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Background:In 2017, a clinical nurse specialist (CNS) triaging role was created within a specialist palliative care community service (SPCCS) in Ireland to enhance the triage process. The aim of this study is to evaluate the effectiveness of the role regarding data collection and reporting. Structured feedback from healthcare professionals (HCPs) was obtained on the effects, challenges and sustainability of this role.Methods:This study used a mixed-methods approach. A quantitative analysis of referrals triaged by the SPCCS CNS over 2 years (2018–2019) was performed. Two focus groups with HCP's within the same service were completed in January 2020 and one-to-one interviews were conducted. The quantitative and qualitative results were merged using a triangulation protocol.Results:In 2017, new health service executive (HSE) standards to categorise the urgency of patient assessment were introduced. Quantitatively, an improvement within the triage process was seen, with an increase in compliance with national access standards. In 2018, compliance was 89.1%. In 2019, this was 96.8%, an improvement of 7.7%. A data discrepancy of 9.5% of referrals was noted over the first 9 months of 2018. After this, data documentation and congruency were seen to improve for the final 3 months of 2018 to 100% and remained at 100%. Qualitative data highlighted the benefits and challenges of the Triage CNS role. Mixed-methods correlation revealed corroboration between both using a triangulation protocol.Conclusion:The triage CNS role was pivotal as an initial point of referral contact. Increased compliance with national access standards occurred resulting in improvements in case and case-load management, information gathering, documentation, data collection and analysis.

ObjectivesIn 2015 the All-Ireland Institute of Hospice and Palliative Care identified access to specialist palliative care (SPC) advice out of hours (OOH) as their number one research priority. Receiving appropriate advice in response to palliative care needs OOH can address a patient/family’s concerns and prevent unnecessary hospital attendances.The aim of this study was to describe the current model of SPC OOH advice in the units that run this service, and gain a greater understanding of the nature of calls received by these services.MethodsA national online survey was sent to staff providing OOH advice to patients with SPC needs and a second survey was sent to the managers of the organisations within Ireland. Surveys were emailed with a link to managers of both inpatient and community services who provide SPC.Results78 clinical staff who provide OOH telephone advice responded to the survey and there were 23 responses to the managers’ survey. The most common type of call received was in relation to symptom management (97%); however, 73% of staff indicated that they had no specific training in giving OOH advice over the phone and furthermore 44% of respondents felt ill equipped and uncomfortable giving OOH advice for a number of reasons.ConclusionsThis survey has highlighted the need for support and training to the staff providing OOH SPC advice and that a set of standards to guide practice would be useful to this cohort of staff.

ObjectivesAllocating resources in palliative care is challenging due to the nature of life-limiting illness coupled with the propensity for significant physical symptoms and psychological distress. At present, there is no established system for triaging referrals and prioritising resource allocation.This study aimed to evaluate the feasibility of using a case mix assessment tool for telephone-assisted triaging of referrals to a specialist palliative care service. This assessed a patient’s phase of illness, Problem Severity Score (PSS) for complexity of symptom burden and psychological distress, and functional status.MethodsUsing a prospective consecutive case series approach, 450 referrals to community palliative care over a 6-month period were assessed. Scores for phase of illness, PSS and functional status were assessed at triage, as was the triage category of urgency of response.ResultsAnalysis demonstrated that phase of illness corresponds with triage category, with terminal or unstable phase patients significantly associated with urgent (category 1) referrals and highest priority for review. Decreased functional status and high PSS were useful predictors for increased urgency of referral.ConclusionsThese results demonstrate that this case mix tool could assist in the telephone assessment and triage of referrals to community palliative care.

Abstract:In an essay on "Phenomenological Aesthetics," the philosopher Roman Ingarden asserted that "works of art have the right to expect to be properly apprehended by observers who are in communion with them and to have their special value justly treated" (269). What does it mean to "properly apprehend" a novel? How do we know how to read something "justly"? What would it mean to claim that something has become "unreadable"? Can books somehow show us how they want to be read? Can lost forms of intelligibility and appreciation be recovered? How do we know whether the way we are reading a book is the way it asks to be read or is the product of our own, differently structured habitus? In this article, I ask these kinds of questions about novels by Sand, Gautier, and a few others with the help of Ingarden and Bourdieu as well as some recent critics.

Background:Healthcare efficiency involves demonstrating flexible inter-relationships between resource utilisation and patient need. In palliative care, five phases of patient illness have been identified: stable, unstable, deteriorating, terminal and bereaved. Evaluating the association between phase of illness and nursing activities could demonstrate clinical efficiency. Aim:The aim of this study was to evaluate the association between the phase of illness and the intensity of nursing care in a specialist palliative care unit. Methods:This was a prospective, observational cohort study of consecutive admissions (n=400) to a specialist palliative care unit. Patient phase of illness was documented on admission and daily thereafter. A nursing activity tool was developed, which scored daily nursing interventions (physical, psychological, family care and symptom control). This score was called the nursing total score (NTS) and reflected the intensity of nursing activities. Data were entered into SPSS and descriptive statistics weregenerated. Results:A total of 342 (85%) patients had full data recorded on admission. Stable, unstable, deteriorating and terminal phases were associated with progressively increasing median NTSs on days 1, 2, 3 and 4 (all P<0.01). Phase stabilisation from the unstable to the stable phase during this timeframe resulted in reductions in physical care (p=0.038), symptom management (p=0.007) and near-significant reductions in family support (p=0.06). Conclusion:A significant association was demonstrated between phase of illness and intensity of nursing activities, which were sensitive to phase changes, from unstable to stable. This demonstrates technically efficient resource utilisation and identifies a potential efficiency model for future evaluations of inpatient palliative care.

ObjectiveAlcohol-related liver disease (ALD) ranges from never-decompensated ALD (ndALD) to the life-threatening decompensated phenotype, known as alcohol-related hepatitis (AH). A multidimensional study of the clinical, histological and molecular features of these subtypes is lacking.DesignTwo large cohorts of patients were recruited in an international, observational multicentre study: a retrospective cohort of patients with ndALD (n=110) and a prospective cohort of patients with AH (n=225). Clinical, analytical, immunohistochemistry and hepatic RNA microarray analysis of both disease phenotypes were performed.ResultsAge and mean alcohol intake were similar in both groups. AH patients had greater aspartate amino transferase/alanine amino transferase ratio and lower gamma-glutamyl transferase levels than in ndALD patients. Patients with AH demonstrated profound liver failure and increased mortality. One-year mortality was 10% in ndALD and 50% in AH. Histologically, steatosis grade, ballooning and pericellular fibrosis were similar in both groups, while advanced fibrosis, Mallory-Denk bodies, bilirubinostasis, severe neutrophil infiltration and ductular reaction were more frequent among AH patients. Transcriptome analysis revealed a profound gene dysregulation within both phenotypes when compare to controls. While ndALD was characterised by deregulated expression of genes involved in matrisome and immune response, the development of AH resulted in a marked deregulation of genes involved in hepatocyte reprogramming and bile acid metabolism.ConclusionsDespite comparable alcohol intake, AH patients presented with worse liver function compared with ndALD patients. Bilirubinostasis, severe fibrosis and ductular reaction were prominent features of AH. AH patients exhibited a more profound deregulation of gene expression compared with ndALD patients.

Prompted by the prior work of critics like Ross Chambers and sociologist Pierre Bourdieu, this article pursues the possibility that there would be a way of reading Madame Bovary that is not just about learning to be a sophisticated and refined enough reader of Gustave Flaubert to appreciate all that he managed to achieve in that novel. Rather, while sophistication and refinement may constitute a typical first step in becoming a reader of Flaubert’s novel, the novel also, from a different perspective, offers a critical experience of the symbolic violence of a cultural universe structured by hierarchies of sophistication, potentially leaving you wondering what your fought-for sophistication is really worth. While pursuing this possibility, I examine how Madame Bovary continually figures acts of reading such as the one it is offering its readers, how a sensibility to free indirect style can be considered an index of sophistication, and how Flaubert uses figural language and certain prosodic effects to create collisions of registers of diction that destabilize any secure sense of linguistic sophistication.

Medical‐refractory severe alcoholic hepatitis (AH) has a high mortality. The national frequency, longer term outcomes and regional practices of AH liver transplantation (LT) in the United States are not well described, despite the increasing mortality from alcohol‐associated liver disease. We analyzed the trends in frequency and outcomes of UNOS data on 39 455 adult patients who underwent LT from 2014 to 2019, including AH LT recipients. LTs for AH increased 5‐fold, from 28 in 2014 to 138 in 2019, varying 8‐fold between UNOS regions. Three transplant centers accounted for 50%‐90% of AH LTs within each region. The number of transplant centers performing AH LTs increased from 14 in 2014 to 47 in 2019. AH patients were younger (mean = 39.4 years), had higher MELD scores (mean = 36.8), and were more often on dialysis (46.0%) and in ICU (38.4%), compared to other indications (all P< .05). One‐ and 5‐year graft survivals for AH LT recipients were 91.7% and 81.9%, respectively. The frequency of AH LT is increasing rapidly, with excellent medium‐term outcomes. An impact of AH recurrence on patient or graft survival is not apparent in this national analysis. There are marked geographic variations in practices, highlighting the lack of selection criteria standardization. This analysis of the US national transplant database shows that liver transplantation for alcoholic hepatitis has dramatically increased in recent years with excellent outcomes despite profound geographic variation in this practice. See the editorial from Maddur and Asrani on page 921.

The survival of patients with alcohol-related liver disease who receive a liver transplant has steadily improved to reach 80–85% at 1 year post-transplantation. The standard requirement for liver transplant—abstinence from alcohol for 6 months before transplantation—has been applied widely, but few data support the use of this rule as the sole criterion for selecting candidates for liver transplantation. When determining the suitability of a patient for transplantation, many liver transplant programmes now try to balance the period of abstinence against the risk of death associated with the severity of liver damage. Data accumulated since 2011 suggest that early liver transplantation (ie, transplantation without a specific period of abstinence) in patients with severe alcoholic hepatitis who do not respond to medical therapy is an effective therapeutic strategy. Further studies are needed to help refine the selection of patients with alcohol-related liver disease who have been abstinent for less than 6 months as suitable liver transplant candidates, and to improve the treatment of alcohol use disorder in those patients who have received a liver transplant.

Although the WHO strategy aims to eliminate the hepatitis C virus (HCV) as a public health threat by 2030, national strategies are variable worldwide. This study aimed to assess the establishment of different policies and strategies to eliminate HCV in the Americas.

Chronic liver disease due to alcohol-use disorder contributes markedly to the global burden of disease and mortality1–3. Alcoholic hepatitis is a severe and life-threatening form of alcohol-associated liver disease. The gut microbiota promotes ethanol-induced liver disease in mice4, but little is known about the microbial factors that are responsible for this process. Here we identify cytolysin—a two-subunit exotoxin that is secreted by Enterococcus faecalis5,6—as a cause of hepatocyte death and liver injury. Compared with non-alcoholic individuals or patients with alcohol-use disorder, patients with alcoholic hepatitis have increased faecal numbers of E. faecalis. The presence of cytolysin-positive (cytolytic) E. faecaliscorrelated with the severity of liver disease and with mortality in patients with alcoholic hepatitis. Using humanized mice that were colonized with bacteria from the faeces of patients with alcoholic hepatitis, we investigated the therapeutic effects of bacteriophages that target cytolytic E. faecalis. We found that these bacteriophages decrease cytolysin in the liver and abolish ethanol-induced liver disease in humanized mice. Our findings link cytolytic E. faecaliswith more severe clinical outcomes and increased mortality in patients with alcoholic hepatitis. We show that bacteriophages can specifically target cytolytic E. faecalis, which provides a method for precisely editing the intestinal microbiota. A clinical trial with a larger cohort is required to validate the relevance of our findings in humans, and to test whether this therapeutic approach is effective for patients with alcoholic hepatitis.

Alcohol-associated cirrhosis (AC) contributes up to 50% of the overall cirrhosis burden in the United States. AC is typically a comorbid condition in association with alcohol-use disorder. AC is often coexistent with other conditions. Several noninvasive methods are available to assist in recognizing the presence of AC. The natural history of AC is governed by the patients continued drinking or abstinence. All treatment starts with abstinence. After decompensation, the progression to acute-on-chronic liver failure heralds death. When patients who have deteriorated are declined liver transplant, palliative care should be considered.

Background:Following abdominal solid organ transplant (aSOT), valganciclovir (VGC) is recommended for cytomegalovirus (CMV) prophylaxis. This agent is associated with efficacy concerns, toxicity, and emergence of ganciclovir resistance. Objective: To evaluate the incidence of high-dose acyclovir (HD-A) prophylaxis failure in seropositive aSOT recipients (R+). Methods:This was a retrospective, single-center study of R+ transplanted without lymphocyte-depleting induction between January 1, 2000, and June 30, 2013, discharged with 3 months of HD-A prophylaxis (800 mg 4 times daily). The primary outcome was incidence of prophylaxis failure. Secondary outcomes were incidence of biopsy-proven tissue-invasive disease and prophylaxis failure for each allograft subgroup. Results:A total of 1525 patients met inclusion criteria: 944 renal (RTX), 108 simultaneous pancreas-kidneys (SPK), 462 liver (LTX), and 11 pancreas (PTX) transplant recipients. The composite rate of HD-A prophylaxis failure was 7%; incidence of tissue-invasive disease was 0.4%. Failure rates were 4.5%, 6.1%, 11%, and 20% in the RTX, SPK, LTX, and PTX populations, respectively; tissue-invasive disease rates were 0.2%, 0%, 0.7%, and 10%. Failure occurred more frequently in the LTX and PTX populations (P< 0.0001, HR = 2.6; P= 0.04 HR = 4.4). Incidence of tissue-invasive disease was minimal and not different in the RTX, LTX and SPK populations (P= 0.34). When evaluating recipients of seronegative allografts (D−), the composite failure rate was 3.4% with no significant difference between allograft subgroups (P= 0.45). Conclusion:HD-A may be a reasonable prophylaxis alternative for D−/R+ recipients, in the absence of lymphocyte-depleting induction, if low incidence viremia is tolerable. Future studies are needed to determine the long-term impact of CMV viremia in the setting of this prophylaxis approach.

This article uses the writings of Erving Goffman, M. M. Bakhtin, and Edward Sapir to pose some questions about what is happening when spoken language is produced. In particular, it looks at certain complexities of the partial roles of “animator,” “author,” and “principal,” into which Goffman proposed breaking down the role of speaker. It suggests that implicit in Goffman’s essay “Footing” is the possibility that even the analytic roles of animator, author, and principal will not be fine-grained enough to capture what happens through language use. This possibility is then pursued through a look at three scenes from Proust’s À la recherche du temps perdu in which the event of someone talking to themselves is represented and then analyzed, notably to reveal that it is not so easy to assume that the speech authored within any single mind-space is owned by the person associated with that mind.

Alcohol‐dependent liver transplantation (LT) patients who resume alcohol consumption are at risk for a number of alcohol‐related problems including liver injury and liver failure. Post‐LTpatients are strongly advised to remain abstinent. However, we do not know how well this population complies due to a lack of valid methods (self‐report and/or biomarkers) to identify alcohol use. Studies suggest as many as 50% resume alcohol use within 5 years. Phosphatidylethanol (PEth) is a new cell‐membrane phospholipid biomarker to identify alcohol use in the past 28 days. This prospective study followed 213 LTrecipients at 2 U.S. liver transplant centers. Sample included 213 LTsubjects; 70.9% (n= 151/213) had a history of alcohol dependence prior to transplantation and 29.1% (n= 62/213) served as non‐alcohol‐dependent controls. Subjects participated in face‐to‐face interviews to assess alcohol use using a 30‐day calendar. The protocol called for collecting blood samples at baseline, 6‐, and 12‐month follow‐up. Seventy percent (149/213) who reported no alcohol use had consistently negative PEth levels (<8 ng/ml). A total of 26.4% (57/213), 44 alcohol‐dependent patients and 13 controls, had a positive PEth test of >8 ng/ml either at baseline and/or during the follow‐up period. Alcohol‐dependent subjects (23.8%; n= 36/151) and 16.1% (n= 10/62) controls reported no alcohol use but had at least 1 positive PEth test. Of the 11.2% (24/213) post‐LTsubjects who reported recent alcohol use, over half (11/24) had a positive PEth. The 13 self‐reported alcohol users with a negative PEth level reported insufficient drinking to trigger PEth formation. Adoption of PEth as part of routine posttransplant care of LTrecipients will enable early identification of patients at risk of alcohol use and facilitate abstinence in patients with a history of alcohol dependence and alcohol‐related liver damage.

This introduction offers an initial account of the usefulness of an interdisciplinary encounter between the fields of linguistic anthropology and literary/cultural studies and, in doing so, introduces a series of key terms from linguistic anthropology and its way of studying language-in-use as a locus in which culture happens: nonreferential (orsocial)indexicality, entextualization, and metapragmatics. It establishes a set of common attitudes toward language and cultural production found in work by Bourdieu, Bakhtin, and a number of linguistic anthropologists (Michael Silverstein in particular). It suggests three analytical levels on which such an interdisciplinary encounter might take place: analysis of (1) works that themselves show an interest in language-in-use (for example, novels by writers such as Proust, Eliot, or Dostoevsky); (2) the “interactive text,” of which any given literary artifact could be said to be a precipitate (one construal of Bourdieu’s approach to an author like Flaubert); and (3) the role of the ongoing uptake of given language-based artifacts in maintaining and altering their meanings and values.

Alcohol-associated liver disease (ALD) and alcohol-associated hepatitis (AH) are dynamic disorders whose prognosis can be challenging to determine. A number of prognostic models have been developed to determine likelihood of death, when to refer for liver transplant (LT) and the role for glucocorticoids. Often these models were created with a specific application in mind but were found to have additional applications with further study. Those prognostic models that have stood the test of time are easy to use, have clear interpretations and employ objective parameters. These parameters most often include total bilirubin, INR and creatinine among other data points. Ideally, these models could be utilized at all phases of disease but in most, it is important for clinicians to consider drinking history and how it might alter the determined scores. Herein we provide a brief review of prognostic models in ALD and AH and provide practical tips and considerations to successfully make use of these tools in a clinical setting.

Alcoholic hepatitis (AH) causes great morbidity and mortality in the United States and throughout the world. Advances in therapy have proven difficult. In part, this reflects challenges in diagnosis, including the distinction between AH and acute-on-chronic liver failure. Liver biopsy is the best method to clarify the cause in circumstances whereby conflicting clinical data confound the diagnosis. All treatment of AH begins with abstinence from alcohol. All patients with AH should be given sufficient nutrition. Prednisolone has become the principal agent for treating patients with severe AH.

Alcohol-related liver disease is the second most frequent indication for liver transplantation (LT), yet as many as 90% to 95% of patients with alcohol-related end-stage liver disease are never formally evaluated for LT. Furthermore, despite its significance as a cause of chronic liver disease and indication for LT, it has received little attention in recent years for several reasons, including the good posttransplant short-term results, and the lack of specific “drugs” used for this disease. A writing group, endorsed by the International Liver Transplant Society, was convened to write guidelines on Liver Transplantation for Alcoholic Liver Disease to summarize current knowledge and provide answers to controversial and delicate ethical as well as clinical problems. We report here a short version of the guidelines (long version available at www.ilts.org) with the final recommendations graded for level of evidence. The writing group membership is expected to remain active for 5 years, reviewing the guideline annually, and updating the online version when appropriate.The ILTS guidelines for liver transplantation for alcoholic liver disease are set forth in this publication. Considerations include the candidate population and the challenges regarding both the assessment of sobriety before and the maintenance of quality of life after transplantation. The authors identify special considerations, including immunosuppression in this setting and the special considerations regarding patients with acute alcoholic hepatitis.

Alcoholic liver disease (ALD) is the major cause of life-threatening liver disease in Western countries. Abstinence from alcohol is the foundation of all treatment programmes for patients with ALD. Liver transplantation is a valuable option for patients with life-threatening ALD. Although the role of liver transplantation in the treatment of alcoholic hepatitis that is unresponsive to medical therapy is controversial, the latest prospective studies support this approach. No single measure gives a reliable estimate of the risk of drinking relapses before or after liver transplantation, but careful evaluation by an addiction specialist with a particular interest in transplant medicine is the best available approach. Survival, both on the waiting list and after the operation, is better in patients with ALD than in patients with HCV infection. Alcohol relapse may lead to liver damage and increased mortality, albeit usually after many years of renewed drinking. After liver transplantation, patients with ALD have increased rates of mortality and morbidity that are attributable to cardiovascular disease and new-onset cancers of the aerodigestive tract. The latter are probably linked to the high prevalence of smoking in this population. Cessation of smoking is thus an important goal in the care of patients with ALD after they have undergone liver transplantation.

Background:Although therapeutic drug monitoring is not required for patients receiving dabigatran to determine therapeutic efficacy, there are a number of other factors to consider. Currently, there are no studies evaluating pharmacist-led management of dabigatran. Objective:The role of inpatient pharmacists related to the management of dabigatran was evaluated. Methods:All adult patients who received at least 1 dose of dabigatran with a length of stay greater than 24 hours in a single-center, community hospital between May 2011 and August 2012 were retrospectively reviewed (n = 176). Results:Almost half of the patients (46%) required pharmacist intervention related to dabigatran management during hospital admission. Of patients receiving dabigatran prior to hospital admission, 18.4% were admitted on an inappropriate home dose. Transitioning between dabigatran and alternative anticoagulants accounted for the majority of pharmacist interventions (74.2%), with patients transitioning from unfractionated heparin to dabigatran occurring most frequently. Renal impairment requiring dose adjustment or drug discontinuation occurred in 6.3% of patients, whereas 6.8% of patients required pharmacist intervention for procedural anticoagulation. Inpatient therapy was determined to be relatively safe, with few patients (1.7%) requiring permanent discontinuation of dabigatran as a result of a bleeding complication. Conclusion:Pharmacists significantly contributed to the safe and appropriate use of dabigatran during hospitalization.

For patients with alcoholic liver disease, most liver transplant programs enforce a mandatory period of sustained abstinence prior to considering transplant. The ‘6-month’ rule may eliminate potentially acceptable transplant candidates from a lifesaving procedure. This review focuses on the use of sobriety length as a determinant of transplant candidacy and as a predictor of future alcohol use. We will also review the use of liver transplant in patients with severe alcoholic hepatitis, and the impact of alcohol use on posttransplant outcomes.

Black recipients undergoing liver transplantation (LT) for hepatitis C virus (HCV) have decreased patient and graft survival compared with white recipients, a finding that is primarily limited to black recipients of livers from white donors. The cause(s) for these discrepant outcomes are unclear but may be related to HCV disease recurrence. The rates of HCV-related disease recurrence and liver fibrosis progression among black and white liver transplant recipients have not been investigated.