Development of a Palliative Care Toolkit for the COVID-19 Pandemic.

The Coronavirus disease 2019 (COVID-19) pandemic has led to high numbers of critically ill and dying patients in need of expert management of dyspnea, delirium, and serious illness communication. The rapid spread of severe acute respiratory syndrome-Coronavirus-2 creates surges of infected patients requiring hospitalization and puts palliative care programs at risk of being overwhelmed by patients, families, and clinicians seeking help. In response to this unprecedented need for palliative care, our program sought to create a collection of palliative care resources for nonpalliative care clinicians. A workgroup of interdisciplinary palliative care clinicians developed the Palliative Care Toolkit, consisting of a detailed chapter in a COVID-19 online resource, a mobile and desktop Web application, one-page guides, pocket cards, and communication skills training videos. The suite of resources provides expert and evidence-based guidance on symptom management including dyspnea, pain, and delirium, as well as on serious illness communication, including conversations about goals of care, code status, and end of life. We also created a nurse resource hotline staffed by palliative care nurse practitioners and virtual office hours staffed by a palliative care attending physician. Since its development, the Toolkit has helped us disseminate best practices to nonpalliative care clinicians delivering primary palliative care, allowing our team to focus on the highest-need consults and increasing acceptance of palliative care across hospital settings.

Emerging Collaborative Care Models for Dementia Care in the Primary Care Setting: A Narrative Review.

The rapidly increasing population living with dementia presents a unique economic and public health challenge. However, primary care physicians, despite their position as first-line providers, often lack the time, support, and training to systematically screen for, diagnose, and treat dementia, as well as provide adequate psychosocial support to unpaid caregivers. Models of collaborative care, which have found success in reducing symptom severity and increasing quality of life for other chronic illnesses, have been studied for feasibility, efficacy, and cost effectiveness in treating individuals with dementia and supporting caregivers. A review of initial data from several models suggests that enrollment in a collaborative care program for dementia is associated with benefits such as reduction in behavioral symptoms of dementia, improved functioning and quality of life, less frequent utilization of acute medical services, and decrease in caregiver burden. These evidence-based models, if implemented widely, stand to facilitate delivery of highly effective dementia care while reducing associated total medical expense. In this narrative review, we examine the key components of collaborative care teams, summarize outcomes of prior studies and discuss barriers and opportunities for wider dissemination of collaborative care models that are partnered with and/or based within primary care settings.

Contribution of HPC1 (RNASEL) and HPCX variants to prostate cancer in a founder population.

BACKGROUND: Prostate cancer is a genetically complex disease with locus and disease heterogeneity. The RNASEL gene and HPCX locus have been implicated in hereditary prostate cancer; however, their contributions to sporadic forms of this malignancy remain uncertain. METHODS: Associations of prostate cancer with two variants in the RNASEL gene (a founder mutation, 471delAAAG, and a non-synonymous SNP, rs486907), and with five microsatellite markers in the HPCX locus, were examined in 979 cases and 1,251 controls of Ashkenazi Jewish descent. Odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using logistic regression models. RESULTS: There was an inverse association between RNASEL rs486907 and prostate cancer in younger men (<65 years) and those with a first-degree relative with prostate cancer; men with AA genotype had ORs of 0.64 and 0.47 (both P < 0.05), respectively, in comparison to men with GG genotype. Within the HPCX region, there were positive associations for allele 135 of bG82i1.1 marker (OR = 1.77, P = 0.01) and allele 188 of DXS1205 (OR = 1.65, P = 0.02). In addition, allele 248 of marker D33 was inversely associated (OR = 0.65, P = 0.05) with Gleason score ≥7 tumors. CONCLUSIONS: Results suggest that variants in RNASEL contribute to susceptibility to early onset and familial forms of prostate cancer, whereas HPCX variants are associated with prostate cancer risk and tumor aggressiveness. The observation that a mutation predicted to completely inactivate RNASEL protein was not associated with prostate cancer, but that a missense variant was associated, suggests that the effect is due to either partial inactivation of the protein, and/or acquisition of a new protein activity.

Secondary hyperparathyroidism and anemia in children treated by hemodialysis.

BACKGROUND: Many patients treated using hemodialysis remain anemic despite exogenous erythropoietin therapy, suggesting that the anemia experienced by these patients is multifactorial in cause. Iron deficiency, infection, inflammation, and malnutrition have been implicated in this process. Additionally, secondary hyperparathyroidism has been associated with anemia in adults, but few data exist about this topic in children. STUDY DESIGN: Cross-sectional retrospective. SETTING & PARTICIPANTS: Children treated in hemodialysis centers (N = 588) within the Centers for Medicare & Medicaid Services' 2002 Clinical Performance Measures Project. PREDICTOR: Intact parathyroid hormone (iPTH) levels assessed in October, November, and December 2001 and categorized as quintiles. OUTCOMES & MEASUREMENTS: Achievement of serum hemoglobin level > or = 11 g/dL was assessed using Poisson regression adjusting for sex, age, race, dialysis vintage, vascular access type, single-pool Kt/V, serum albumin level, normalized protein catabolic rate, calcium-phosphorus product, and erythropoietin alfa dose. RESULTS: Using the second quintile (iPTH, 103-224 pg/mL) as the reference quintile, there was no association between iPTH quintile and achievement of the hemoglobin goal: quintile 1 prevalence ratio, 1.0 (95% CI, 0.9-1.2); quintile 3, 0.95 (95% CI, 0.8-1.1); quintile 4, 0.99 (95% CI, 0.8-1.2); and quintile 5, 0.97 (95% CI, 0.8-1.1). Only serum albumin level >/= 3.5 g/dL (bromocresol green assay method) or > or = 3.2 g/dL (bromocresol purple assay method) was significantly associated with meeting the hemoglobin goal: 1.4 (95% CI, 1.2-1.6). LIMITATIONS: The simultaneous collection of iPTH and hemoglobin limits causal inference. Iron stores and iron therapy are potential confounders not accounted for in this study. CONCLUSIONS: In the largest study of this topic in children, no association was found between iPTH level and achievement of a hemoglobin level > or = 11 g/dL. Serum albumin level was associated strongly with achievement of the hemoglobin goal.

Juvenile myelomonocytic leukemia presenting with facial nerve paresis: a unique presentation.

Juvenile myelomonocytic leukemia (JMML) is a distinct myeloproliferative malignancy of early childhood with a varied clinical presentation that may include failure to thrive, malaise, fever, bleeding, pallor, lymphadenopathy, and hepatosplenomegaly. Skin, pulmonary, and gastrointestinal involvement have also been reported. There are no reports of central nervous system (CNS) involvement at diagnosis of this disease. This is a report of a 21-month old boy who had a right facial paresis at presentation. A brain mass was demonstrated on magnetic resonance imaging and cerebrospinal fluid analysis confirmed CNS leukemic infiltration. We report the presence of CNS infiltration as a part of the natural course of JMML and provide a review of the literature.

Sexual health risks and protective resources in gay, lesbian, bisexual, and heterosexual homeless youth.

ISSUES AND PURPOSE: To compare sexual health risks and protective resources of homeless adolescents self-identified as gay (G), lesbian (L), or bisexual (B), with those self-identified as heterosexual, and to determine the differences between these two groups and the differences within the GLB group. DESIGN AND METHODS: A secondary analysis of survey data collected from a nonprobability sample of 425 homeless adolescents between 16 and 20 years of age. RESULTS: Sexual health risks and protective resources differed between those self-identified as GLB and those self-identified as heterosexual. More G/L youth reported a history of sexual abuse and being tested and treated for HIV, and more scored lower on the assertive communication measure than did bisexual or heterosexual youth. Moreover, there were gender differences within the GLB group; more males than females self-identified as homosexual and more females than males self-identified as bisexual. PRACTICE IMPLICATIONS: Sexual health interventions for this population should be both gender- and sexual orientation-specific.

Physical and transcript map of the hereditary prostate cancer region at xq27.

We have recently mapped a locus for hereditary prostate cancer (termed HPCX) to the long arm of the X chromosome (Xq25-q27) through a genome-wide linkage study. Here we report the construction of an approximately 9-Mb sequence-ready bacterial clone contig map of Xq26.3-q27.3. The contig was constructed by screening BAC/PAC libraries with markers spaced at approximately 85-kb intervals. We identified overlapping clones by end-sequencing framework clones to generate 407 new sequence-tagged sites, followed by PCR verification of overlaps. Contig assembly was based on clone restriction fingerprinting and the landmark information. We identified a minimal overlap contig for genomic sequencing, which has yielded 7.7 Mb of finished sequence and 1.5 Mb of draft sequence. The transcriptional mapping effort localized 57 known and predicted genes by database searching, STS content mapping, and sequencing, followed by sequence annotation. These transcriptional units represent candidate genes for HPCX and multiple other hereditary diseases at Xq26.3-q27.3.