Exploring the Psychological Aspects of Palliative Care: Lessons Learned from an Interdisciplinary Seminar of Experts.

Palliative care has been shown to help patients live well with serious illness, but the specific psychological factors that contribute to this benefit remain investigational. Although support of patient coping has emerged as a likely factor, it is unclear how palliative care helps patients to cope with serious illness. The therapeutic relationship has been proposed as a key element in beneficial patient outcomes, possibly undergirding effective patient and family coping. Understanding the distress of our patients with psychological depth requires the input of varied clinicians and thinkers. The complex conceptual model we developed draws upon the contributions of medicine, nursing, psychology, spiritual care, and social work disciplines. To elucidate these issues, we convened an interdisciplinary seminar of content experts to explore the psychological components of palliative care practice. "Healing Beyond the Cure: Exploring the Psychodynamic Aspects of Palliative Care" was held in May 2019 at Harvard University's Radcliffe Institute for Advanced Study. Over two days, the working group explored these essential elements of successful palliative care encounters through lecture and open discussion. This special report describes the key psychological aspects of palliative care that we believe underlie optimal adaptive coping in palliative care patients. We also outline key areas for further development in palliative care research, education, and clinical practice. The discussion held at this meeting became the basis for a planned series of articles on the psychological elements of palliative care that will be published in the Journal of Palliative Medicine on a monthly basis during the fall and winter of 2021-2022.

When the Fight Becomes Personal: Physicians Share Their Stories of Contracting COVID-19.

It's no surprise that many physicians were among the more than 1.3 million confirmed COVID-19 cases in Texas last year. Texas Medicine spoke with three Texas physicians who contracted COVID-19 to learn how the disease affected them physically and impacted their outlook as caregivers.

Q&A: Stethoscopes and Telescopes.

Ever since he was a boy, Temple family physician John Manning, MD, has been fascinated by space. Now, Dr. Manning is also an amateur photographer. About 10 years ago, he merged his interests in photography and space into his latest obsession: astrophotography.

Therapeutic Holding.

Relationships of care for those facing illness are inherent to the practice of medicine. Palliative care provides interpersonal space to patients and families that helps them face serious illness and dying. We consider therapeutic holding uniquely critical in palliative care but see it as applying in varied forms throughout medicine. Its optimization requires a deep understanding of its nature. We use theoretical foundations of psychodynamic therapy, which uses the therapeutic relationship as its sole intervention, to identify the key elements of palliative care's therapeutic holding. We draw together six major concepts to do so. Using a fairly typical case, we illustrate how a palliative care team that included a psychodynamic therapist created therapeutic holding. This article came as part of a discussion group about psychodynamic cases involving serious illness and evolved in discussion with the rest of the authors. Northwestern's Institutional Review Board (IRB) exempted this project. This case is anonymized; sociodemographic and specific illustrations are changed. This case exemplifies how psychodynamic theory discerns and describes elements of palliative care's therapeutic holding. The case further illuminates the important place of therapeutic holding in effective palliative care and shows how psychodynamic therapy can help. We urge further research on therapeutic holding in palliative care.

Q&A: Physician Podcaster Jeffrey Jarvis, MD.

A love of teaching is what propelled Jeffrey Jarvis, MD, into his latest undertaking: hosting a nationally distributed podcast.

Q&A: Food Allergies in Children a Public Health Problem.

Ask Austin allergist Allen Lieberman, MD, which public health issue hasn't received the attention it deserves, and his answer shouldn't be a surprise. "Eight percent of kids have a food allergy," Dr. Lieberman, who founded Austin Family Allergy and Asthma in 2016, told Texas Medicine. "It's literally a food-allergy epidemic right now."

Q&A: El Paso Surgeon On-Call During Mass Shooting Response.

Just as Alan Tyroch, MD, sat down to breakfast in Las Vegas on the morning of Aug. 3, celebrating his mother in-law's 90th birthday, a gunman walked into a Walmart hundreds of miles away in his hometown of El Paso and opened fire, ultimately killing 22 people and injuring 24 more. Over the following minutes, as shooting victims were rushed to hospitals throughout El Paso, Dr. Tyroch - chief of surgery and trauma medical director at University Medical Center of El Paso - was coordinating and delegating duties via text to the hospital's numerous surgeons, physicians, residents, and other health care professionals.

Q&A: Hard Hats for Little Heads Advocates Alan Howell, MD, and Martha Howell.

Promoting public health initiatives in local communities can help physicians build relationships with the people they care for every day. Martha Howell and her husband, infectious disease specialist Alan Howell, MD, have taken that idea a few steps further with Hard Hats for Little Heads.

Q&A: Lubbock Radiologist Finds Creative Ways to Introduce Science to Children.

For the past few years, Eman Attaya, MD, has channeled her pragmatic and artistic sides in a variety of ways. She is a member of the 2019 class of the Texas Medical Association's Leadership College, which helps train young physicians, or those early in their medical careers, for leadership positions at the county and state levels. Dr. Attaya plans to use the experience to help improve science education in Lubbock elementary schools.

Q&A: Austin Family Physician Quenches Her Patients' Thirst for Improved Health.

Austin primary care physician Georgeanne Freeman, DO, aims to improve her patients' overall well-being while increasing and diversifying the clinic's revenue.

A Conversation With Travis County Chief Medical Examiner J. Keith Pinckard, MD.

Texas Medicine recently caught up with Dr. Pinckard, who has been the chief medical examiner at the Travis County Medical Examiner's Office since 2015.

Q&A: Thomas Kim, MD, Internist, Psychiatrist, Telehealth Advocate.

Thomas Kim, MD, is an avid user and advocate of telehealth, and the Austinite regularly shares his expertise and experience with fellow physicians and state lawmakers. "If you recognize telehealth as a skill to be mastered, you can apply it to most any population you want," he said.

Texas Cardiologist Recalls Boston Marathon Bombing.

When two pressure-cooker bombs filled with nails, ball bearings, and black powder exploded at the finish line of the 2013 Boston Marathon, killing three people and wounding hundreds more, Jorge Alvarez, MD, did what he believes anybody would do: Run toward the danger.

Q&A.

Medical director, Department of State Health Services Office of Science and Population Health.

This Surgeon Puts Broken Spurs Back in the NBA Saddle.

David R. Schmidt, MD, team physician for the San Antonio Spurs.

Upper airways sensory irritation responses of mice exposed to mainstream smoke from four cigarette types.

Relative sensory irritation responses for Swiss-Webster mice exposed nose-only to mainstream tobacco smoke were evaluated for several cigarette types using a smoking regimen consisting of a 35-ml puff, 2 s in duration, taken once per minute. The degree of sensory irritation for each cigarette type was evaluated as the smoke concentration inducing a 50% reduction in breathing frequency. The smoke concentration inducing 50% respiratory depression is called the RD(50) value. Study findings suggest that mainstream tobacco smoke from the Eclipse cigarette, which primarily heats rather than burns tobacco, yielded an RD(50) that was significantly higher (approximately twofold) than a tobacco-burning leading ultralight or the 2R4F or 1R5F reference cigarettes. This is indicative of reduced upper airways irritation by Eclipse that may be due to its distinct design. Study findings suggest that the irritating nature of mainstream tobacco smoke from different cigarette types can be evaluated effectively in terms of smoke concentration using the relative sensory irritation assessment. These findings constitute the first report about use of the RD(50) sensory irritation response during comparative evaluations of mainstream tobacco smoke.

Distinct regulatory profiles of interleukins and chemokines in response to cigarette smoke condensate in normal human bronchial epithelial (NHBE) cells.

Bronchial epithelium is frequently exposed to air pollutants, and it is hypothesized that these cells elicit inflammatory responses as early elements in pulmonary defense. Our purpose was to evaluate changes in messenger RNA levels of 84 genes representing cytokines and receptors over a repetitive-exposure time course to further define the inflammatory responses associated with mainstream cigarette smoke (MSS) exposure in an in vitro lung model. Normal human bronchial epithelial cells were treated with mainstream cigarette smoke condensate (CSC) prepared from Kentucky 2R4F cigarettes (60 microg total particulate matter/mL media, 0.2% dimethylsulfoxide), and examined by quantitative real-time polymerase chain reaction. Applications of CSC were designed in seven groups to test immediate, early, intermediate, and late responses evaluated at the end of alternating exposure/recovery periods. Three predominant gene expression responses were observed: adaptive (return to baseline), sustained (maintained expression during treatment), and chronic (maintained expression posttreatment). Overall, 25 genes exhibited statistically significant changes: 14 genes exclusively elevated, 10 genes exclusively depressed, and 1, interleukin-8 (IL8), exhibiting both up- and downregulation in the seven groups. The most responsive genes were osteopontin (34-fold upregulation) and CXCL14 (23-fold downregulation). Our observations suggest that specific genes involved in inflammatory pathways respond to CSC in chronic, sustained, or adaptive patterns with the chronic pattern as the predominant behavior.

The time course of expression of genes involved in specific pathways in normal human bronchial epithelial cells following exposure to cigarette smoke.

This study was conducted to determine the time course of gene expression associated with specific signaling pathways in normal human bronchial epithelial (NHBE) cells after exposure to 2 concentrations of 2R4F tobacco mainstream smoke (MSS). Expression of 84 genes representing 18 signal transduction pathways was quantitated in MSS- and air-exposed cultures using real-time polymerase chain reaction (PCR) arrays at 1, 4, and 24 hours following exposure. A confidence score, calculated based on statistical analysis of the degree and reproducibility of expression changes, was used to identify potential biologically significant changes in gene expression. Stimulation of NIAP, an apoptosis inhibitor, suppression of NFKB1 and MYC, representing pro-apoptotic activity, and down-regulation of TCF7 and up-regulation of KLK2, representing anti-/pro-inflammatory responses, were altered 1 hour after exposure to the high concentration of MSS. At the 4-hour time point, the pattern had changed such that 10 different genes were now up-regulated and an additional gene was now down-regulated. Significant changes included genes involved in inflammatory response (LTA, SELPLG, and IL8), repair and wound-healing activity (MMP10), and growth activity (GREB1, EGR1), suggesting repair in this period. By 24 hours, the only up-regulated genes in common with the 4-hour profile were SELPLG and IL8, suggesting continued inflammatory signaling. These results suggest that identification of specific gene expression-based biomarkers of MSS toxicity is promising for investigating specific mechanisms of cellular damage. As expected, the expressed signals were dependent on the concentration of MSS and the postexposure times.

Comparative 13-week inhalation study of cigarette smoke from cigarettes containing cast sheet tobacco.

A subchronic, nose-only inhalation study was conducted to compare the effects of mainstream smoke from a reference cigarette containing conventional reconstituted tobacco sheet at 30% of the finished blend to mainstream smoke from cigarettes containing 10% or 15% cast sheet (a specific type of reconstituted tobacco sheet) substituted for part of the conventional reconstituted tobacco. Male and female Sprague-Dawley rats were exposed for 1 h/day, 5 d/wk, for 13 wk to mainstream smoke at 0, 0.06, 0.20, or 0.80 mg wet total particulate matter per liter of air. Clinical signs, body and organ weights, clinical chemistry, hematology, carboxyhemoglobin (COHb), serum nicotine, plethysmography, gross pathology, and histopathology were determined. Exposure to cigarette smoke induced a number of changes in respiratory physiology, histopathology, and serum nicotine and COHb levels when compared to sham animals. When corresponding dose groups of reference and cast sheet mainstream smokes were compared, no biological differences were noted. At the end of the exposure period, subsets of rats from each group were maintained without smoke exposures for an additional 13 wk (recovery period). At the end of the recovery period, there were no statistically significant differences in histopathological findings observed between the reference and either cast sheet cigarette. Substitution of 10% or 15% cast sheet tobacco for conventional reconstituted tobacco sheet does not alter the inhalation toxicology of the mainstream smoke when compared to mainstream smoke from a reference cigarette containing conventional reconstituted tobacco sheet.