This project demonstrated the beneficial effects of music in a patient population that struggles with symptom management when only pharmacologic management is used. These data elucidate biological and psychosocial factors that are positively impacted by the intervention. With additional evidence in music as well as other artistic modalities, it is promising that arts-based programs in inpatient hospice and palliative care settings will continue to expand and flourish.
PURPOSE: The coronavirus pandemic has transformed the practice of medicine, forcing a rapid transition to telehealth. As a specialty, palliative care relies upon expert-level communication and interdisciplinary care. We describe the transition of the Dana-Farber Cancer Institute palliative care clinic into a predominantly telemedicine model. RESULTS: We document how we significantly increased goals of care conversations while maintaining patient volume and interdisciplinary care. We present how the components of a palliative visit translate into a virtual model. DISCUSSION: While the transition away from in person visits occurred rapidly, telehealth is likely here to stay. We define the challenges and benefits encountered through increased use of telehealth and identify disparities in healthcare access that will become more pronounced as we move into a communication technology dependent future. We discuss how the pandemic changed the delivery of palliative care in ways that will endure beyond the coronavirus pandemic.
There is a well-described need to increase the competence of the primary care workforce in the principles of geriatrics and palliative care, and as value-based payment models proliferate, there is increased incentive for the acquisition of these skills. Through a Geriatric Workforce Enhancement Program grant, we developed an adaptable curriculum around commonly encountered topics in palliative care and geriatrics that can be delivered to multidisciplinary clinicians in primary care settings. All participants in this training were part of an Accountable Care Organization (ACO) and were motivated to improve to care for complex older adults. A needs assessment was performed on each practice or group of learners and the curriculum was adapted accordingly. With the use of patient education and screening tools with strong validity evidence, the participants were trained in the principals of geriatrics and palliative care with a focus on advance care planning and assessing for frailty and functional decline. Comparison of pre- and post-test scores demonstrated increased confidence and knowledge in goals of care and basic geriatric assessment. Participants described feeling more able to address needs, have conversations around goals of care, and more able to recognize patients who would benefit from collaboration with geriatrics and palliative care.
BackgroundNeonatal nurse practitioners are often the front line providers in discussing unexpected news with parents. This study seeks to evaluate whether a simulation based Difficult Conversations Workshop for neonatal nurse practitioners leads to improved skills in conducting difficult conversations.
PURPOSE: As part of a larger effort to integrate palliative care into a cancer center, we identified barriers to palliative care referral for patients with breast or gynecologic cancer and developed a pilot program to improve access to palliative care services. METHODS: We developed a multidisciplinary steering committee to uncover barriers to palliative care referral and developed a pilot program, called the Warm Handoff. Through ongoing collaboration and midpilot feedback sessions, we identified several additional barriers and opportunities to increase access to palliative care. RESULTS: Clinicians used the initial Warm Handoff process only 20 times over a period of 7 months. Of those calls, 10 were for issues outside of those that the Warm Handoff pilot was intended to address. During the pilot, we identified lack of access to urgent visits and clinician telephone availability for clinical case discussion as additional barriers to access. Increased collaboration led to the creation of a clinical provider of the day (CPOD) care model, which allowed for a notable increase in the capacity to see urgent consults. After this intervention, we observed an average of 19 patients seen urgently per month. In addition, there was a trend toward increasing referrals from breast oncology after the initiation of the CPOD. CONCLUSION: A CPOD model, developed via close oncology/palliative care collaboration, resulted in increased utilization of palliative care services.
Sequences at the left terminus of U3 in the left long terminal repeat (LTR) and at the right terminus of U5 in the right LTR are important for integration of retroviral DNA. In the infectious pathogenic molecular clone of simian immunodeficiency virus strain mac239 (SIVmac239), 10 of the 12 terminal base pairs form an imperfect inverted repeat structure (5 TGGAAGGGATTT 3 [nucleotides 1 to 12] and 3 ACGATCCCTAAA 5 [nucleotides 10279 to 10268]). Nineteen different mutant forms of SIVmac239 proviral DNA with changes at one or more of the positions in each of the 12-terminal-base-pair regions were constructed. Viral replication was severely or completely compromised with nine of these mutants. Revertants appeared 40 to 50 days after transfection in two independent experiments with mutant 7, which contained changes of AGG to TAC at positions 5 to 7 in U3 and TCC to GAA at positions 10275 to 10273 in U5. Virus produced at these times from mutant 7 transfection replicated upon reinfection with only a slight delay when compared to the wild type.
Sequence analysis of the LTR and integrase regions from infected cultures revealed two predominant changes:G to A at position 10275 in U5 and Glu to Lys at position 136 in integrase. Derivatives of clone 7 in which these changes were introduced individually and together were constructed by site-specific mutagenesis. Each change individually restored replication capacity only partially. However, the combination of both mutations restored replicative capacity to that of the original revertants. These results indicate that changes in integrase can compensate for mutations in the terminal nucleotides of the SIV LTR. The results further indicate that resistance to integrase inhibitors may include both integrase and LTR mutations.
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