British Society of Gastroenterology guidelines for the management of hepatocellular carcinoma in adults.

Deaths from the majority of cancers are falling globally, but the incidence and mortality from hepatocellular carcinoma (HCC) is increasing in the United Kingdom and in other Western countries. HCC is a highly fatal cancer, often diagnosed late, with an incidence to mortality ratio that approaches 1. Despite there being a number of treatment options, including those associated with good medium to long-term survival, 5-year survival from HCC in the UK remains below 20%. Sex, ethnicity and deprivation are important demographics for the incidence of, and/or survival from, HCC. These clinical practice guidelines will provide evidence-based advice for the assessment and management of patients with HCC. The clinical and scientific data underpinning the recommendations we make are summarised in detail. Much of the content will have broad relevance, but the treatment algorithms are based on therapies that are available in the UK and have regulatory approval for use in the National Health Service.

Digitally Recording Comfort Observations in the Last Days of Life.

Background: 37.5% of deaths in our area occur in hospital. There are known high unmet needs of adult patients dying in hospital, this unmet need can be reduced by using an individualised care plan and specialist palliative care review. Intervention: In 2022 UHSussex developed an electronic comfort observation chart and individualised care plan, with a centralised dashboard allowing Palliative Care Teams (SPCT) to view trends, target interventions, and a rolling prospective audit. Results: 3000 patients have had their care supported with electronic comfort observations (e-comfort obs). Over 72% of all deaths in the Trust in the last 3 months have been on e-comfort obs, with 2/3 of all deaths in the first 12 months on e-comfort obs. The average length of time on e-comfort obs is 4 days resulting in 70,000 sets of e-comfort obs recorded since launch. Seven percent of e-comfort obs record moderate or severe symptoms. We have identified benefits to people who are dying, those important to them, ward staff, SPCT and on a systems level. Conclusion: E-comfort obs can be successfully embedded in a large acute Trust. This development should improve quality of end of life care in our hospitals both for individuals and for future patients, through on-going targeted education and intervention. Further work is needed to develop the system further including integrating data from electronic prescribing.

Seeking Excellence in End of Life Care UK (SEECare UK): a UK multi-centred service evaluation.

OBJECTIVE: To evaluate the care of patients dying in hospital without support from specialists in palliative care (SPC), better understand their needs and factors influencing their care. METHODS: Prospective UK-wide service evaluation including all dying adult inpatients unknown to SPC, excluding those in emergency departments/intensive care units. Holistic needs were assessed through a standardised proforma. RESULTS: 88 hospitals, 284 patients. 93% had unmet holistic needs, including physical symptoms (75%) and psycho-socio-spiritual needs (86%). People were more likely to have unmet needs and require SPC intervention at a district general hospital (DGH) than a teaching hospital/cancer centre (unmet need 98.1% vs 91.2% p0.02; intervention 70.9% vs 50.8% p0.001) and when end-of-life care plans (EOLCP) were not used (unmet need 98.3% vs 90.3% p0.006; intervention 67.2% vs 53.3% p0.02). Multivariable analyses demonstrated the independent influence of teaching/cancer hospitals (adjusted OR (aOR)0.44 CI 0.26 to 0.73) and increased SPC medical staffing (aOR1.69 CI 1.04 to 2.79) on need for intervention, however, integrating the use of EOLCP reduced the impact of SPC medical staffing. CONCLUSION: People dying in hospitals have significant and poorly identified unmet needs. Further evaluation is required to understand the relationships between patient, staff and service factors influencing this. The development, effective implementation and evaluation of structured individualised EOLCP should be a research funding priority.

Influence of Water Hardness on Chronic Toxicity of Potassium Chloride to a Unionid Mussel (Lampsilis siliquoidea).

Elevated concentrations of potassium (K) often occur in effluents from wastewater treatment plants, oil and gas production operations, mineral extraction processes, and other anthropogenic sources. Previous studies have demonstrated that freshwater mussels are highly sensitive to K in acute and chronic exposures, and that acute toxicity of K decreases with increasing water hardness. However, little is known about the influence of hardness on the chronic toxicity of K. The objective of our study was to evaluate the chronic toxicity of K (tested as KCl) to a commonly tested unionid mussel (fatmucket, Lampsilis siliquoidea) at five hardness levels (25, 50, 100, 200, and 300 mg/L as CaCO3 ) representing most surface waters in the United States. Chronic 28-day K toxicity tests were conducted with 3-week-old juvenile fatmucket in the five hardness waters using an ASTM International standard method. The maximum acceptable toxicant concentrations (geometric mean of the no-observed-effect concentration and the lowest-observed-effect concentration) increased from 15.1 to 69.3 mg K/L for survival and from 15.1 to 35.8 mg K/L for growth (length and dry wt) and biomass when water hardness was increased from 25 mg/L (soft) to 300 mg/L (very hard). These results provide evidence to support water hardness influence on chronic K toxicity to juvenile fatmucket. However, the chronic effect concentrations based on the more sensitive endpoint (growth or biomass) increased only 2.4-fold from the soft water to the very hard water, indicating that water hardness had a limited influence on the chronic toxicity of K to the mussels. These results can be used to establish chronic toxicity thresholds for K across a broad range of water hardness and to derive environmental guideline values for K to protect freshwater mussels and other organisms. Environ Toxicol Chem 2023;42:1085-1093. Published 2023. This article is a U.S. Government work and is in the public domain in the USA.

Seeking Excellence in End of Life Care (SEE Care): A Multi-Centered Acute Hospitals Service Evaluation.

CONTEXT: A proportion of UK hospital inpatients have palliative care needs but do not access specialist services. OBJECTIVES: To contemporaneously evaluate the significance of unmet specialist palliative care needs within the hospital inpatient population. METHODS: Prospective multi-centered service evaluation was conducted through 4 snapshots across 4 acute NHS hospital trusts. All patients identified as dying in each hospital were included. Data extraction included symptom burden, medications and completion of care plans. RESULTS: End-of-life care plans were completed for 73%, symptom-focused prescribing present in 96%. Symptoms were not well managed for 22%, with 4% suffering moderate to severely. Specific intervention was triggered in 56% of patients, consisting of prescribing advice and holistic support. CONCLUSION: There are significant unmet specialist palliative care needs within the hospital inpatient population. Contemporaneous data collection coupled with an outreach approach helps palliative care services better understand the experiences of dying people, alongside where improvement is needed.

Method Development for a Short-Term 7-Day Toxicity Test with Unionid Mussels.

The US Environmental Protection Agency's short-term freshwater effluent test methods include a fish (Pimephales promelas), a cladoceran (Ceriodaphnia dubia), and a green alga (Raphidocelis subcapitata). There is a recognized need for additional taxa to accompany the three standard species for effluent testing. An appropriate additional taxon is unionid mussels because mussels are widely distributed, live burrowed in sediment and filter particles from the water column for food, and exhibit high sensitivity to a variety of contaminants. Multiple studies were conducted to develop a relevant and robust short-term test method for mussels. We first evaluated the comparative sensitivity of two mussel species (Villosa constricta and Lampsilis siliquoidea) and two standard species (P. promelas and C. dubia) using two mock effluents prepared by mixing ammonia and five metals (cadmium, copper, nickel, lead, and zinc) or a field-collected effluent in 7-day exposures. Both mussel species were equally or more sensitive (more than two-fold) to effluents compared with the standard species. Next, we refined the mussel test method by first determining the best feeding rate of a commercial algal mixture for three age groups (1, 2, and 3 weeks old) of L. siliquoidea in a 7-day feeding experiment, and then used the derived optimal feeding rates to assess the sensitivity of the three ages of juveniles in a 7-day reference toxicant (sodium chloride [NaCl]) test. Juvenile mussels grew substantially (30%-52% length increase) when the 1- or 2-week-old mussels were fed 2 ml twice daily and the 3-week-old mussels were fed 3 ml twice daily. The 25% inhibition concentrations (IC25s) for NaCl were similar (314-520 mg Cl/L) among the three age groups, indicating that an age range of 1- to 3-week-old mussels can be used for a 7-day test. Finally, using the refined test method, we conducted an interlaboratory study among 13 laboratories to evaluate the performance of a 7-day NaCl test with L. siliquoidea. Eleven laboratories successfully completed the test, with more than 80% control survival and reliable growth data. The IC25s ranged from 296 to 1076 mg Cl/L, with a low (34%) coefficient of variation, indicating that the proposed method for L. siliquoidea has acceptable precision. Environ Toxicol Chem 2021;40:3392-3409. © 2021 SETAC.

The Sensitivity of a Unionid Mussel (Lampsilis Siliquoidea) to a Permitted Effluent and Elevated Potassium in the Effluent.

Freshwater mussels are one of the most imperiled groups of animals in the world and are among the most sensitive species to a variety of chemicals. However, little is known about the sensitivity of freshwater mussels to wastewater effluents. The objectives of the present study were to (1) assess the toxicity of a permitted effluent, which entered the Deep Fork River, Oklahoma (USA), to a unionid mussel (Lampsilis siliquoidea) and to two standard test species (cladoceran Ceriodaphnia dubia; and fathead minnow Pimephales promelas) in short-term 7-day effluent tests; (2) evaluate the relative sensitivities of the three species to potassium (K), an elevated major ion in the effluent, using 7-day toxicity tests with KCl spiked into a Deep Fork River upstream reference water; (3) determine the potential influences of background water characteristics on the acute K toxicity to the mussel (96-h exposures) and cladoceran (48-h exposure) in four reconstituted waters that mimicked the hardness and ionic composition ranges of the Deep Fork River; and (4) determine the potential influence of temperature on acute K toxicity to the mussel. The effluent was found to be toxic to mussels and cladocerans, and it contained elevated concentrations of major cations and anions relative to the upstream Deep Fork River reference water. The K concentration in the effluent was 48-fold greater than in the upstream water. Compared with the standard species, the mussel was more than 4-fold more sensitive to the effluent in the 7-day effluent tests and more than 8-fold more sensitive to K in the 7-day K toxicity tests. The acute K toxicity to the mussel decreased by a factor of 2 when the water hardness was increased from soft (42 mg/L as CaCO3 ) to very hard (314 mg/L as CaCO3 ), whereas the acute K toxicity to the cladoceran remained almost the same as hardness increased from 84 to 307 mg/L as CaCO3 . Acute K toxicity to the mussel at 23 °C was similar to the toxicity at an elevated temperature of 28 °C. The overall results indicate that the two standard test species may not represent the sensitivity of the tested mussel to both the effluent and K, and the toxicity of K was influenced by the hardness in test waters, but by a limited magnitude. Environ Toxicol Chem 2021;40:3410-3420. Published 2021. This article is a U.S. Government work and is in the public domain in the USA.

A Dual-Center Observational Review of Hospital-Based Palliative Care in Patients Dying With COVID-19.

The current coronavirus disease 2019 (COVID-19) pandemic has put significant strain on all aspects of health care delivery, including palliative care services. Given the high mortality from this disease, particularly in the more vulnerable members of society, it is important to examine how best to deliver a high standard of end-of-life care during this crisis. This case series collected data from two acute hospitals examining the management of patients diagnosed with COVID-19 who subsequently died (n = 36) and compared this with national and local end-of-life audit data for all other deaths. Our results demonstrated a shorter dying phase (38.25 hours vs. 74 hours) and higher rates of syringe driver use (72% vs. 33% in local audits), although with similar average mediation doses. Of note was the significant heterogeneity in the phenotype of deterioration in the dying phase, two distinct patterns emerged, with one group demonstrating severe illness with a short interval between symptom onset and death and another group presenting with a more protracted deterioration. This brief report suggests a spectrum of mode of dying. Overall, the cohort reflects previously described experiences, with increased frailty (median Clinical Frailty Scale score of 5) and extensive comorbidity burden. This brief report provides clinicians with a contemporaneous overview of our experience, knowledge, and pattern recognition when caring for people with COVID-19 and highlights the value of proactive identification of patients and risk of deterioration and palliation.

Use of vacuum assisted closure therapy in the palliation of a malignant wound.

Vaccum assisted closure (VAC) therapy is a novel method of wound healing using topical negative pressure across the wound bed and containing all exudate within a sealed system. We report the use of VAC therapy to control pain and exudate of a malignant wound.