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Background Early identification of older cardiac patients at high risk of readmission or mortality facilitates targeted deployment of preventive interventions. In the Netherlands, the frailty tool of the Dutch Safety Management System (DSMS-tool) consists of (the risk of) delirium, falling, functional impairment, and malnutrition and is currently used in all older hospitalised patients. However, its predictive performance in older cardiac patients is unknown. Aim To estimate the performance of the DSMS-tool alone and combined with other predictors in predicting hospital readmission or mortality within 6 months in acutely hospitalised older cardiac patients. Methods An individual patient data meta-analysis was performed on 529 acutely hospitalised cardiac patients ≥70 years from four prospective cohorts. Missing values for predictor and outcome variables were multiply imputed. We explored discrimination and calibration of: (1) the DSMS-tool alone; (2) the four components of the DSMS-tool and adding easily obtainable clinical predictors; (3) the four components of the DSMS-tool and more difficult to obtain predictors. Predictors in model 2 and 3 were selected using backward selection using a threshold of p = 0.157. We used shrunk c-statistics, calibration plots, regression slopes and Hosmer-Lemeshow p-values (PHL) to describe predictive performance in terms of discrimination and calibration. Results The population mean age was 82 years, 52% were males and 51% were admitted for heart failure. DSMS-tool was positive in 45% for delirium, 41% for falling, 37% for functional impairments and 29% for malnutrition. The incidence of hospital readmission or mortality gradually increased from 37 to 60% with increasing DSMS scores. Overall, the DSMS-tool discriminated limited (c-statistic 0.61, 95% 0.56–0.66). The final model included the DSMS-tool, diagnosis at admission and Charlson Comorbidity Index and had a c-statistic of 0.69 (95% 0.63–0.73; PHL was 0.658). Discussion The DSMS-tool alone has limited capacity to accurately estimate the risk of readmission or mortality in hospitalised older cardiac patients. Adding disease-specific risk factor information to the DSMS-tool resulted in a moderately performing model. To optimise the early identification of older hospitalised cardiac patients at high risk, the combination of geriatric and disease-specific predictors should be further explored.

Background: Palliative needs in older patients are often not timely identified. The Surprise Question (SQ) ‘would I be surprised if this patient died in the next year?’ is a well-researched tool that could aid in this effort. Most studies thus far involved physicians or specialist nurses, however the predictive value of the SQ when used by general nurses caring for hospitalized older patients is unknown. Objectives: To assess the predictive value of the SQ when used by general nurses and student nurses, in determining one year mortality in acutely hospitalized older patients. Design: Observational cohort study with an one year follow-up. Setting: One academic and one regional hospital in the Netherlands. Participants: Patients ≥70 years acutely hospitalized for at least 48 hours. Methods: Registered nurses and student nurses answered the SQ with ‘No’ (a positive SQ), ‘Yes’ or ‘Don't know’. Data on student nurses was analysed separately. The sensitivity, specificity, negative- and positive predictive values were calculated. Furthermore, logistic regression was performed to determine the odds of death. Results: 66 registered nurses answered the SQ for 252 patients of whom 77 (30.6%) died in the year after inclusion. Respectively, 44%, 14% and 22% died within the ‘No’, ‘Yes’ and ‘Don't know’ group. 85% of patients who died during admission or in the first three months post-discharge were identified. The sensitivity and specificity were 76.7% and 56.6%. The positive and negative predictive values were 43.7% and 84.6 %. Compared to persons in whom the SQ was answered with yes, a no answer was associated with an 4.7 times increased odds of dying in the next 12 months (odds ratio 4.71, 95% CI 2.43-9.12, p

Context Inadequate handovers between hospital and home can lead to adverse health outcomes. A group particularly at risk is patients at the end of life because of complex health problems, frequent care transitions, and involvement of many professionals. Objectives To investigate health care providers' views and experiences with regard to the transition from hospital to primary care in palliative care. Methods This was a descriptive qualitative study. Three focus group discussions were held with 28 nurses and two focus groups with nine physicians. Participants were recruited from primary and hospital care. The focus groups were audiorecorded, transcribed verbatim, and analyzed thematically. Results The following themes emerged from the data: lack of identification of and communication about the last phase of life; incomplete and insufficient handover; and uncertainty about responsibilities. Professionals emphasize the importance of proper handovers and transitional processes in these vulnerable patients. The transition between hospital to primary care is hindered by a lack of identification of the palliative phase and uncertainties about patient awareness. Direct communication between professionals is needed but lacking. The handover itself is currently primarily focused on physical aspects where psychosocial aspects were also found necessary. Furthermore, uncertainties with regard to physicians' responsibility for the patient seem to further hinder professionals in the transitional process. Conclusion Efforts should be made to enhance knowledge and skills around identification of palliative needs and communication with patients about the end of life, especially in the hospital setting.

Background Early start of palliative care improves the quality of life of eligible patients and their relatives. However, in hospital, patients who could benefit from palliative care are often not identified timely. The aim of this study is to assess how hospital-based nurses and physicians define the palliative phase, how they identify the palliative phase and what difficulties they face. Methods Semi-structured interviews were held with ten nurses and 18 physicians working at seven hospitals in the Netherlands. Data was analysed using thematic analysis. Results Nurses and physicians feel insecure about how to define the palliative phase and differentiate between an acute and extended phase. Great variation existed in what life expectancy is attributed to each phase. A variety of ways to identify the palliative phase were described: 1) Prognostication. 2) Treatment trade-off. 3) Assessment of patients’ preferences and needs. 4) Interprofessional collaboration. Professionals base prognostication on their experience but also search for clinical indicators. When benefits of treatment no longer outweigh the negatives, this was considered an, albeit late, identification point. To start a conversation on a patients’ palliative care needs was found to be difficult. Therefore, some respondents wait for patients to vocalize preferences themselves. Many professionals rely on interprofessional collaboration for identification, however uncertainty exist about responsibilities. Difficulties in identification occurred because of variance in definitions, unpredictability of non-oncological diseases, focus on treatment and difficulties in communication and collaboration. Conclusion These results provide insight into the challenges and difficulties hospital-based professionals experience in timely identification of patients with palliative care needs. Electronic supplementary material The online version of this article (10.1186/s12904-019-0439-0) contains supplementary material, which is available to authorized users.

Wnt/β-catenin signaling plays a crucial role in the regulation of colon tissue regeneration and the development of colon tumors. Under physiological conditions, β-catenin activity is tightly controlled. However, the majority of sporadic forms of colorectal cancer are characterized by inactivation of the tumor suppressor gene APC due to loss of heterozygosity (LOH), resulting in deregulation of the protein β-catenin. Apart from known β-catenin target genes like MYC, OPG, and DKK4, the gene TNFRSF19, a member of the TNF receptor superfamily, is regulated by β-catenin in mesenchymal stem cells (hMSC). We found that TNFRSF19 is frequently overexpressed in colorectal cancer cell lines and primary colorectal carcinomas. Further characterization revealed that both isoforms of TNFRSF19, TNFRSF19.1 and TNFRSF19.2, are regulated in a β-catenin dependent manner. The transcript TNFRSF19.2 encodes a 417 amino acid long protein containing a TRAF-binding site that links the TNFRSF19.2 to NF-κB signaling, whereas the isoform TNFRSF19.1 lacks this TRAF-binding site. Nevertheless both isoform 1 and 2 induced the activity of an NF-κB reporter gene. NF-κB signaling is important for inflammatory processes and chronic inflammatory diseases like ulcerative colitis and Crohn's disease, which are associated with increased risk for developing colorectal cancer. The observation that TNFRSF19 is a β-catenin target gene and TNFRSF19 receptor molecules activate NF-κB signaling shows that β-catenin regulates NF-κB activity via TNFRSF19, suggesting that TNFRSF19 may contribute to the development of colorectal tumors with deregulated β-catenin activity.