The mission of the American Heart Association/American Stroke Association includes increasing access to high-quality, evidence-based care that improves patient outcomes such as health-related quality ...of life and is consistent with the patients' values, preferences, and goals. Awareness of and access to palliative care interventions align with the American Heart Association/American Stroke Association mission. The purposes of this policy statement are to provide background on the importance of palliative care as it pertains to patients with advanced cardiovascular disease and stroke and their families and to make recommendations for policy decisions. Palliative care, defined as patient- and family-centered care that optimizes health-related quality of life by anticipating, preventing, and treating suffering, should be integrated into the care of all patients with advanced cardiovascular disease and stroke early in the disease trajectory. Palliative care focuses on communication, shared decision making about treatment options, advance care planning, and attention to physical, emotional, spiritual, and psychological distress with inclusion of the patient's family and care system. Our policy recommendations address the following: reimbursement for comprehensive delivery of palliative care services for patients with advanced cardiovascular disease and stroke; strong payer-provider relationships that involve data sharing to identify patients in need of palliative care, identification of better care and payment models, and establishment of quality standards and outcome measurements; healthcare system policies for the provision of comprehensive palliative care services during hospitalization, including goals of care, treatment decisions, needs of family caregivers, and transition to other care settings; and health professional education in palliative care as part of licensure requirements.
Abstract Context Patients with serious medical problems who live at home may not be able to access specialist-level palliative care when the need develops. Nurse practitioner (NP)-based models may be ...able to increase the availability of specialist care in the community. Objectives The aim of this study was to evaluate the financial sustainability and feasibility of two NP-based models in an urban setting. Methods In one model, an NP was linked with a social worker (SW) to create a new palliative home care team (PHCT-NP-SW), which would provide consultation and direct care to referred homebound elderly patients with advanced illnesses. In a second model, an NP was assigned to a hospice program (Hospice-NP) for the purpose of enhancing the reach and impact of a home care team. The revenue generated by each model was compared with direct costs; the PHCT-NP-SW model also was evaluated for its feasibility and impact on patient-level outcomes. Results Over a two-year period, the NP in the PHCT-NP-SW model made 350 visits and followed 114 patients at home. Annualized revenue through reimbursement from patient billing offset less than 50% of the NP’s salary costs. In contrast, the Hospice-NP model led to a 360% increment in hospice referrals, yielding sufficient new revenue to support this position indefinitely after only seven months. The PHCT-NP-SW model provided numerous interventions that yielded a significant decline in symptom distress during the initial two weeks after referral ( P = 0.003), 100% compliance with advance care planning, 21% admission rate to hospice, access to other community services, and crisis management. Nonetheless, lack of funding led to closure of this model after the two years. Conclusion This experience suggests that a PHCT-NP-SW model is not sustainable in this urban environment through reimbursement-based revenue, whereas a Hospice-NP model for hospice can be sustainable based on the growth of hospice census. The PHCT-NP-SW model appears to offer benefits, and additional efforts are needed to establish the funding mechanisms to sustain such programs, create mixed models of hospice and nonhospice funding, or provide a basis for sustainability through cost reduction.
Information and Communications Technology (ICT) has been the focus of much debate and development within education, especially in the primary sector. This text offers tried and tested ideas for using ...IT effectively across the whole primary curriculum.
Since its popularity increased in April 2017, the fidget spinner has been the cause of multiple 911-related responses for persons with their finger stuck in the toy. As first responders, firefighters ...must have a plan to deal with removing a victim from these types of devices. This article discusses the necessary steps to safely disentangle a victim.
Transport of poly- and perfluoroalkyl substances (PFAS) at aqueous film-forming foam (AFFF)-impacted sites is limited by various processes that can retain PFAS mass within the source area. This study ...used concentration data obtained via a high-resolution sampling and analytical protocol to estimate the PFAS mass distribution in source and downgradient areas of a former firefighter training area. The total PFAS mass present at the site was approximately 222 kg, with 106 kg as perfluoroalkyl acids (PFAAs) and 116 kg as polyfluorinated precursors. Zwitterionic and cationic PFAS represented 83% of the total precursor mass and were found primarily in the source and up/side-gradient areas (75%), likely due to preferential hydrophobic partitioning, electrostatic interactions, and diffusion into lower-permeability soils. Based on the release history and the high percentage of total PFAS mass represented by precursors (primarily electrochemical fluorination-derived compounds), the estimated conversion rate of precursors to PFAAs was less than 2% annually. Eighty-two percent of the total PFAS mass was encountered in lower-permeability soils, which limited the potential for advection and transformation. This contributed to a 99% decrease in the mass discharge rate at the far-downgradient plume (0.048 kg/yr compared to the near-source area (3.6 kg/yr)). The results provide field-scale evidence of the importance of these PFAS retention processes at sites where AFFF has been released.
The timing of migration is one of the key life‐history parameters of migratory birds. It is expected to be under strong selection, to be sensitive to changing environmental conditions and to have ...implications for population dynamics. However, most phenological studies do not describe arrival and departure phenologies for a species in a way that is robust to potential biases, or that can be clearly related to breeding populations. This hampers our ability to understand more fully how climate change may affect species’ migratory strategies, their life histories and ultimately their population dynamics. Using generalized additive models (GAMs) and extensive large‐scale data collected in the UK over a 40‐year period, we present standardized measures of migration phenology for common migratory birds, and examine how the phenology of bird migration has changed in the UK since the 1960s. Arrival dates for 11 of 14 common migrants became significantly earlier, with six species advancing their arrival by more than 10 days. These comprised two species, Blackcap Sylvia atricapilla and Chiffchaff Phylloscopus collybita, which winter closest to Britain in southern Europe and the arid northern zone of Africa, Common Redstart Phoenicurus phoenicurus, which winters in the arid zone, and three hirundines (Sand Martin Riparia riparia, House Martin Delichon urbicum and Barn Swallow Hirundo rustica), which winter in different parts of Africa. Concurrently, departure dates became significantly later for four of the 14 species and included species that winter in southern Europe (Blackcap and Chiffchaff) and in humid zones of Africa (Garden Warbler Sylvia borin and Whinchat Saxicola rubetra). Common Swift Apus apus was the exception in departing significantly earlier. The net result of earlier arrival and later departure for most species was that length of stay has become significantly longer for nine of the 14 species. Species that have advanced their timing of arrival showed the most positive trends in abundance, in accordance with previous studies. Related in part to earlier arrival and the relationship above, we also show that species extending their stay in Great Britain have shown the most positive trends. Further applications of our modelling approach will provide opportunities for more robust tests of relationships between phenological change and population dynamics than have been possible previously.
We report baseline results of a community-based, targeted, low-dose CT (LDCT) lung cancer screening pilot in deprived areas of Manchester. Ever smokers, aged 55-74 years, were invited to 'lung health ...checks' (LHCs) next to local shopping centres, with immediate access to LDCT for those at high risk (6-year risk ≥1.51%, PLCO
calculator). 75% of attendees (n=1893/2541) were ranked in the lowest deprivation quintile; 56% were high risk and of 1384 individuals screened, 3% (95% CI 2.3% to 4.1%) had lung cancer (80% early stage) of whom 65% had surgical resection. Taking lung cancer screening into communities, with an LHC approach, is effective and engages populations in deprived areas.
We introduce a number of extensions and enhancements to a genetic algorithm for crystal structure prediction, to make it suitable to study magnetic systems. The coupling between magnetic properties ...and crystal structure means that it is essential to take a holistic approach, and we present for the first time, a genetic algorithm that performs a simultaneous global optimisation of both magnetic structure and crystal structure. We first illustrate the power of this approach on a novel test system—the magnetic Lennard–Jones potential—which we define. Then we study the complex interface structures found at the junction of a Heusler alloy and a semiconductor substrate as found in a proposed spintronic device and show the impact of the magnetic interface structure on the device performance.
PDF
