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Background and Aims The incidence of frailty increases as GFR decreases. In the end stage renal disease (ESRD) population frailty is associated with early mortality, increased hospitalisations, and significant symptom burden. We examined the use of formal frailty scoring and its role in identifying deteriorating patients with advanced renal disease. Method The Rockwood Clinical Frailty Scale (CFS) has high inter-rater reliability and correlates well with objective measures of frailty. We introduced routine recording of the CFS from January 2018 in the renal electronic record for patients on hospital haemodialysis therapy and those undergoing renal replacement therapy (RRT) planning. Based on CFS scoring patients were divided into ‘frail’ (CFS≥6) or ‘robust’ based (CFS Results A total of 1663 scores were recorded in 800 patients. 57.3% of patients were male. The median age at entry date was 66 (IQR 55,75) years. The median CFS score was 4 (IQR 3,5). At follow-up 74 (9.3%) had died. The median score prior to death was 5.5. 182 (22.8%) were ‘frail’. During the study period 469 patients had more than one score documented. Death at follow-up was more common in those who were ‘frail’, 20.9 vs 5.8%, p Conclusion The presence of ‘frailty’ as measured by CFS, or deterioration in CFS is associated with death at follow-up, independent of age, sex or diabetic nephropathy. Routine monitoring of frailty using the CFS provides a simple method to identify patients who are deteriorating and at risk of death. High or deteriorating CFS score should trigger clinical review and anticipatory care planning where appropriate.

Withdrawal of dialysis was the second most common cause of death recorded for renal replacement therapy (RRT) in Scotland in 2017; 23% of all deaths.1 In those ≥75 years, this rises to 28%; withdrawal and cardiovascular disease the equal primary causes.1 With an ageing population and more older patients on RRT, considerations around dialysis withdrawal are of increasing importance.1 There is a mean survival of 7.4 (range, 0–40) days once dialysis is withdrawn.2 Successful advanced care planning (ACP) improves end-of-life care (EOLC), the likelihood of dying in their preferred place of death (PPOD) and reduces psychological impact on the surviving carers.3 The degree to which ACP is initiated in this population is unknown which prompted this work. We did a retrospective analysis of adults receiving dialysis for end-stage renal disease. They were identified by the electronic patient record (EPR) (Strathclyde Electronic Renal Patient Record (SERPR), Vitalpulse, UK) in combination with the Greater Glasgow and Clyde electronic records (GGCER). Using SERPR, we identified deaths after dialysis withdrawal over 19 months (2015–2017). All data were anonymised. …

Background Over the last thirty years, the management of Malignant Ureteric Obstruction (MUO) has evolved from a single disciplinary decision to a multi-disciplinary approach. Careful consideration must be given to the risks and benefits of decompression of hydronephrosis for an individual patient. Though there is some recommendations within cancer specific guidelines, both the European Association of Urology and the American Urological Association guidelines recommend drainage or de-obstructing the urinary systems, there is a lack of consensus of opinion as well as strong evidence to support the decision process. Methodology The review was conducted using Cochrane and PRISMA guidelines. Outcomes that were identified amongst patients undergoing treatment for MUO included prognosis, quality of life (QOL), complications, morbidity and prognostication tools. Results The initial review found 169 papers. A total of 56 papers were included. Median survival was 6.4 months in the 50 papers that stated this outcome. The average reported complication rate was 41% with one fifth of patients never leaving hospital post procedure. Significant predictors to poor outcomes included low serum albumin, hyponatremia, the number of malignancy related events, and performance status of 2 or worse on the European cooperative cancer group. For those patients with 2 or more risk factors, median survival ranged from 1.7–2.6 months and 12-month survival ranged from 0%–12%. QOL using several measures ranged from 41–88%. Conclusion In this post Montgomery era with the concept of the 9reasonable patient9, can we continue to justify discussing decompression without stating the evidence-based risks from the emergent body of literature? We propose a multi-centre review of outcomes to enable evidence-based consultations for patients and their families.

Introduction: The Liverpool care pathway (LCP) was created to aid in the delivery of high-quality palliative care across myriad healthcare providers. After high-profile criticism of the pathway and a subsequent inquiry its use was suspended in the United Kingdom.Objective: The aim of this article is to systematically summarize the conditions leading to the rise and fall of the pathway. The authors also summarize the latest trials, which may point to a beneficial role of the pathway across diverse international settings.Methods: We comprehensively search PubMed, Embase, and Cochrane databases for articles on the use of the LCP from 1997 to present. Keywords ‘LCP,’ ‘Liverpool care pathway,’ and ‘palliative care pathway’ were used. Reference lists of included articles were also assessed for relevant articles.Results: There are two systematic reviews to date with no papers meeting criteria for inclusion. Several studies reported improvements in nausea and breathlessness when using the LCP. One comparative stu...

Background: Healthcare professionals find breaking bad news difficult and upsetting. Increasing cultural diversity has led to a greater number of patients whose first language differs to that of the healthcare provider, with more patients requiring a translator to facilitate communication. Hospitals often ask non-clinical translators to facilitate breaking bad news. We sought to explore the experiences of translators within a specialist oncology centre. Methods: Following ethical and governance approvals, semi-structured interviews were undertaken with five translators recruited from the specialist oncology centre. Interviews were audiotaped and transcribed verbatim. The data were analysed thematically, with major themes and subthemes identified. Setting: Outpatient setting of a regional cancer centre. Participants: Translators serving a regional cancer centre. Main outcome measures: Qualitative data identified through thematic analysis. Results: Major themes included the significant emotional impact of translating distressing information, the challenges of accurately conveying information in a culturally congruent format and the need for formal briefing, debriefing and support. Subthemes included feeling guilty for divulging distressing news, being the focus of patients’ distress or anger, and feeling in conflict with the patient or family and issues surrounding confidentiality. Translators also felt a strong sense of advocacy for the patients and found encounters with death and dying emotionally challenging. Conclusions: The increasing use of translators in the care of patients with advanced cancer is increasingly resulting in lay people being subject to similar emotional pressures faced by clinical staff, yet without the necessary formal training or support mechanisms that are recommended for clinicians. This exploratory study highlights the training and support needs of non-clinical staff as identifying a unique set of communication challenges faced by translators.

Choline is an essential nutrient necessary for synthesis of membrane phospholipids, cell signalling molecules and acetylcholine. The aim of this study was to detect and characterize the choline transporter-like 1 (CTL1/SLC44A1) protein in CNS tissues and the hybrid neuroblastoma x glioma cell line NG108-15, which synthesizes acetylcholine and has high affinity choline transport but does not express the cholinergic high affinity choline transporter 1. The presence of CTL1 protein in NG108-15 cells was confirmed using our antibody G103 which recognizes the C-terminal domain of human CTL1. Three different cognate small interfering RNAs were used to decrease CTL1 mRNA in NG108-15 cells, causing lowered CTL1 protein expression, choline uptake and cell growth. None of the small interfering RNAs influenced carnitine transport, demonstrating the absence of major non-specific effects. In parental C6 cells knockdown of CTL1 also reduced high affinity choline transport. Our results support the concept that CTL1 protein is necessary for the high affinity choline transport which supplies choline for cell growth. The presence of CTL1 protein in rat and human CNS regions, where it is found in neuronal, glial and endothelial cells, suggests that malfunction of this transporter could have important implications in nervous system development and repair following injury, and in neurodegenerative diseases.