91 To What Extent are Patients’ Future Care Preferences Shared Between Secondary and Primary Care? A Retrospective Chart Review

Introduction

When a doctor is informed of a patient’s future care preferences if they were to lose capacity, there is an ethical and legal obligation to share this information with the treating medical team. In frail older patients, conversations about treatment preferences often occur during hospital admission. We sought to assess the communication of these preferences to the patient’s GP.

Methods

Retrospective chart review of consecutive discharges from acute geriatric wards across seven hospitals. Records were excluded if the patient was admitted for less than 48 hours, was under orthogeriatric care, or died in hospital.

Results

339 notes were included, 41-50 from each hospital. GPs were informed of the resuscitation status of 28% of all patients. 52% of patients had an inpatient DNACPR, the GP was informed of 54% of these. 36% of patients had an inpatient ceiling of treatment documented, of which GPs were informed of 19%. 53% of hospital DNACPRs were converted into community DNACPRs on discharge: GPs were informed of only 24% of new community DNACRPs. 47% of patients discharged with a new community DNACPR lacked capacity to be involved in that decision; for just 6% of these was the GP asked to review the DNACPR order in the community. Inpatient Advance Care Planning (ACP) discussions were held for 9% of patients, of which the GP was informed in 59% of cases. 49% of ACP conversations involved the next-of-kin but not the patient. Among patients who had a new DNACPR decision made during their admission (n=124), there was documentary evidence in only 25% that the patient or next-of-kin was informed whether this was time-limited or indefinite.

Conclusions

Communication from hospitals to GPs about resuscitation, ceiling of care and ACP discussions is very limited. For patients who have expressed ongoing future care preferences, there is a legal obligation to share this information with the treating medical team, which on discharge is the GP.

There is poor documentary evidence of discussions with patients about whether DNACPR decisions are time-limited or indefinite. Furthermore, many hospitalised frail patients lack capacity to make DNACPR decisions but they may subsequently regain capacity, particularly those with delirium. Despite this, GPs are rarely asked to review new community DNACPRs, including those made for patients without capacity.

95 Goals-Of-Care and Advance Care Planning Discussions with Hospitalised Frail Older People: What is the Evidence?

Introduction

National guidelines suggest that patients in the last year of life should be identified, their prognosis and future care options discussed, with advance care planning (ACP) recorded. Goals-of-care should be discussed with hospitalised patients at risk of deteriorating or with life-limiting conditions. The stated purpose of ACP and goals-of-care discussions is to increase goal-concordant care (i.e. patients receiving treatments they would wish to receive, and not receiving those they would not want). This literature review investigates the evidence-base for these policies and outcomes.

Review question

What is the evidence for goals-of-care and ACP discussions with hospitalised frail older people?

Methods

Systematic literature review and narrative synthesis. Electronic search of MEDLINE, CINAHL, ASSIA, PsycINFO, and Embase databases from January 1990 to September 2017. An updated search until May 2019 is currently underway.

Results

Of 8077 unique articles identified, 17 met inclusion criteria. There is no evidence that goals-of-care discussions lead to increased goal-concordant care; there is observational evidence that they increase the accuracy of documented preferences. Currently, rates of goals-of-care discussions are variable (38-72%), and there is poor concordance between patients’ actual and documented preferences, with agreement in only 31-33% of cases.

Present rates of ACP are very low (0-3%), with mixed evidence for benefits of ACP. One single-centre randomised controlled trial suggests ACP improves outcomes for patients who die within 6 months of discharge, including increased goal-concordant care and reduced family distress.

There is very limited evidence concerning patients’ and family members’ experiences of these discussions, their reasons for wishing (or not) to participate in discussions, or their perceptions of the important outcomes. Most (80%) patients would like to be involved in decisions about their care; 48% consider these conversations very important. The views and experiences of healthcare professionals have been little studied.

Conclusions

The asserted aim of goals-of-care and ACP discussions is to increase goal-concordant care; the extent to which this reflects patients’ priorities is unknown. In younger patient populations, while 40% of patients consider goal-concordant care the most important outcome, one third of patients consider family-related outcomes to be more important. Further research is needed to understand the perspectives of frail older patients, their families and clinicians, in order to make these discussions and subsequent care truly patient-centred.

A versatile dual-species Zeeman slower for caesium and ytterbium

We describe the design, construction, and operation of a versatile dual-species Zeeman slower for both Cs and Yb, which is easily adaptable for use with other alkali metals and alkaline earths. With the aid of analytic models and numerical simulation of decelerator action, we highlight several real-world problems affecting the performance of a slower and discuss effective solutions. To capture Yb into a magneto-optical trap (MOT), we use the broad (1)S0 to (1)P1 transition at 399 nm for the slower and the narrow (1)S0 to (3)P1 intercombination line at 556 nm for the MOT. The Cs MOT and slower both use the D2 line (6(2)S1/2 to 6(2)P3/2) at 852 nm. The slower can be switched between loading Yb or Cs in under 0.1 s. We demonstrate that within a few seconds the Zeeman slower loads more than 10(9) Yb atoms and 10(8) Cs atoms into their respective MOTs. These are ideal starting numbers for further experiments on ultracold mixtures and molecules.

Production and characterization of a dual species magneto-optical trap of cesium and ytterbium

We describe an apparatus designed to trap and cool a Yb and Cs mixture. The apparatus consists of a dual species effusive oven source, dual species Zeeman slower, magneto-optical traps in a single ultra-high vacuum science chamber, and the associated laser systems. The dual species Zeeman slower is used to load sequentially the two species into their respective traps. Its design is flexible and may be adapted for other experiments with different mixtures of atomic species. The apparatus provides excellent optical access and can apply large magnetic bias fields to the trapped atoms. The apparatus regularly produces 10(8) Cs atoms at 13.3 μK in an optical molasses, and 10(9) (174)Y b atoms cooled to 22 μK in a narrowband magneto-optical trap.

Optimisation of patient dose for the horizontal beam technique in lateral lumbar spine radiographic examinations

In the emergency department, patients undergoing lateral lumbar spine radiography examinations are positioned either lying on their side on an X-ray table with the X-ray beam vertical or lying supine on a trolley with the X-ray beam horizontal. The measured dose-area product (DAP) values were found to differ significantly, typically 1.3 Gy cm(2) for those patients examined on the X-ray table and 2.7 Gy cm(2) for those on a trolley. This work investigates the reason for higher DAP values with the horizontal beam technique. The UK's current recommended national diagnostic reference level (NDRL) for the lateral lumbar spine is 2.5 Gy cm(2). The measurements of body diameter on volunteers showed that rotating the patients from their side to their back resulted in an increase in tissue thickness of between 2 cm and 9 cm for the lumbar region. X-ray absorption increases exponentially with increasing tissue thickness. An increase of 5 cm in body diameter for a lateral lumbar spine at 93 kV will increase the DAP by more than two-fold. Mathematical modelling and measurements with polymethyl methacrylate provided data to predict the tube potential increase necessary to reduce the DAP. For the horizontal beam technique, the tube potential was increased from 93 kV to 102 kV and the average DAP reduced to 2.3 Gy cm(2). Radiographic technique should be understood when auditing the dose. Tube potential must be increased to optimise the horizontal beam technique. The 2.5-Gy cm(2) NDRL relates predominantly to the more common vertical beam technique. Separate local diagnostic reference levels for horizontal and vertical beam techniques are recommended.

Magnetic transport apparatus for the production of ultracold atomic gases in the vicinity of a dielectric surface

We present an apparatus designed for studies of atom-surface interactions using quantum degenerate gases of (85)Rb and (87)Rb in the vicinity of a room temperature dielectric surface. The surface to be investigated is a super-polished face of a glass Dove prism mounted in a glass cell under ultra-high vacuum. To maintain excellent optical access to the region surrounding the surface, magnetic transport is used to deliver ultracold atoms from a separate vacuum chamber housing the magneto-optical trap (MOT). We present a detailed description of the vacuum apparatus highlighting the novel design features; a low profile MOT chamber and the inclusion of an obstacle in the transport path. We report the characterization and optimization of the magnetic transport around the obstacle, achieving transport efficiencies of 70% with negligible heating. Finally, we demonstrate the loading of a hybrid optical-magnetic trap with (87)Rb and the creation of Bose-Einstein condensates via forced evaporative cooling close to the dielectric surface.

Off-resonance laser frequency stabilization using the Faraday effect

We present a simple technique for stabilization of a laser frequency off resonance using the Faraday effect in a heated vapor cell with an applied magnetic field. In particular, we demonstrate stabilization of a 780 nm laser detuned up to 14 GHz from the (85)Rb D(2) 5(2)S(1/2) F = 2 to 5(2)P(3/2) F' = 3 transition. Control of the temperature of the vapor cell and the magnitude of the applied magnetic field allows locking ~6-14 GHz red and blue detuned from the atomic line. We obtain an rms fluctuation of 7 MHz over 1 h without stabilization of the cell temperature or magnetic field.

Lipid differences in rod outer segment membranes of rats with P23H and S334ter opsin mutations

PURPOSE

Retinal degenerations and diets low in n-3 fatty acids are associated with decreased docosahexaenoic acid (22:6n-3) in retina and plasma and with sterol abnormalities in retina and sperm. Using wild type (WT) and transgenic rats with P23H and S334ter opsin mutations, we evaluated retinal cholesterol levels, cholesterol synthesis, and fatty acid compositions of phospholipid classes in animals fed diets enriched in n-3 or n-6 polyunsaturated fatty acids.

METHODS

Pregnant WT and heterozygous P23H and S334ter transgenic (TG) rats were fed safflower (safflower oil [SO], high n-6, trace n-3 fatty acids) or flaxseed oil (flaxseed oil [FO], high n-3, moderate n-6 fatty acids) diets beginning at E15, and pups were continued on the diets after weaning. Rod outer segment (ROS) membranes were prepared from 55-day-old rats, and the ratios of total fatty acid to cholesterol and the fatty acid compositions of phosphatidylcholine (PC), phosphatidylethanolamine (PE), and phosphatidylserine (PS) in ROS were determined. Intravitreal injections of [3H]acetate were given to 35-day-old WT and TG rats fed standard chow-diets. Endogenous cholesterol mass and de novo [3H]cholesterol synthesis were measured and normalized to total ROS fatty acid content. Multivariate analysis of variance (ANOVA) with post hoc Newman-Keuls tests were used to determine statistical differences.

RESULTS

The relative levels of PC, PE, and PS were similar in all three rat strains independent of diet. Total lipids, PC, PS, and PE of ROS FO fed rats had higher levels of 22:6n-3 and lower levels of 22:5n-6 than those fed SO. Rats fed SO had higher levels of 22:5n-6 than those fed FO. Significant increases in 18:1n-9 were seen in PC and PS of P23H and S334ter rats; arachidonate (20:4n-6) increased only in PE. These changes were independent of diet. ROS membranes of transgenic rats were cholesterol enriched, relative to WT ROS, yet retinal cholesterol synthesis was not altered. Plasma cholesterol levels of transgenic rats were not different from those of WT rats.

CONCLUSIONS

Endogenous levels of cholesterol, 18:1n-9, 20:4n-6, 22:5n-6, and 22:6n-3 were altered in ROS membranes of P23H and S334ter compared to WT rats. There appear to be two pools of 22:6n-3 in rat ROS, one that is sensitive to retinal degenerations and one that is not. The stress induced reduction in 22:6n-3 was not specific to any phospholipid class and was not caused by alteration of relative amounts of PC, PS, or PE in the membrane. Elevated retinal cholesterol may be a result of either an increased half life or an increased uptake of cholesterol from the blood.

Experimental observation of a superfluid gyroscope in a dilute Bose-Einstein condensate

We have observed a three-dimensional gyroscopic effect associated with a vortex in a dilute Bose-Einstein condensed gas. A condensate with a vortex possesses a single quantum of circulation, and this causes the plane of oscillation of the scissors mode to precess around the vortex line. We have measured the precession rate of the scissors oscillation. From this we deduced the angular momentum associated with the vortex line and found a value close to Planck's over 2pi per particle, as predicted for a superfluid.

Docosahexaenoic, arachidonic, palmitic, and oleic acids are differentially esterified into phospholipids of frog retina

Docosahexaenoic acid (22:6n-3) is highly enriched in the retina. To determine if retinal cells take up and metabolize fatty acids in a specific manner, retinas from Rana pipiens were incubated for 3 h with an equimolar mixture of tritiated 22:6n-3, arachidonic acid (20:4n-6), palmitic acid, and oleic acid. The radiolabeling of retinal lipids was determined and compared to the endogenous fatty acid content of the lipids. The results showed that in most, but not all, cases, the relative labeling with the four precursor fatty acids was similar to their relative abundance in each glycerolipid. Thus, during retinal glycerolipid synthesis, either through de novo or acyl exchange reactions, fatty acids are incorporated in proportions reflecting their steady-state mass levels. Since other studies with labeled glycerol have shown greater differences between early labeling patterns and molecular species mass, the final incorporation we report may be due primarily to acyl exchange reactions.

Direct observation of irrotational flow and evidence of superfluidity in a rotating Bose-Einstein condensate

We have observed the expansion of vortex-free, rotating Bose condensates after their sudden release from a slowly rotating anisotropic trap. Conservation of angular momentum, combined with the constraint of irrotational flow, cause the rotating condensate to expand in a distinctively different way to one released from a static (nonrotating) trap. This difference provides clear experimental evidence of the purely irrotational velocity field associated with a superfluid. We observed this behavior in absorption images taken along the rotation axis.

Vortex nucleation in Bose-Einstein condensates in an oblate, purely magnetic potential

We have investigated the formation of vortices by rotating the purely magnetic potential confining a Bose-Einstein condensate. We modified the bias field of an axially symmetric TOP trap to create an elliptical potential that rotates in the radial plane. This enabled us to study the conditions for vortex nucleation over a wide range of eccentricities and rotation rates.

Observation of the scissors mode and evidence for superfluidity of a trapped bose-einstein condensed Gas

We report the observation of the scissors mode of a Bose-Einstein condensed gas of 87Rb atoms in a magnetic trap, which gives direct evidence of superfluidity in this system. The scissors mode of oscillation is excited by a sudden rotation of the anisotropic trapping potential. For a gas above T(c) (normal fluid) we detect the occurrence of oscillations at two frequencies, with the lower frequency corresponding to the rigid body value of the moment of inertia. Well below T(c) the condensate oscillates at a single frequency, without damping, as expected for a superfluid.

A recombinant Salmonella typhimurium vaccine strain is taken up and survives within murine Peyer's patch dendritic cells

The attenuated Salmonella typhimurium PhoPc strain is avirulent but immunogenic via the oral route in mice and is attenuated in survival in macrophage cell lines. In this study, the fate of PhoPc bacteria expressing green fluorescent protein was investigated in murine Peyer's patches. The survival of PhoPc was monitored after orogastric inoculation of BALB/c mice. Bacteria persisted for several weeks in the Peyer's patches and were also recovered from the mesenteric lymph nodes and spleen. Confocal microscopy analysis identified dendritic cells as the Peyer's patch cell type that internalized PhoPc expressing green fluorescent protein at early time points. In addition, live PhoPc were found in Peyer's patch dendritic cells and not in B cells 3 days after orogastric inoculation. Taken together, these results provide strong evidence that PhoPc is internalized and survives within Peyer's patch dendritic cells. As these cells are potent antigen-presenting cells, these data could explain the immunogenicity of S. typhimurium vaccine strains in vivo.

Antigen sampling by epithelial tissues: implication for vaccine design

Mucosal surfaces of the respiratory, digestive and urogenital tracts are covered by a specialized epithelium which constitutes an efficient physical barrier against environmental pathogens. These surfaces differ greatly in their cellular organisation and in antigen sampling. In stratified epithelia, professional antigen-presenting cells, the dendritic cells or Langerhans cells, are intimately associated with the epithelial barrier and take up samples of foreign material from the external environment which they transport to local or distant organized lymphoid tissues. In simple epithelia highly specialised cells, the so-called M cells, sample foreign material and microorganisms and deliver them by transepithelial transport from the lumen to the underlying organized lymphoid tissue (MALT). The interaction of lymphocytes with the follicle-associated epithelium (FAE) is responsible for the loss of digestive functions and the acquisition of transepithelial transport activity. The three way interaction of epithelium, lymphoid cells, and microorganisms seen in the FAE which controls the formation of MALT provides a dramatic demonstration of the phenotypic plasticity of the intestinal epithelium and probably of all simple epithelia. We have shown that all mucosal surfaces, covered by stratified or simple epithelia are able to sample and transport live recombinant bacterial vaccines, which elicit systemic and local immune responses against the carrier and the foreign antigen. In gut and nasal-associated lymphoid tissue, Salmonella are taken up by dendritic cells which form a dense cellular network in the dome regions of MALT. Targeting bacterial vaccine candidates to dendritic or M cells is likely to facilitate their sampling by epithelial tissues and to contribute to strong mucosal and systemic immune responses.

The prevalence of bulimia nervosa in the US college student population

A phone survey to determine the prevalence of bulimia nervosa was conducted with a national probability sample of 1,007 male and female students from a stratified sample of 53 universities and colleges in the continental United States. Using the revised (DSM IIIR) diagnostic criteria, 1 per cent of the women and 0.2 per cent of the men were classified as bulimic. Bulimia was most prevalent (2.2 per cent prevalence rate) among undergraduate women living in group housing on campus.