During the Covid-19 pandemic, remote consultations were widely adopted. However, the evidence base is limited and the role in palliative care settings remains to be established.1 At Royal Trinity Hospice, the majority of face-to-face community visits changed to telephone consultations from March 2020. The primary aim of this service evaluation was to assess patient and staff satisfaction with telephone consultations.
Methods
Patients (n=181) and staff (n=32) who participated in telephone consultations between 1st August and 30th November were identified from electronic patient records. Questionnaires were sent to staff by email and to patients by email or post. Questionnaires were anonymised and analysed using descriptive statistics and thematic analysis.
Results
Response rates were 20% for patients and 34% for staff. Of the patient questionnaires, 22% were completed by carers. Overall, 31% of patients reported that they had good technology skills. Only one patient (3%) experienced technical difficulties, whereas 84% felt comfortable with the convenience and experience of telephone consultations. Only 24% of patients preferred telephone to face-to-face consultations. A higher proportion of staff expressed confidencein use of technology (73%). Staff satisfaction with telephone consultations was high - including effectiveness (73%), convenience (64%), rapport building (73%) and safe assessment (64%). Half of patients and 90% of staff reported situations in which telephone consultations were not appropriate (e.g. patients with cognitive or sensory impairments). Staff expressed more positive views than patients regarding future use of video consultations. Key themes from analysis of qualitative data included telephone consultations as a positive method of communication, limitations for those with cognitive or sensory impairments, and a preference for face-to-face consultations.
Conclusions
This project demonstrated high levels of patient and staff satisfaction with telephone consultations. Sensory and cognitive impairments were identified as barriers. This project continues to inform the remodelling of Hospice community services.
Increasing evidence points to the functional importance of alternative splice variations in cancer pathophysiology. Two splice variants are derived from the CASP9 gene via the inclusion (Casp9a) or exclusion (Casp9b) of a four exon cassette. Here we show that alternative splicing of Casp9 is dysregulated in non‐small cell lung cancers (NSCLC) regardless of their pathological classification. Based on these findings we hypothesized that survival pathways activated by oncogenic mutation regulated this mechanism. In contrast to K‐RasV12 expression, EGFR overexpression or mutation dramatically lowered the Casp9a/9b splice isoform ratio. Moreover, Casp9b downregulation blocked the ability of EGFR mutations to induce anchorage‐independent growth. Furthermore, Casp9b expression blocked inhibition of clonogenic colony formation by erlotinib. Interrogation of oncogenic signaling pathways showed that inhibition of PI3K or Akt dramatically increased the Casp9a/9b ratio in NSCLC cells. Finally, Akt was found to mediate exclusion of the exon 3,4,5,6 cassette of Casp9 via the phosphorylation state of the RNA splicing factor SRp30a via serines 199, 201, 227 and 234. Taken together, our findings demonstrate that oncogenic factors activating the PI3Kinase/Akt pathway can regulate alternative splicing of Casp9 via a coordinated mechanism involving the phosphorylation of SRp30a.
There are many recognised challenges for people experiencing homelessness in accessing palliative and end of life care services, despite a high burden of complex needs among this population. These challenges include navigating complex healthcare systems, managing unstable housing situations, and previous negative experiences with healthcare services (Schulman, Hudson, Low, et al. Palliat Med. 2018; 32(1): 36–45). Health needs among this patient group often include drug and/or alcohol dependence and mental health problems in association with physical health issues (known as 'tri-morbidity') (Himsworth, Paudyal, Sargeant. Br J Gen Pract. 2020; 70(695): e406–e411). Prognosis may be uncertain and professionals working with those experiencing homelessness may not have the appropriate training to identify those who are approaching the end of life (Marie Curie. Care for people experiencing homelessness in palliative care. [Internet]).
Aims
The aim of this service evaluation is to describe and evaluate an outreach service established at a hospice in London to support residents and members of staff at two local homeless hostels.
Methods
The hospice homelessness group is a team of cross-department staff members who collaboratively developed an outreach programme with the aim to improve the quality of palliative and end of life care provided to patients experiencing homelessness in our local community. The work primarily focused on two homeless hostels, and included direct clinical care, informal 'pre-referral' support regarding patients hesitant to be formally referred, regular MDT attendance, community outreach work with hostel staff and residents and an education programme for hostel staff. This service evaluation will outline the results of qualitative and quantitative feedback from hostel residents and staff members.
Results
The results of this project will be presented as an evaluation of our service on behalf of patients and members of staff.
Conclusions
The hospice outreach programme will continue to be developed in light of feedback obtained. Further conclusions will follow depending on the results of the service evaluation.
Treatment escalation plans (TEP) are a tool to promote advance care planning, appropriate decision making and good communication between professionals, patients and carers, in line with national guidelines.1 2 In 2018, this Trust introduced guidance that all patients at risk of acute deterioration and/or with a National Early Warning Score (NEWS) of 5 should have a TEP.
Aim
To assess the proportion of patients on the palliative care caseload with a TEP and/or DNACPR decision in place over a three-month period.
Methods
The palliative care caseload was reviewed weekly between December 2018 and March 2019. Two audit standards were set with a target of 100% compliance: Completion of a TEP Documented decision regarding CPR
Results
The total sample size was 545 patients. Whilst the mean compliance with the audit standard for TEP was low (40%), over the three-month audit period there was an increase from 25% to 50%. Medical wards had a higher proportion of patients with a TEP (43%), compared with surgery (35%), ITU (33%) and oncology/haematology (31%). The proportion of patients with a documented decision regarding CPR status was high throughout (98%).
Conclusions
Reasons for the increase in uptake of TEP may include increased awareness resulting from the audit process, and the focus on TEP as a priority within the Trust. The results were disseminated at divisional level and to the Deteriorating Adults Governance Group. Recommendations include TEP 'champions' to share examples of best practice, targeted education sessions, adopting appropriate use of TEP as a key quality indicator for the Trust and replacing the paper TEP form with an online version as part of the electronic patient record system. The audit will be repeated in 9–12 months to assess the impact of these interventions.
References
Bailey S and Cogle K. Talking about dying. Royal College of Physicians. October 2018. National Palliative and End of Life Care Partnership. Ambitions for palliative and end of life care: a national framework for local action 2015–2020. 2015.
Increasing evidence points to the functional importance of alternative splice variations in cancer pathophysiology with the alternative pre-mRNA processing of caspase 9 as one example. In this study, we delve into the underlying molecular mechanisms that regulate the alternative splicing of caspase 9. Specifically, the pre-mRNA sequence of caspase 9 was analyzed for RNA cis-elements known to interact with SRSF1, a required enhancer for caspase 9 RNA splicing. This analysis revealed 13 possible RNA cis-elements for interaction with SRSF1 with mutagenesis of these RNA cis-elements identifying a strong intronic splicing enhancer located in intron 6 (C9-I6/ISE). SRSF1 specifically interacted with this sequence, which was required for SRSF1 to act as a splicing enhancer of the inclusion of the 4 exon cassette. To further determine the biological importance of this mechanism, we employed RNA oligonucleotides to redirect caspase 9 pre-mRNA splicing in favor of caspase 9b expression, which resulted in an increase in the IC(50) of non-small cell lung cancer (NSCLC) cells to daunorubicin, cisplatinum, and paclitaxel. In contrast, downregulation of caspase 9b induced a decrease in the IC(50) of these chemotherapeutic drugs. Finally, these studies showed that caspase 9 RNA splicing was a major mechanism for the synergistic effects of combination therapy with daunorubicin and erlotinib. Overall, we have identified a novel intronic splicing enhancer that regulates caspase 9 RNA splicing and specifically interacts with SRSF1. Furthermore, we showed that the alternative splicing of caspase 9 is an important molecular mechanism with therapeutic relevance to NSCLCs.
Abstract : The overall objective of this project was to field demonstrate and evaluate the effectiveness of two technologies for characterizing coastal contaminate migration. The specific objectives of this demonstration were to demonstrate (1) that the Trident probe can be used to help delineate areas where groundwater seepage is occurring and Contaminant of Concern concentrations in those areas, (2) that the UltraSeep system can be used to quantify the flow of groundwater and concentration of contaminants that may be impinging on the surface water system, (3) the technology to end-users to determine the utility of these tools for making decisions at DoD coastal landfills and hazardous waste sites, and (4) the quantification of the costs associated with the operation of each technology. The first demonstration was at Naval Support Activity Panama City. The Trident probe was used successfully to identify areas of groundwater discharge from the site to the surface waters of St. Andrews Bay, and the UltraSeep was used successfully to quantify groundwater discharge rates and volatile organic compound (VOC) discharge concentrations in two discharge zones identified with the Trident probe. The second demonstration was performed at the former Naval Training Center Orlando. The Trident probe successfully identified areas of groundwater discharge from the site to the surface waters of Druid Lake and the UltraSeep successfully quantified groundwater discharge rates and VOC discharge concentrations in two discharge zones identified with the Trident probe. The cost analysis indicated that the cost of an integrated Trident probe/UltraSeep survey is expected to be on the order of $120K, which represents a cost savings of about 42% relative to the estimated cost for the baseline technology of about $210K.
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