Haematological malignancies are complex diseases, affecting the entire age spectrum, and having marked differences in presentation, treatment, progression and outcome. Patients have a significant ...symptom burden and despite treatment improvements for some sub-types, many patients die from their disease. We carried out a systematic review and meta-analysis to examine the proportion of patients with haematological malignancies that received any form of specialist palliative or hospice care. Twenty-four studies were identified, nine of which were suitable for inclusion in the meta-analysis. Our review showed that patients with haematological malignancies were far less likely to receive care from specialist palliative or hospice services compared to other cancers (Risk Ratio 0.46, 95% confidence intervals 0.42–0.50). There are several possible explanations for this finding, including: ongoing management by the haematology team and consequent strong bonds between staff and patients; uncertain transitions to a palliative approach to care; and sudden transitions, leaving little time for palliative input. Further research is needed to explore: transitions to palliative care; potential unmet patient needs; where patients want to be cared for and die; existing practices in the delivery of palliative and end-of-life care; and barriers to specialist palliative care and hospice referral and how these might be overcome.
Haematological malignancies (leukaemias, lymphomas and myeloma) are complex cancers that are relatively common, affect all ages and have divergent outcomes. Although the symptom burden of these ...diseases is comparable to other cancers, patients do not access specialist palliative care (SPC) services as often as those with other cancers. To determine the reasons for this, we asked SPC practitioners about their perspectives regarding the barriers and facilitators influencing haematology patient referrals.
We conducted a qualitative study, set within the United Kingdom's (UK's) Haematological Malignancy Research Network (HMRN: www.hmrn.org ), a population-based cohort in the North of England. In-depth, semi-structured interviews were conducted with 20 SPC doctors and nurses working in hospital, community and hospice settings between 2012 and 2014. Interviews were digitally audio-recorded, transcribed and analysed for thematic content using the 'Framework' method.
Study participants identified a range of barriers and facilitators influencing the referral of patients with haematological malignancies to SPC services. Barriers included: the characteristics and pathways of haematological malignancies; the close patient/haematology team relationship; lack of role clarity; late end of life discussions and SPC referrals; policy issues; and organisational issues. The main facilitators identified were: establishment of inter-disciplinary working patterns (co-working) and enhanced understanding of roles; timely discussions with patients and early SPC referral; access to information platforms able to support information sharing; and use of indicators to 'flag' patients' needs for SPC. Collaboration between haematology and SPC was perceived as beneficial and desirable, and was said to be increasing over time.
This is the first UK study to explore SPC practitioners' perceptions concerning haematology patient referrals. Numerous factors were found to influence the likelihood of referral, some of which related to the organisation and delivery of SPC services, so were amenable to change, and others relating to the complex and unique characteristics and pathways of haematological cancers. Further research is needed to assess the extent to which palliative care is provided by haematology doctors and nurses and other generalists and ways in which clinical uncertainty could be used as a trigger, rather than a barrier, to referral.
Background:
People with haematological malignancies have different end-of-life care patterns from those with other cancers and are more likely to die in hospital. Little is known about patient and ...relative preferences at this time and whether these are achieved.
Aim:
To explore the experiences and reflections of bereaved relatives of patients with leukaemia, lymphoma or myeloma, and examine (1) preferred place of care and death; (2) perceptions of factors influencing attainment of preferences; and (3) changes that could promote achievement of preferences.
Design:
Qualitative interview study incorporating ‘Framework’ analysis.
Setting/participants:
A total of 10 in-depth interviews with bereaved relatives.
Results:
Although most people expressed a preference for home death, not all attained this. The influencing factors include disease characteristics (potential for sudden deterioration and death), the occurrence and timing of discussions (treatment cessation, prognosis, place of care/death), family networks (willingness/ability of relatives to provide care, knowledge about services, confidence to advocate) and resource availability (clinical care, hospice beds/policies). Preferences were described as changing over time and some family members retrospectively came to consider hospital as the ‘right’ place for the patient to have died. Others shared strong preferences with patients for home death and acted to ensure this was achieved. No patients died in a hospice, and relatives identified barriers to death in this setting.
Conclusion:
Preferences were not always achieved due to a series of complex, interrelated factors, some amenable to change and others less so. Death in hospital may be preferred and appropriate, or considered the best option in hindsight.
Haematological malignancies are a common, heterogeneous and complex group of diseases that are often associated with poor outcomes despite intensive treatment. Research surrounding end-of-life ...issues, and particularly place of death, is therefore of paramount importance, yet place of death has not been formally reviewed in these patients.
A systematic literature review and meta-analysis was undertaken using PubMed to identify all studies published between 1966 and 2010. Studies examining place of death in adult haematology patients, using routinely compiled morbidity and mortality data and providing results specific to this disease were included. 21 studies were identified with descriptive and/or risk-estimate data; 17 were included in a meta-analysis.
Compared to other cancer deaths, haematology patients were more than twice as likely to die in hospital (Odds Ratio 2.25 95% Confidence Intervals, 2.07-2.44).
Home is generally considered the preferred place of death but haematology patients usually die in hospital. This has implications for patients who may not be dying where they wish, and also health commissioners who may be funding costly end-of-life care in inappropriate acute hospital settings. More research is needed about preferred place of care for haematology patients, reasons for hospital deaths, and how these can be avoided if home death is preferred.
Hospital death is comparatively common in people with haematological cancers, but little is known about patient preferences. This study investigated actual and preferred place of death, concurrence ...between these and characteristics of preferred place discussions.
Set within a population-based haematological malignancy patient cohort, adults (≥18 years) diagnosed 2004-2012 who died 2011-2012 were included (n=963). Data were obtained via routine linkages (date, place and cause of death) and abstraction of hospital records (diagnosis, demographics, preferred place discussions). Logistic regression investigated associations between patient and clinical factors and place of death, and factors associated with the likelihood of having a preferred place discussion.
Of 892 patients (92.6%) alive 2 weeks after diagnosis, 58.0% subsequently died in hospital (home, 20.0%; care home, 11.9%; hospice, 10.2%). A preferred place discussion was documented for 453 patients (50.8%). Discussions were more likely in women (p=0.003), those referred to specialist palliative care (p
0.001), and where cause of death was haematological cancer (p
0.001); and less likely in those living in deprived areas (p=0.005). Patients with a discussion were significantly (p<0.05) less likely to die in hospital. Last recorded preferences were: home (40.6%), hospice (18.1%), hospital (17.7%) and care home (14.1%); two-thirds died in their final preferred place. Multiple discussions occurred for 58.3% of the 453, with preferences varying by proximity to death and participants in the discussion.
Challenges remain in ensuring that patients are supported to have meaningful end-of-life discussions, with healthcare services that are able to respond to changing decisions over time.
Patients with haematological malignancies are more likely to die in hospital, and less likely to access palliative care than people with other cancers, though the reasons for this are not well ...understood. The purpose of our study was to explore haematology nurses' perspectives of their patients’ places of care and death.
Qualitative description, based on thematic content analysis. Eight haematology nurses working in secondary and tertiary hospital settings were purposively selected and interviewed. Transcriptions were coded and analysed for themes using a mainly inductive, cross-comparative approach.
Five inter-related factors were identified as contributing to the likelihood of patients’ receiving end of life care/dying in hospital: the complex nature of haematological diseases and their treatment; close clinician-patient bonds; delays to end of life discussions; lack of integration between haematology and palliative care services; and barriers to death at home.
Hospital death is often determined by the characteristics of the cancer and type of treatment. Prognostication is complex across subtypes and hospital death perceived as unavoidable, and sometimes the preferred option. Earlier, frank conversations that focus on realistic outcomes, closer integration of palliative care and haematology services, better communication across the secondary/primary care interface, and an increase in out-of-hours nursing support could improve end of life care and facilitate death at home or in hospice, when preferred.
•Patients with haematological malignancies are more likely to die in hospital than people with other cancers.•No previous research has reported on UK haematology nurses' perspectives of their patients' place of care and place of death.•Hospital deaths were largely attributed to disease characteristics, nature of treatment and difficulties with prognostication.•However, other modifiable factors were also identified as barriers to death at home.
•Soil legacy data are rescued in many parts of the world.•Soil profiles data and soil maps are stored in harmonized databases.•These data are capitalized upon using digital soil mapping ...techniques.•High resolution maps of soil properties are produced according to GlobalSoilMap specifications.
Legacy soil data have been produced over 70 years in nearly all countries of the world. Unfortunately, data, information and knowledge are still currently fragmented and at risk of getting lost if they remain in a paper format. To process this legacy data into consistent, spatially explicit and continuous global soil information, data are being rescued and compiled into databases. Thousands of soil survey reports and maps have been scanned and made available online. The soil profile data reported by these data sources have been captured and compiled into databases. The total number of soil profiles rescued in the selected countries is about 800,000. Currently, data for 117, 000 profiles are compiled and harmonized according to GlobalSoilMap specifications in a world level database (WoSIS). The results presented at the country level are likely to be an underestimate. The majority of soil data is still not rescued and this effort should be pursued. The data have been used to produce soil property maps. We discuss the pro and cons of top-down and bottom-up approaches to produce such maps and we stress their complementarity. We give examples of success stories. The first global soil property maps using rescued data were produced by a top-down approach and were released at a limited resolution of 1km in 2014, followed by an update at a resolution of 250m in 2017. By the end of 2020, we aim to deliver the first worldwide product that fully meets the GlobalSoilMap specifications.
Recent global crises reveal an emerging pattern of causation that could increasingly characterize the birth and progress of future global crises. A conceptual framework identifies this pattern’s deep ...causes, intermediate processes, and ultimate outcomes. The framework shows how multiple stresses can interact within a single social-ecological system to cause a shift in that system’s behavior, how simultaneous shifts of this kind in several largely discrete social-ecological systems can interact to cause a far larger intersystemic crisis, and how such a larger crisis can then rapidly propagate across multiple system boundaries to the global scale. Case studies of the 2008-2009 financial-energy and food-energy crises illustrate the framework. Suggestions are offered for future research to explore further the framework’s propositions.
Synthesis of helically chiral aromatics resulting from fusion of pyrene and 4‐ or 5helicene has been accomplished using photoredox catalysis employing a Cu‐based sensitizer as the key step. ...Photocyclisation experiments for the synthesis of the target compounds were carried out in batch and using continuous flow strategies. The solid‐state structures, UV/Vis absorption spectra and fluorescence spectra of the pyrene–helicene hybrids were investigated and compared to that of the parent 5helicene to discern the effects of merging a pyrene moiety within a helicene skeleton. The studies demonstrated that pyrene–helicene hybrids adopt co‐planar or stacked arrangements in the solid state, in contrast to the solid‐state structure of the parent 5helicene. The UV/Vis and fluorescence spectra of the pyrene–helicene hybrids exhibited strong red‐shifts when compared to the parent 5helicene. DFT calculations suggest that the strategy of extending the π surface in the y axis of the helicenes increased their HOMO levels while also decreasing their LUMO levels, resulting in significantly reduced band gaps.
One‐way stretch: Novel helically chiral aromatics resulting from fusion of pyrene and 4‐ or 5helicene have been synthesised using Cu‐based photoredox catalysis in batch and in continuous flow (see diagram). This extension of the skeleton along the y axis results in an increase in the π surface. The solid‐state structure, UV/Vis absorption and fluorescence spectroscopy of the pyrene–helicene hybrids are compared to that of the parent 5helicene.
Application of metabolic magnetic resonance imaging measures such as cerebral blood flow in translational medicine is limited by the unknown link of observed alterations to specific ...neurophysiological processes. In particular, the sensitivity of cerebral blood flow to activity changes in specific neurotransmitter systems remains unclear. We address this question by probing cerebral blood flow in healthy volunteers using seven established drugs with known dopaminergic, serotonergic, glutamatergic and GABAergic mechanisms of action. We use a novel framework aimed at disentangling the observed effects to contribution from underlying neurotransmitter systems. We find for all evaluated compounds a reliable spatial link of respective cerebral blood flow changes with underlying neurotransmitter receptor densities corresponding to their primary mechanisms of action. The strength of these associations with receptor density is mediated by respective drug affinities. These findings suggest that cerebral blood flow is a sensitive brain-wide in-vivo assay of metabolic demands across a variety of neurotransmitter systems in humans.
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