Advance Care Planning in Patients with Suspected or Proven COVID: Are We Meeting Our Own Standards?

OBJECTIVE

Given the importance of advance care planning (ACP) in the context of a pandemic, we aimed to assess current adherence to local policy recommending ACP in all hospitalised adult patients with suspected or proven COVID-19 at Liverpool Hospital, Sydney, Australia.

DESIGN

A retrospective cohort study.

SETTING

A tertiary referral and teaching hospital.

PARTICIPANTS

A select sample of adult patients admitted to Liverpool Hospital in 2019-2021 with suspected or proven COVID-19.

MAIN OUTCOME MEASURES

Proportion of patients with documented ACP and format of ACP.

RESULTS

Amongst 209 patients with proven or suspected COVID-19 hospitalised between March 2019 through to September 2021, median frailty score was 3, the median Charlson Comorbidity Score was 4, median age of the patients was 71 years, and median length of hospital stay was 5 days (range 0-98 days). Almost all patients were tested for COVID-19 (n = 207, 99%) of which 15% (31) were positive. Fewer than a quarter of the patients had documented ACPs (50, 24%) and 17 patients had existing formal advance care directives. Patients who had ACP were older, more likely to be frail and more likely to have higher rates of comorbidity compared to those without ACP. ACP was more commonly discussed with family members (41/50) than patients (25/50) and others (5/50).

CONCLUSION

Adherence to the local ACP policy mandating such discussions was low. This reinforces the need for prioritising ACP discussions, especially for unwell patients such as those with COVID, likely involving further input to improve awareness and rates of formal documentation.

Advanced care planning in the early phase of COVID-19: a rapid review of the practice and policy lessons learned

Background

The importance of advance care planning (ACP) has been highlighted by the advent of life-threatening COVID-19. Anecdotal evidence suggests changes in implementation of policies and procedures is needed to support uptake of ACPs. We investigated the barriers and enablers of ACP in the COVID-19 context and identify recommendations to facilitate ACP, to inform future policy and practice.

Methods

We adopted the WHO recommendation of using rapid reviews for the production of actionable evidence for this study. We searched PUBMED from January 2020 to April 2021. All study designs including commentaries were included that focused on ACPs during COVID-19. Preprints/unpublished papers and Non-English language articles were excluded. Titles and abstracts were screened, full-texts were reviewed, and discrepancies resolved by discussion until consensus.

Results

From amongst 343 papers screened, 123 underwent full-text review. In total, 74 papers were included, comprising commentaries (39) and primary research studies covering cohorts, reviews, case studies, and cross-sectional designs (35). The various study types and settings such as hospitals, outpatient services, aged care and community indicated widespread interest in accelerating ACP documentation to facilitate management decisions and care which is unwanted/not aligned with goals. Enablers of ACP included targeted public awareness, availability of telehealth, easy access to online tools and adopting person-centered approach, respectful of patient autonomy and values. The emerging barriers were uncertainty regarding clinical outcomes, cultural and communication difficulties, barriers associated with legal and ethical considerations, infection control restrictions, lack of time, and limited resources and support systems.

Conclusion

The pandemic has provided opportunities for rapid implementation of ACP in creative ways to circumvent social distancing restrictions and high demand for health services. This review suggests the pandemic has provided some impetus to drive adaptable ACP conversations at individual, local, and international levels, affording an opportunity for longer term improvements in ACP practice and patient care. The enablers of ACP and the accelerated adoption evident here will hopefully continue to be part of everyday practice, with or without the pandemic.

Role of neuropilin-1 and its expression in Egyptian acute myeloid and acute lymphoid leukemia patients

Neuropilins are expressed in tumors vasculature and cells. Their expression is thought to be correlated with tumor angiogenesis and progression. In this study, we analyzed NRP-1 expression level in 40 acute leukemia patients [20 acute myeloid leukemia (AML) and 20 acute lymphoblastic leukemia (ALL)] and 10 healthy controls using Real-Time Quantitative Reverse-Transcriptase Polymerase Chain Reaction (RTQ-PCR) aiming to show Neuropilin-1 (NRP-1) gene expression pattern in acute leukemia patients and its role in disease severity and progression. NRP-1 was expressed in 80% and 95% of ALL and AML respectively with levels higher in patients than controls and in ALL than AML patients. NRP-1 levels were significantly correlated with blast percentage and complete remission. We conclude that NRP-1 is significantly associated with acute leukemia and that its level might serve as an indicator for disease severity and progression. NRP-1 signaling may represent a novel therapeutic approach for the treatment of acute leukemia subsets.

Lipoprotein lipase in heart and myocytes: characteristics with intralipid as substrate

1. Intralipid is a suitable substrate for measuring lipoprotein lipase activity in the presence of other triacylglycerol lipases in heart and myocytes. 2. Triacylglycerol lipase activity in heart and myocytes was increased 10-fold in the presence of serum at pH 7.4 and 8.1. The serum-stimulated activity in myocytes was 95% inhibited by saturating concentrations of antiserum to lipoprotein lipase. 3. Both heparin-releasable and non-releasable lipoprotein lipase fractions had similar Km values for Intralipid and a similar pattern of inhibition by high density lipoprotein but different responses to heparin. 4. Isoproterenol did not alter lipoprotein lipase activity in cardiac myocytes.