Implementation of a threefold intervention to improve palliative care for persons experiencing homelessness: a process evaluation using the RE-AIM framework.

BACKGROUND: Palliative care provision for persons experiencing homelessness is often poor. A threefold consultation service intervention was expected to increase knowledge of palliative care and multidisciplinary collaboration, and improve palliative care for this population. This intervention comprised: 1) consultation of social service professionals by palliative care specialists and vice versa; 2) multidisciplinary meetings with these professionals; and 3) training and education of these professionals. We aimed to evaluate the implementation process and its barriers and facilitators of this service implemented within social services and healthcare organizations in three Dutch regions. METHODS: A process evaluation using structured questionnaires among consultants, semi-structured individual and group interviews among professionals involved, and (research) diaries. Qualitative data were analysed using thematic analysis. The process evaluation was structured using the Reach, Adoption, Implementation and Maintenance dimensions of the RE-AIM framework. RESULTS: All three regions adopted all three activities of the intervention, with differences between the three regions in the start, timing and frequency. During the 21-month implementation period there were 34 consultations, 22 multidisciplinary meetings and 9 training sessions. The professionals reached were mainly social service professionals. Facilitators for adoption of the service were a perceived need for improving palliative care provision and previous acquaintance with other professionals involved, while professionals' limited skills in recognizing, discussing and prioritizing palliative care hindered adoption. Implementation was facilitated by a consultant's expertise in advising professionals and working with persons experiencing homelessness, and hindered by COVID-19 circumstances, staff shortages and lack of knowledge of palliative care in social service facilities. Embedding the service in regular, properly funded meetings was expected to facilitate maintenance, while the limited number of persons involved in this small-scale service was expected to be an obstacle. CONCLUSIONS: A threefold intervention aimed at improving palliative care for persons experiencing homelessness is evaluated as being most usable when tailored to specific regions, with bedside and telephone consultations and a combination of palliative care consultants and teams of social service professionals. It is recommended to further implement this region-tailored intervention with palliative care consultants in the lead, and to raise awareness and to remove fear of palliative care provision.

Evaluating the perceived added value of a threefold intervention to improve palliative care for persons experiencing homelessness: a mixed-method study among social service and palliative care professionals.

BACKGROUND: Palliative care for persons experiencing homelessness who reside in social service facilities is often late or lacking. A threefold intervention was implemented to improve palliative care for this population by increasing knowledge and collaboration between social service and palliative care professionals. This consultation service comprised: 1) consultations between social service professionals and palliative care professionals; 2) multidisciplinary meetings involving these professionals; and 3) training of these professionals. This study aims to evaluate the perceived added value of this threefold consultation service in three regions in the Netherlands. METHODS: A mixed-methods evaluation study using structured questionnaires for consultants, requesting consultants, and attendees of multidisciplinary meetings, semi-structured group and individual interviews with social service and palliative care professionals involved, weekly diaries filled out by consultants, and an implementation diary. Qualitative data were analyzed following the principles of thematic analysis. Quantitative data were analyzed descriptively. RESULTS: Thirty-four consultations, 22 multidisciplinary meetings and 9 training sessions were studied during the implementation period of 21 months. Social service professionals made up the majority of all professionals reached by the intervention. In all regions the intervention was perceived to have added value for collaboration and networks of social service and palliative care professionals (connecting disciplines reciprocally and strengthening collaborations), the competences of especially social service professionals involved (competency in palliative care provision, feeling emotionally supported in complex situations), and the quality and timing of palliative care (more focus on quality of life and dying, advance care planning and looking ahead, and greater awareness of death and palliative care). CONCLUSIONS: The threefold consultation service particularly helps social service professionals connect with palliative care professionals. It helps them to identify palliative care needs in good time and to provide qualitatively better palliative care to persons experiencing homelessness.

Care avoidance among homeless people and access to care: an interview study among spiritual caregivers, street pastors, homeless outreach workers and formerly homeless people.

BACKGROUND: Because of their poor health and social vulnerability, homeless people require specific care. However, due to care avoidance, homeless people are often not involved in care. This study aims to get insights into reasons for and kinds of care avoidance among homeless people and to provide suggestions to reach this target group. METHODS: Semi-structured individual interviews were conducted among street pastors (n = 9), spiritual caregivers (n = 9), homeless outreach workers (n = 7) and formerly homeless people (n = 3). Participants were recruited by purposive sampling in the four major cities in the Netherlands (Amsterdam, Utrecht, Rotterdam, The Hague). The verbatim transcripts were analysed using thematic analysis. RESULTS: The term care avoidance was perceived as stigmatizing. Care avoidance is found to be related to characteristics of the homeless person (e.g. having complex problems, other priorities) as well as of the system (e.g. complex system, conditions and requirements of organizations). The person-related characteristics suggestions to involve homeless persons include tailoring care and building relationships, which might even be prioritised over starting care interventions. Setting limits on behaviour without rejecting the person, and an attitude reflecting humanity, dignity and equality were also important factors in making care more accessible and lasting. As regards system-related characteristics, the suggestions include clear information and communication to homeless people who avoid care as being crucial in order to make care more accessible. Other suggestions include quiet and less busy shelters, a non-threatening attitude and treatment by professionals, self-reflection by professionals and finally a change of policy and legislation regarding available time. CONCLUSIONS: Reasons for care avoidance can be found in the interplay between both the individual and the system; measures to reduce care avoidance should be taken at both levels. These measures are centred on lowering the barriers to care inter alia by incorporating building trust and understanding into the care provided.

The Views of Homeless People and Health Care Professionals on Palliative Care and the Desirability of Setting Up a Consultation Service: A Focus Group Study.

CONTEXT: Palliative care for homeless people is often given late, if at all. Professionals in both palliative care and shelter care are often insufficiently equipped to provide this complex care. OBJECTIVES: To provide insights into the palliative care experiences of professionals and homeless people, including barriers and facilitators to care, and to investigate whether a consultative function can help improve palliative care for homeless people. METHODS: Six focus groups were included; four with professionals (n = 19) and two with severely ill homeless people (n = 15). Professionals were sampled purposively in organizations providing (palliative) care to the homeless. Homeless people were recruited by opportunity sampling. RESULTS: Palliative care for homeless people is especially complex and differs substantially from regular palliative care. It differs greatly among professionals, institutions, and cities. Homeless people get less autonomy than they would like. Homeless people and professionals have different perceptions of the care provided. Trusting relationships between professionals and homeless people is essential and easily accessible, and flexible care is needed. Consultation, in particular involving exchange of expertise between professionals, can provide added value to professionals. Homeless people consider consultation primarily as an opportunity to train professionals to show more understanding, provide tailored palliative care, and enhance professional collaboration. The local situation, characteristics of a consultant, and role of a consultant in providing information and education must be considered when developing the consultation process. CONCLUSION: Consultation can play an important role in improving palliative care by linking disciplines, providing support to professionals and appropriate palliative care to homeless people.

The palliative performance scale applied in high-care residential hospice: a retrospective study.

BACKGROUND: The Palliative Performance Scale (PPS) is a tool that is widely used to predict end of life. In Ontario, Canada, the PPS is used to mark the terminal phase of life and eligibility for terminal care. OBJECTIVE: The aim of this retrospective study was to confirm that a PPS level of 40% can be used as a marker for the terminal phase of life. METHOD: PPS levels from 78 patients were calculated based on the intake reports made at admission to an inpatient hospice. RESULTS: Although 77 patients passed away within a period of 3 months, PPS levels at admission varied from 10% to 70%. Fifty-six percent of all patients had a PPS level of 40% or less. Regarding survival, three significant PPS profiles, consisting of two or more PPS levels could be distinguished.

Myocardial carnitine palmitoyltransferase I expression and long-chain fatty acid oxidation in fetal and newborn lambs.

Carnitine palmitoyltransferase I (CPT I) catalyzes the conversion of acyl-CoA to acylcarnitine at the outer mitochondrial membrane and is a key enzyme in the control of long-chain fatty acid (LC-FA) oxidation. Because myocardial LC-FA oxidation increases dramatically after birth, we determined the extent to which CPT I expression contributes to these changes in the perinatal lamb. We measured the steady-state level of transcripts of the CPT1A and CPT1B genes, which encode the liver (L-CPT I) and muscle CPT I (M-CPT I) isoforms, respectively, as well as the amount of these proteins, their total activity, and the amount of carnitine in left ventricular tissue from fetal and newborn lambs. We compared these data with previously obtained myocardial FA oxidation rates in vivo in the same model. The results showed that CPT1B was already expressed before birth and that total CPT I expression transiently increased after birth. The protein level of M-CPT I was high throughout development, whereas that of L-CPT I was only transiently upregulated in the first week after birth. The total CPT I activity in vitro also increased after birth. However, the increase in myocardial FA oxidation measured in vivo (112-fold) by far exceeded the increase in gene expression (2.2-fold), protein amount (1.1-fold), and enzyme activity (1.2-fold) in vitro. In conclusion, these results stress the importance of substrate supply per se in the postnatal increase in myocardial FA oxidation. M-CPT I is expressed throughout perinatal development, making it a primary target for metabolic modulation of myocardial FA oxidation.

Structural and functional genomics of the CPT1B gene for muscle-type carnitine palmitoyltransferase I in mammals.

Muscle-type carnitine palmitoyltransferase I (M-CPT I) is a key enzyme in the control of beta-oxidation of long-chain fatty acids in the heart and skeletal muscle. Because knowledge of the mammalian genes encoding M-CPT I may aid in studies of disturbed energy metabolism, we obtained new genomic and cDNA data for M-CPT I for the human, mouse, rat, and sheep. The introns of these compact genes are 80% (mouse versus rat) and 60% (mouse versus human) identical. Sheep and goat, but not cow, pig, rodent, or human promoter sequences contain a short interspersed repeated sequence (SINE) upstream of highly conserved regulatory elements. These elements constitute two promoters in humans, sheep, and mice, and, contrary to previous reports, there is a second promoter in rats as well. Thus, the transcriptional organization of these genes is more uniform than previously supposed, with interspecies differences in the 5'-ends of the mRNAs reflecting differences in splicing; only in humans extensive splicing and splice variation is found in the 5'- and 3'-untranslated regions. In the mouse, intron retention was detected in heart, muscle, and testes and may indicate an additional mechanism of regulation of M-CPT I expression. Splice variation in the coding region was previously proposed to lead to expression of CPT I enzymes with altered malonyl-CoA sensitivity (Yu, G. S., Lu, Y. C., and Gulick, T. (1998) Biochem. J. 334, 225-231). However, when expressed in the yeast Pichia pastoris, none of three earlier described splice variants had CPT I activity. Therefore, the involvement of splice variation of M-CPT I in the modulation of malonyl-CoA inhibition of fatty acid oxidation may be less relevant than hitherto assumed.

Gametic products transmitted by chickens heterozygous for chromosomal rearrangements.

Chromosomal analysis was made from 3744 chick embryos derived from reciprocal matings between parents, one of which was heterozygous for a pericentric inversion, a centric fission, or one of three translocations. The objectives were to determine the types and frequencies of genetically balanced and unbalanced gametes transmitted to early embryos by rearrangement heterozygotes and to ascertain if some gametic types were preferentially produced or utilized. The array of embryos obtained from the heterozygous sires did not deviate significantly from the expected, except in the case of the centric fission group. Among embryos derived from heterozygous dams, however, significant deviations from the expected 1:1 ratio for complementary gametic products, resulting from specific balanced and unbalanced segregation types, were found consistently in all three translocation groups and the centric fission group (P less than 0.025). It was concluded that differences exist between heterozygous sires and dams in the frequencies at which some gametic types are produced. The deviations from the expected ratios among progeny of heterozygous dams may be the result of anaphase lagging during the meiotic division of oogenesis.

The parental source of heteroploidy in chick embryos determined with chromosomally marked gametes.

Males homozygous for chromosomal translocations were mated to karyologically normal females. The resulting embryos, after incubation for 16-18 h, were prepared for cytogenetic analysis. Of the 62 embryos analysed, 54 (7.8%) were heteroploid or contained a major heteroploid cell line. Each of the 638 normal 2n embryos contained one marker and one normal chromosome, indicating that none arose from gynogenesis. Thirteen homogeneous haploid embryos were identified; 24 embryos were chimaeric 1n/2n and one was 1n/3n. All haploid cell lines contained a marker chromosome indicating androgenetic origins. The 9 homogeneous triploid (3n) embryos and the 3n cell line in a single 1n/3n embryo contained a single marker. All resulted from fertilization by single spermatozoon of eggs that were diploid as a result of suppression of the second meiotic division. The 3n lines of two 2n/3n embryos were derived from other mechanisms. A single homogeneous tetraploid (4n) embryo and the 4n cell lines of three 2n/4n mosaic embryos each contained two marker chromosomes and presumable resulted from failure of cytokinesis in an early cleavage division.

Structural rearrangements of chromosomes in the domestic chicken: experimental production by X-irradiation of spermatozoa.

In order to produce chicks heterozygous for structural aberrations of chromosomes, 67 hens were inseminated with semen that had been exposed to 1200 R of X-rays. A sample of 204 chicks was hatched and survived. Among these, 18 (8.9%) contained rearrangements comprising 19 translocations and one pericentric inversion. All 10 males and eight females heterozygous for rearrangements were fertile and transmitted these rearrangements to approximately half their hatched progeny. Each of the major chromosomes of the chicken karyotype, except number 6, was involved in one or more of the translocations. The pericentric inversion was of a segment of chromosome number 2.

Cytogenetic and phenotypic effects of a chromosomal rearrangement involving the Z-chromosome and micro-chromosome in the chicken.

Measurements demonstrated that the Z-chromosome was truly metacentric. Forty-six percent of one arm of a female's Z-chromosome had been translocated to a microchromosome (Z-micro) by irradiation of semen. The bread was 23 crossover units distal to the late feathering (K) locus. The barring (B) locus on the non-broken arm assorted almost independently of the Z-micro segment. Semen from eight sons of this Z-micro female was used to inseminate 98 dwarf (dw) broiler-type females. From karyotypes of 147 male and 149 female progeny, we identified 69 males heterozygous and 79 females hemizygous for Z-micro. Body weight of 43 males heterozygous for Z-micro was significantly greater than that of 45 normal Z paternal half-brothers at all ages from 2 to 24 weeks. In contrast, body weight of 57 Z-micro females compared with their 56 normal Z paternal half-sisters was depressed significantly at 2, 4, and 6 weeks but not significantly at 8, 12, 16, and 24 weeks of age. Age at first egg was retarded 8 days and egg production over a 153 day test period was reduced 19.6%, primarily due to a reduction of egg laying sequence from 2.7 to 2.1 days in the Z-micro females.

Body growth response to selection and crossbreeding in dwarf and normal broiler-type chickens.

A normal-bodied broiler population and one dwarfed by the dw sex-linked gene were each sub-divided into two lines. AGB (normal) and D2B (dwarf) were selected only for superior body weight at eight weeks of age. AGE (normal) and D2E (dwarf) were sublines in which prospective dams were selected for large egg weight while prospective sires were selected for eight-week body weight. Selection for large eight-week weight of both sexes in both dwarf and normal populations during each of three generations resulted in superior growth rate to that observed when the dams were selected for egg weight. When the selected dams were tested each generation for their ability to produce superior broiler crossbreds using a commercial broiler sire strain, AGE proved superior to AGB in the second and third generations while D2B and D2E dams produced crossbreds with similar broiler weights. Normal-bodied dams which produced crossbreds having superior growth to that of the dwarf dams in the first generation lost most of this superiority by the third generation in sons and the second generation in daughters. Reproductive fitness was superior within the dwarf lines as well as in their ability to produce more crossbred progeny.

Incidence and origin of heteroploidy, especially haploidy, in chick embryos from intraline and interline matings.

Preparations for chromosomal analysis were made from 2107 chick embryos at 16 hours of incubation. The embryos resulted from intraline and reciprocal interline matings of two genetically different stocks (AG and D6). The two stocks had been previously characterized as producers of high (AG) and low (D6) frequencies of chromosomally aberrant embryos. The overall frequency of aberrant embryos was 4.0 plus or minus 0.42%. The types and frequencies of abnormalities were: haploidy and haploid-euploid mosaics, 57%; polyploidy and polyploid-diploid mosaics, 19%; aneuploidy, 17%; aneuploid-diploid mosaics, 5%; and structural aberrations, 2%. Although there were no significant differences among the four types of matings in the overall frequency of heteroploid embryos (P greater than 0.1), a significant difference (P smaller than 0.01) in the frequency of haploid and haploid-euploid mosaic embryos was found. The difference was entirely attributable to the line of dam; D6 dams had 1.2% and AG dams had 2.7% haploid and haploid-euploid mosaic embryos. The difference between lines of sires was not significant. In addition, there was evidence of nonrandom distribution, among dams of both lines, of haploid and haploid-euploid mosaic embryos. It was concluded that the genotype of dam is an important influencing factor in the production of haploid cell lines in embryos. The superfluous genome in triploid embryos is usually maternal in origin, resulting from retention of the second polar body in the ovum. Sex-chromosome aneuploidy in chick embryos apparently derives from nondisjunction at meiosis I of oogenesis. The sex proportion of 2023 chromosomally sexed, diploid embryos was 50.2 plus or minus 1.1% male. No significant heterogeneity was observed among the types of matings. Sex proportion was not significantly influenced by any of a number of nongenetic variables.

An attempt to force molt small egg-type pullets.

Small 1.1 kg. egg-type pullets having the sex-linked dw dwarfing gene were more resistant to a force molting program started at 11 months of age than were their 1.4 kg. non-dwarf counterparts. Water deprivation appeared to prevent egg production sooner in the dwarfs than in the non-dwarfs but egg production eight weeks after initiation of the force molt program was 46 per cent versus 64 per cent for the non-dwarf pullets.