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Peer reviewed: True, BACKGROUND: The need for end-of-life care in the community increased significantly during the COVID-19 pandemic. Primary care services, including general practitioners and community nurses, had a critical role in providing such care, rapidly changing their working practices to meet demand. Little is known about primary care responses to a major change in place of care towards the end of life, or the implications for future end-of-life care services. AIM: To gather general practitioner and community nurse perspectives on factors that facilitated community end-of-life care during the COVID-19 pandemic, and to use this to develop recommendations to improve future delivery of end-of-life care. DESIGN: Qualitative interview study with thematic analysis, followed by refinement of themes and recommendations in consultation with an expert advisory group. PARTICIPANTS: General practitioners (n = 8) and community nurses (n = 17) working in primary care in the UK. RESULTS: General practitioner and community nurse perspectives on factors critical to sustaining community end-of-life care were identified under three themes: (1) partnership working is key, (2) care planning for end-of-life needs improvement, and (3) importance of the physical presence of primary care professionals. Drawing on participants' experiences and behaviour change theory, recommendations are proposed to improve end-of-life care in primary care. CONCLUSIONS: To sustain and embed positive change, an increased policy focus on primary care in end-of-life care is required. Targeted interventions developed during COVID-19, including online team meetings and education, new prescribing systems and unified guidance, could increase capacity and capability of the primary care workforce to deliver community end-of-life care.

Community nursing caseloads are vast, with differing complexities. The Sheffield Caseload Classification Tool (SCCT) was co-produced with community nurses and nurse managers to help assign patients on a community caseload according to nursing need and complexity of care. The tool comprises 12 packages of care and three complexities. The present study aimed to test the inter-rater reliability of the tool. This was a table top validation exercise conducted in one city in South Yorkshire. A purposive sample of six community nurses assessed 69 case studies using the tool and assigned a package of care and complexity of need to each. These were compared with pre-determined answers. Cronbach's alpha for the care package was 0.979, indicating very good reliability, with individual nurse reliability values also being high. Fleiss's kappa coefficient for the care packages was 0.771, indicating substantial agreement among nurses; it was 0.423 for complexity ratings, indicating moderate agreement. The SCCT can reliably assign patients to the appropriate skilled nurse and care package. It helps prioritise and plan a community nursing caseload, ensuring efficient use of staff time to deliver appropriate care to patients with differing needs.

Editorial, 19 June Higginson and colleagues highlight the need for high quality, community end-of-life care as a significant ongoing concern for the NHS.1 The role of primary care in end-of-life care needs much more attention, as reported by The BMJ over the past two decades.23 Primary care has had a key role in the delivery of end-of-life care to patients dying at home during the covid-19 pandemic, adapting rapidly to meet increased need. …

End-of-life (EoL) care is an important role in community nursing. In order to assess a community nursing team's performance in the delivery of EoL care, an evaluation of the EoL care template was undertaken from electronic patient records. Records were assessed against a set of four care priorities across 23 nursing teams in a large acute/community trust. Some 103 electronic patient records were evaluated out of a convenience sample of 110 (94% response rate). The results demonstrated that patients' wishes are being discussed and documented and the priorities of care are being considered with patients needing EoL care. Thus, patients and their families are being supported by the community nursing service, which is communicating with them sensitively and involving patients in the decision-making process. In some cases, the EoL Care Template was not fully completed, which would result in poorer communication across teams and organisations of practice within the wider community. Future action will be focused on continuing to encourage and improve the use of the EoL care template as well as the local online e-learning package for EoL care.

AimsTo assess the ‘Okay to Stay’ plan to investigate if this reduces visits to emergency departments, unplanned admissions and elective admission to hospital in elderly patients with long-term health conditions.BackgroundThe incidence of long-term conditions is rising as the elderly population increases, resulting in more people from this group attending emergency departments and being admitted to hospital. Okay to Stay is a simple plan for people with long-term conditions to help them remain in their own home if they suffer an acute exacerbation in their health. It was co-designed with professional and patient representatives with the aim of empowering patients and their carers to more effectively manage their long-term conditions.MethodsData from 50 patients (20 males, 30 females, mean baseline age 77.5 years) were compared 12 months before implementation of the plan and in the subsequent 12 months, with the significance of effects assessed at the 5 per cent significance level using t-tests.FindingsVisits to emergency departments were reduced by 1.86; unplanned emergency admissions were reduced by 1.28 and planned elective admissions were raised by 0.22 admissions per annum. The reduction in visits to the emergency department was significant (p = 0.009) and the reduction in emergency admissions was significant (p = 0.015). The change in elective admissions was not significant (p = 0.855). The Okay to Stay plan is effective in reducing visits to the emergency department and unplanned hospital admissions in people with long-term conditions. This is a positive step to supporting vulnerable and complex patients who are cared for at home, and facilitates the recognition by the individual of the possibility to stay at home with the support of health professionals. There are potential cost benefits to the investment of initiating an Okay to Stay plan through the avoidance of visits to the emergency department and non-elective admissions to hospital.

Acuity and dependency in the community nursing caseload in combination with safe staffing levels are a national issue of concern. Current evidence suggests that there are no clear approaches to determining staff capacity and skill mix in these community settings. As community nursing caseloads are large with differing complexities, there is a need to allocate community nursing with the best skill mix to achieve the best patient outcomes. A city-wide service improvement initiative developed a tool to classify and categorise patient demand and this was linked to an electronic patient record system. The aim was to formulate an effective management response to different levels of acuity and dependency within community nursing teams and a consensus approach was used to allow the definition of complexity for twelve packages of care. The tool was piloted by a group of community nurses to assess the validity as a method to achieve a caseload classification. Seventy nurses were trained and applied the tool to 3000 patient referrals. Based on this, standards of care were agreed including expectations of assessment, intervention, visit length and frequency. Community nursing caseloads can now be organised according to acuity and complexity of patient need, which determines allocation of staff and skill mix.

The ability of native uncoupling protein-3 (UCP3) to uncouple mitochondrial oxidative phosphorylation is controversial. We measured the expression level of UCP3 and the proton conductance of skeletal muscle mitochondria isolated from transgenic mice overexpressing human UCP3 (UCP3-tg) and from UCP3 knockout (UCP3-KO) mice. The concentration of UCP3 in UCP3-tg mitochondria was approximately 3 microg/mg protein, approximately 20-fold higher than the wild type value. UCP3-tg mitochondria had increased nonphosphorylating respiration rates, decreased respiratory control, and approximately 4-fold increased proton conductance compared with the wild type. However, this increased uncoupling in UCP3-tg mitochondria was not caused by native function of UCP3 because it was not proportional to the increase in UCP3 concentration and was neither activated by superoxide nor inhibited by GDP. UCP3 was undetectable in mitochondria from UCP3-KO mice. Nevertheless, UCP3-KO mitochondria had unchanged respiration rates, respiratory control ratios, and proton conductance compared with the wild type under a variety of assay conditions. We conclude that uncoupling in UCP3-tg mice is an artifact of transgenic expression, and that UCP3 does not catalyze the basal proton conductance of skeletal muscle mitochondria in the absence of activators such as superoxide.

Uncoupling protein-3 (UCP-3) is a recently identified member of the mitochondrial transporter superfamily that is expressed predominantly in skeletal muscle. However, its close relative UCP-1 is expressed exclusively in brown adipose tissue, a tissue whose main function is fat combustion and thermogenesis. Studies on the expression of UCP-3 in animals and humans in different physiological situations support a role for UCP-3 in energy balance and lipid metabolism. However, direct evidence for these roles is lacking. Here we describe the creation of transgenic mice that overexpress human UCP-3 in skeletal muscle. These mice are hyperphagic but weigh less than their wild-type littermates. Magnetic resonance imaging shows a striking reduction in adipose tissue mass. The mice also exhibit lower fasting plasma glucose and insulin levels and an increased glucose clearance rate. This provides evidence that skeletal muscle UCP-3 has the potential to influence metabolic rate and glucose homeostasis in the whole animal.

In order to better understand the practice of dispersant use, a review has been undertaken of marine oil spills over a 10 year period (1995-2005), looking in particular at variations between different regions and oil-types. This viewpoint presents and analyses the review data and examines a range of dispersant use policies. The paper also discusses the need for a reasoned approach to dispersant use and introduces past cases and studies to highlight lessons learned over the past ten years, focussing on dispersant effectiveness and monitoring; toxicity and environmental effects; the use of dispersants in low salinity waters; response planning and future research needs.

This article is based on the premise that mental wellness for older adults can be promoted through communication and presents a model drawing on the constructs of contemplating, caring, coping, and conversing. The importance of interpersonal communication processes in the care of older adults and some barriers to communication and mental wellness are briefly reviewed. This article challenges nurses to develop awareness of their own caregiving styles and communication processes, and to assist others (e.g., family caregivers, care receivers) to communicate and interact more effectively to advance mental wellness for older adults.

The chiral synthesis of the potent and selective alpha-2A antagonist, BRL 48962, is described. Evaluation of BRL 48962 at cloned human alpha-adrenoceptors indicates that this antagonist has a selectivity in the order of 30-fold for the alpha-2A subtype.

Although research-based practice was advocated in 1972 in the Briggs report, it is suggested that nursing has failed to rise to the challenge. This paper examines some of the explanations why nurses have difficulty in combining research-based theory and practice.