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Many patients with advanced serious illness or at the end of life experience delirium, a potentially reversible form of acute brain dysfunction, which may impair ability to participate in medical decision-making and to engage with their loved ones. Screening for delirium provides an opportunity to address modifiable causes. Unfortunately, delirium remains underrecognized. The main objective of this pilot was to validate the brief Confusion Assessment Method (bCAM), a two-minute delirium-screening tool, in a veteran palliative care sample.
This was a pilot prospective, observational study that included hospitalized patients evaluated by the palliative care service at a single Veterans’ Administration Medical Center. The bCAM was compared against the reference standard, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition. Both assessments were blinded and conducted within 30 minutes of each other.
We enrolled 36 patients who were a median of 67 years (interquartile range 63–73). The primary reasons for admission to the hospital were sepsis or severe infection (33%), severe cardiac disease (including heart failure, cardiogenic shock, and myocardial infarction) (17%), or gastrointestinal/liver disease (17%). The bCAM performed well against the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, for detecting delirium, with a sensitivity (95% confidence interval) of 0.80 (0.4, 0.96) and specificity of 0.87 (0.67, 0.96).
Significance of Results
Delirium was present in 27% of patients enrolled and never recognized by the palliative care service in routine clinical care. The bCAM provided good sensitivity and specificity in a pilot of palliative care patients, providing a method for nonpsychiatrically trained personnel to detect delirium.
The aim of this study was to explore the support needs of Dutch informal caregivers of patients with amyotrophic lateral sclerosis (ALS).
Individual semi-structured interviews were conducted with 21 caregivers of ALS patients. Audio-taped interviews were transcribed and data were analyzed thematically.
A total of four global support needs emerged: “more personal time”, “assistance in applying for resources”, “counseling”, and “peer contact”. Despite their needs, caregivers are reluctant to apply for and accept support. They saw their own needs as secondary to the needs of the patients.
Significance of results
ALS seems to lead to an intensive caregiving situation with multiple needs emerging in a short period. This study offers targets for the development of supportive interventions. A proactive approach seems essential, acknowledging the importance of the role of the caregivers in the care process at an early stage, informing them about the risk of burden, monitoring their wellbeing, and repeatedly offering support opportunities. Using e-health may help tailor interventions to the caregivers’ support needs.
Depression and metabolic syndrome (MetS) are frequently comorbid disorders that are independently associated with premature mortality. Conversely, cardiorespiratory fitness (CRF) is associated with reduced mortality risk. These factors may interact to impact mortality; however, their effects have not been assessed concurrently. This analysis assessed the mortality risk of comorbid depression/MetS and the effect of CRF on mortality in those with depression/MetS.
Prospective study of 47 702 adults in the Cooper Center Longitudinal Study. Mortality status was attained from the National Death Index. History of depression was determined by patient response (yes or no) to a standardized medical history questionnaire. MetS was categorized using the American Heart Association/National Heart, Lung, and Blood Institute criteria. CRF was estimated from the final speed/grade of a treadmill graded exercise test.
13.9% reported a history of depression, 21.4% met criteria for MetS, and 3.0% met criteria for both MetS and history of depression. History of depression (HR = 1.24, p = 0.003) and MetS (HR = 1.28, p < 0.001) were independently associated with an increased mortality risk, with the greatest mortality risk among individuals with both a history of depression and MetS (HR = 1.59, p < 0.001). Higher CRF was associated with a significantly lower risk of mortality (p < 0.001) in all individuals, including those with MetS and/or a history of depression.
Those with higher levels CRF had reduced mortality risk in the context of depression/MetS. Interventions that improve CRF could have substantial impact on the health of persons with depression/MetS.
Measurements made by an underwater glider deployed near the Ross Ice Shelf were used to identify the presence of Ice Shelf Water (ISW), which is defined as seawater with its potential temperature lower than its surface freezing point temperature. Properties logged by the glider included in situ temperature, electrical conductivity, pressure, GPS location at surfacings and time. For most of the first 30 recorded dives of its deployment, evidence suggests the glider was prevented from surfacing due to being under the ice shelf. For dives under the ice shelf, farthest from the ice shelf front, ISW layers of varying thicknesses and depth locations were observed; between 2 m thick (centred at 231 m depth) to >93 m thick (centred at >360 m). For dives under the ice shelf, close to the ice shelf front, either no ISW was observed or ISW layers were centred at shallower depths (116–127 m). Thicker ISW layers (e.g. up to 250 m thickness centred at 421 m) were observed for some glider dives in open water in front of the Ross Ice Shelf. No in situ supercooling (water colder than the pressure-dependent freezing point temperature) was observed.
Objectives: The aim of this study was to describe cognitive, academic, and psychosocial outcomes after an incident demyelinating event (acquired demyelinating syndromes, ADS) in childhood and to investigate the contribution of brain lesions and confirmed MS diagnosis on outcome. Methods: Thirty-six patients with ADS (mean age=12.2 years, SD=2.7, range: 7–16 years) underwent brain MRI scans at presentation and at 6-months follow-up. T2-weighted lesions on MRI were assessed using a binary classification. At 6-months follow-up, patients underwent neuropsychological evaluation and were compared with 42 healthy controls. Results: Cognitive, academic, and behavioral outcomes did not differ between the patients with ADS and controls. Three of 36 patients (8.3%) were identified with cognitive impairment, as determined by performance falling ≤1.5 SD below normative values on more than four independent tests in the battery. Poor performance on a visuomotor integration task was most common, observed among 6/32 patients, but this did not differ significantly from controls. Twelve of 36 patients received a diagnosis of MS within 3 years post-ADS. Patients with MS did not differ from children with monophasic ADS in terms of cognitive performance at the 6-months follow-up. Fatigue symptoms were reported in 50% of patients, irrespective of MS diagnosis. Presence of brain lesions at onset and 6 months post-incident demyelinating event did not associate with cognitive outcome. Conclusions: Children with ADS experience a favorable short-term neurocognitive outcome, even those confirmed to have MS. Longitudinal evaluations of children with monophasic ADS and MS are required to determine the possibility of late-emerging sequelae and their time course. (JINS, 2016, 22, 1050–1060)
Background: Sarcoidosis is a multiorgan autoimmune disease characterized by the presence of non-caseating granulomas. The diagnosis can be difficult, particularly with central nervous system (CNS) involvement, and pathology outside of the CNS has to be carefully evaluated. Early and correct diagnosis is crucial for appropriate management particularly in children where sarcoidosis and neurosarcoidosis are rare. Methods: We describe a 16 year old previously healthy boy who presented with progressive pyramidal neurological signs and symptoms localizable primarily to the brain stem. Results: Initial imaging revealed striking brainstem, as well as cerebral, cerebellar and spinal cord perivascular enhancement. Lung involvement was subclinical with a miliary pattern on chest imaging and needle biopsy revealed an interstitial lymphocytic infiltration. Extensive serum and CSF rheumatological, autoimmune and infectious investigations were noncontributory. Serum ACE levels were at first within normal limits. Steroid treatment stabilized symptoms and perhaps coincidentally, separate rituximab treatments were followed within days by vertigo (with a new pontine lesion) or a respiratory decompensation. A wedge lung biopsy revealed granulomatosis. Current treatment consists of mycophenolate, methotrexate with a prednisone wean. Conclusions: This case report reinforces the varied manifestations and mimics of sarcoidosis (including CLIPPERS) and highlights the need for a high index of suspicion despite apparently negative investigations.
The goal of the present study was to apply experimental economic methods in an online supermarket to examine the effects of nutrient profiling, and differential pricing based on the nutrient profile, on the overall diet quality, energy and macronutrients of the foods purchased, and diet cost.
Participants were provided nutrient profiling scores or price adjustments based on nutrient profile scores while completing a hypothetical grocery shopping task. Prices of foods in the top 20 % of nutrient profiling scores were reduced (subsidized) by 25 % while those in the bottom 20 % of scores were increased (taxed) by 25 %. We evaluated the independent and interactive effects of nutrient profiling or price adjustments on overall diet quality of foods purchased as assessed by the NuVal® score, energy and macronutrients purchased and diet cost in a 2×2 factorial design.
A large (>10 000 food items) online experimental supermarket in the USA.
Seven hundred and eighty-one women.
Providing nutrient profiling scores improved overall diet quality of foods purchased. Price changes were associated with an increase in protein purchased, an increase in energy cost, and reduced carbohydrate and protein costs. Price changes and nutrient profiling combined were associated with no unique benefits beyond price changes or nutrient profiling alone.
Providing nutrient profile score increased overall NuVal® score without a reduction in energy purchased. Combining nutrient profiling and price changes did not show an overall benefit to diet quality and may be less useful than nutrient profiling alone to consumers who want to increase overall diet quality of foods purchased.
A distinctive feature of polar regions is the formation of ice clusters attached to the seabed, known as ‘anchor ice’. Anchor ice plays an important role in mobilizing bed sediments, and serves ecological roles providing habitats, or as an agent of disturbance creating potentially fatal environments to benthic fauna. The sublittoral zone associated with the landward margin represents the most likely environment for anchor ice formation, where conditions conducive to the advection of supercooled water from sub-ice-shelf cavities are favourable. We develop a framework to estimate the areal extent of anchor ice formation assuming a northerly flow of 75m deep supercooled water plumes from the Ross and McMurdo Ice Shelf cavities, Antarctica. In McMurdo Sound our results indicate that regions beneath the McMurdo Ice Shelf, extending along Brown Peninsula and White and Black Islands, are likely conducive to anchor ice formation. Anchor ice may also form along the Hut Point Peninsula and around Ross Island, and in pockets along the southern Victoria Land coast. The limitations of our approach include an imposed northerly flow of Ice Shelf Water, poorly constrained sub-ice-shelf bathymetry, and temporal variability in supercooled water depth production, particularly in the eastern Sound.
In North America, terrestrial records of biodiversity and climate change that span Marine Oxygen Isotope Stage (MIS) 5 are rare. Where found, they provide insight into how the coupling of the ocean–atmosphere system is manifested in biotic and environmental records and how the biosphere responds to climate change. In 2010–2011, construction at Ziegler Reservoir near Snowmass Village, Colorado (USA) revealed a nearly continuous, lacustrine/wetland sedimentary sequence that preserved evidence of past plant communities between ~140 and 55 ka, including all of MIS 5. At an elevation of 2705 m, the Ziegler Reservoir fossil site also contained thousands of well-preserved bones of late Pleistocene megafauna, including mastodons, mammoths, ground sloths, horses, camels, deer, bison, black bear, coyotes, and bighorn sheep. In addition, the site contained more than 26,000 bones from at least 30 species of small animals including salamanders, otters, muskrats, minks, rabbits, beavers, frogs, lizards, snakes, fish, and birds. The combination of macro- and micro-vertebrates, invertebrates, terrestrial and aquatic plant macrofossils, a detailed pollen record, and a robust, directly dated stratigraphic framework shows that high-elevation ecosystems in the Rocky Mountains of Colorado are climatically sensitive and varied dramatically throughout MIS 5.
There have been a number of studies that have attempted to estimate the past radiocarbon reservoir effects in Qinghai Lake, China. This article reports on measurements on modern samples collected at the lake in October 2003 and October 2009, which allow us to better understand the systematics of the lake and shed new insights on the processes occurring in the lake. The results indicate that atmospheric exchange of 14C is the main process affecting surface dissolved inorganic carbon (DIC) in the lake, but dissolved organic carbon (DOC) can be explained as a combination of sources. We also conclude that sediment carbon can be explained by a model where input from the surrounding rivers and groundwater are important, in agreement with the model of Yu et al. (2007).
Attacks on and interference with health care services, providers, facilities, transports, and patients in situations of armed conflict, civil disturbance, and state repression pose enormous challenges to health care delivery in circumstances where it is most needed. In times of armed conflict, international humanitarian law (IHL) provides robust protection to health care services, but it also contains gaps. Moreover, IHL does not cover situations where an armed conflict does not exist. This paper focuses on the importance of a human rights approach to addressing these challenges, relying on the highest attainable standard of health as well as to civil and political rights. In particular we take the Committee on Economic, Social and Cultural Rights General Comment No. 14 (on Article 12 of the International Covenant on Economic, Social and Cultural Rights) as a normative framework from which states' obligations to respect, protect and fulfil the right to health across all conflict settings can be further developed.
Sharper nanotips are required for application in nanoprobing systems due to a shrinking contact size with each new transistor technology node. We describe a two-step etching process to fabricate W nanotips with controllable tip dimensions. The first process is an optimized AC electrochemical etching in KOH to fabricate nanotips with a radius of curvature (ROC) down to 90 nm. This was followed by a secondary nanotip sharpening process by laser irradiation in KOH. High aspect ratio nanotips with ROC close to 20 nm were obtained. Finally we demonstrate the application of the fabricated nanotips for nanoprobing on advanced technology SRAM devices.
The dependence of oxygen isotope fractionation on ice growth rate during the freezing of sea water is investigated based on laboratory experiments and field observations in McMurdo Sound, Antarctica. The laboratory experiments were performed in a tank filled with sea water, with sea ice grown under calm conditions at various room temperatures ranging from −5°C to −20°C. In McMurdo Sound, the ice growth rate was monitored using thermistor probes for first-year landfast ice that grew to ∼2 m in thickness. Combining these datasets allows, for the first time, examination of fractionation at a wide range of growth rates from 0.8 × 10−7 to 9.3 × 10−7 m s−1. In the analysis a stagnant boundary-layer model is parameterized using these two independent datasets. As a result, the optimum values of equilibrium pure-ice fractionation factor and boundary-layer thickness are estimated. It is suggested that a regime shift may occur at a growth rate of ∼2.0 × 10−7 m s−1. A case study on sea ice in the Sea of Okhotsk, where the growth rate is modeled by coupling the thermodynamic properties of the sea ice with meteorological data, demonstrates the utility of the fitted models.
This study compared the receptive and expressive language profiles of verbally expressive children and adolescents with Down Syndrome (DS) and those with Fragile X syndrome (FXS) and examined the extent to which these profiles reliably differentiate the diagnostic groups. A total of twenty-four verbal participants with DS (mean age: 12 years), twenty-two verbal participants with FXS (mean age: 12 years), and twenty-seven participants with typical development (TD; mean age = 4 years) completed standardized measures of receptive and expressive vocabulary and grammar, as well as a conversational language sample. Study results indicate that there are distinct DS and FXS language profiles, which are characterized by differences in grammatical ability. The diagnostic groups were not differentiated based on vocabulary performance. This study supports the existence of unique language profiles associated with DS and FXS.