroxide and Their Implication in Protecting Hot Dip Galvanized Steel by Means of Organic Coatings

Zn2Al/-layered double hydroxide (LDH) with intercalated MoO4(2-) was investigated as a potential source of soluble molybdate inhibitor in anticorrosion coatings for hot dip galvanized steel (HDG). The effect of solution pH, soluble chlorides, and carbonates on the release kinetics of the interleaved MoO4(2-) ions from the LDH powder immersed in solutions containing different anions was studied by X-ray diffraction, in situ attenuated total reflectance infrared (ATR-IR) spectroscopy, and inductively coupled plasma atomic emission spectroscopy (ICP-AES). The effect of the solution composition on the total release and the release kinetics was demonstrated. Less than 30% of the total amount of the intercalated MoO4(2-) was released after 24 h of the immersion in neutral 0.005-0.5 M NaCl and 0.1 M NaNO3 solutions whereas the complete release of MoO4(2-) was observed after 1 h in 0.1 M NaHCO3 or Na2SO4 and in alkaline solutions. The in situ ATR-IR experiments and quantification of the released soluble species by ICP-AES demonstrated the release by an anion exchange in neutral solutions and by the dissolution of Zn2Al/-LDH in alkaline solutions. The anion exchange kinetics with monovalent anions was described by the reaction order n = 0.35 ± 0.05 suggesting the diffusion control; for divalent anions, n = 0.70 ± 0.06 suggested the control by a surface reaction. Dissolution of Zn from coated HDG with and without Zn2Al/-MoO4(2-) fillers, leaching of MoO4(2-) from the coating, and the electrochemical impedance spectroscopy response of the coated systems were measured during the immersion in 0.5 M NaCl solutions with and without 0.1 M NaHCO3. Without carbonates, the release of soluble MoO4(2-) was delayed for 24 h with no inhibiting effect whereas with 0.1 M NaHCO3 the immediate release was accompanied by the immediate and strong inhibiting effect on Zn dissolution. The concept of controlling the inhibition performance of LDH hybrid coatings by means of the environment composition is discussed.

Implementation of a shared data repository and common data dictionary for fetal alcohol spectrum disorders research

Many previous attempts by fetal alcohol spectrum disorders researchers to compare data across multiple prospective and retrospective human studies have failed because of both structural differences in the collected data and difficulty in coming to agreement on the precise meaning of the terminology used to describe the collected data. Although some groups of researchers have an established track record of successfully integrating data, attempts to integrate data more broadly among different groups of researchers have generally faltered. Lack of tools to help researchers share and integrate data has also hampered data analysis. This situation has delayed improving diagnosis, intervention, and treatment before and after birth. We worked with various researchers and research programs in the Collaborative Initiative on Fetal Alcohol Spectrum Disorders (CI-FASD) to develop a set of common data dictionaries to describe the data to be collected, including definitions of terms and specification of allowable values. The resulting data dictionaries were the basis for creating a central data repository (CI-FASD Central Repository) and software tools to input and query data. Data entry restrictions ensure that only data that conform to the data dictionaries reach the CI-FASD Central Repository. The result is an effective system for centralized and unified management of the data collected and analyzed by the initiative, including a secure, long-term data repository. CI-FASD researchers are able to integrate and analyze data of different types, using multiple methods, and collected from multiple populations, and data are retained for future reuse in a secure, robust repository.

Hyaluronan modifies inflammatory response and peritoneal permeability during peritonitis in rats

The effect of high-molecular-weight hyaluronan (HA) on peritoneal and systemic inflammation and peritoneal permeability to water and solutes was studied during endotoxin-induced peritonitis in rats. Acute peritonitis was induced by adding lipopolysaccharide (LPS) to the dialysis fluid (Dianeal 3.86; Baxter Healthcare, Ireland, Castlebar). HA was added to the dialysis solution in a concentration of 10 mg/dL. During 4- and 8-hour dwells of the dialysis fluid, we studied the intensity of peritoneal (dialysate) and systemic (blood) inflammation (dialysate cell count and differential, cytokine and HA levels), as well as the transperitoneal transport of solutes and water. In rats, the addition of LPS to the dialysis fluid induced changes in inflammatory reaction and transperitoneal transport similar to those seen in continuous ambulatory peritoneal dialysis patients with peritonitis. During peritonitis, the addition of HA to the dialysis fluid reduced the loss of ultrafiltration, which resulted in a greater peritoneal creatinine clearance during the 8 hours of dwell (29.9 +/- 6.7 mL/8 h in the HA-LPS group versus 19.7 +/- 7.8 mL/8 h in the LPS group; P < 0.05). Dialysate interferon-gamma (INF-gamma) levels during peritonitis were greater in HA-treated animals (536.8 +/- 296.6 pg/mL in the HA-LPS group versus 169.8 +/- 137.8 pg/mL in the LPS group; P < 0.05). Dialysate elastase activity increased during peritonitis (44.4 +/- 9.3 versus 14.2 +/- 4.1 U/mL in peritonitis-free rats); during peritonitis, the increase in dialysate elastase activity was less pronounced in the rats that had HA in the dialysate (27.3 +/- 4.1 U/mL versus the LPS group; P: < 0.01). We conclude that HA added to the dialysis fluid reduces loss of ultrafiltration during peritonitis in rats. In the presence of HA dialysate, INF-gamma levels during peritonitis increased, whereas elastase activity decreased; these changes might improve the peritoneal immune reaction during peritonitis and at the same time prevent peritoneal membrane injury.

Evaluation and validation of virus removal by ultrafiltration during the production of diaspirin crosslinked haemoglobin (DCLHb)

Virus retention during ultrafiltration through A/G Technology filter cartridges was investigated to characterize the removal process and validate the degree of virus titre reduction during the filtration of red blood cell haemolysates performed as part of the production of diaspirin crosslinked haemoglobin (DCLHb). When viruses were suspended in phosphate buffered saline solution, retention was greater with larger sized viruses and smaller filter pore size. Virus titre was maintained at starting levels in the filter retentate circuit during the course of filtration, suggesting that the virus removal mechanism is predominantly size exclusion. Evaluation of specific processing variables indicated that the retention of phiX174 virus was increased in the presence of red blood cell haemolysate or at high membrane crossflow rates and transmembrane pressures, while the retention of EMC virus was less sensitive to variations in these parameters. Using these results to design a validation protocol, log reduction values of >7.9 were demonstrated for the retention of human immunodeficiency virus, pseudorabies virus and bovine viral diarrhoea viruses, 7.6 for hepatitis A virus, and 4.2 for porcine parvovirus. It was also shown that the retention of viruses was maintained during repetitive use of the same filter cartridge.

Patterns of predeath service use by dementia patients with a family caregiver

OBJECTIVE

To describe site of death and patterns of predeath service use (hospital, nursing home, and in-home services) among persons with dementia who have a family caregiver.

DESIGN

Family caregivers who experienced the death of their relative while participating in a 5-year longitudinal study were surveyed retrospectively about service use patterns in the 90 days before the death of their relative.

SETTING

Community.

SUBJECTS

Eighty-two family caregivers of a person with dementia who experienced the death of their relative while participating in a longitudinal study (n = 326) were included in this analysis. All participants were providing care to a relative with dementia in the home at entry into the study.

MAIN OUTCOME MEASURES

Survey items were used to identify site of death and measure use of the following services in the 90 days before death: hospital, nursing home, skilled nursing services, home health aides, and physician home visits.

RESULTS

Sixty-nine percent of the caregivers were spouses, and 28% were adult children. Family caregivers had been providing care for an average of 6 years (SD = 3.9) before the death of their relative. The most frequent setting for patient death was home (42%), followed by nursing home (32%) and hospital (26%). The average number of days spent at home in the 90 days before death by the sample was more than 60 days. Thirty-four percent of the dementia patients were cared for exclusively in the home in the 90 days before death, and 34% spent more than half of the 90 days before death at home. Hospital stays were brief, and less than one-fourth of the sample spent all of the 90 days before death in an institutional setting. Twenty-one percent of the sample used no in-home services in the 90 days before death, 48% of the sample did not use skilled nursing services, and only 27% received a physician home visit.

CONCLUSIONS

The results of this study suggest that dementia patients who have a family caregiver receive a significant proportion of their care at home in the 90 days before death. A hospice approach may help address the needs for assistance of families who provide terminal care in the home for a relative with dementia.

Osteoptysis: a complication of cervical spine surgery

The case is described of a lady who developed dysphagia and dysphonia misdiagnosed first as hysteria, then as myasthenia gravis, one year after a Cloward's operation for cervical disc disease. After a bout of coughing the bony dowel was expelled and the correct diagnosis was made.