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To examine factors that influence decision-making, preferences, and plans related to advance care planning (ACP) and end-of-life care among persons with dementia and their caregivers, and examine how these may differ by race.
13 geographically dispersed Alzheimer’s Disease Centers across the United States.
431 racially diverse caregivers of persons with dementia.
Survey on “Care Planning for Individuals with Dementia.”
The respondents were knowledgeable about dementia and hospice care, indicated the person with dementia would want comfort care at the end stage of illness, and reported high levels of both legal ACP (e.g., living will; 87%) and informal ACP discussions (79%) for the person with dementia. However, notable racial differences were present. Relative to white persons with dementia, African American persons with dementia were reported to have a lower preference for comfort care (81% vs. 58%) and lower rates of completion of legal ACP (89% vs. 73%). Racial differences in ACP and care preferences were also reflected in geographic differences. Additionally, African American study partners had a lower level of knowledge about dementia and reported a greater influence of religious/spiritual beliefs on the desired types of medical treatments. Notably, all respondents indicated that more information about the stages of dementia and end-of-life health care options would be helpful.
Educational programs may be useful in reducing racial differences in attitudes towards ACP. These programs could focus on the clinical course of dementia and issues related to end-of-life care, including the importance of ACP.
The Ceratitis FAR complex (Diptera, Tephritidae) includes four economically important frugivorous flies (Ceratitis anonae, Ceratitis fasciventris, Ceratitis quilicii, Ceratitis rosa) whose immature stages and adult females cannot be properly resolved through morphological identification. In order to develop a simplified molecular tool for the identification of two of these species (C. rosa, C. quilicii), we selected a subset of six microsatellite markers out of a panel of 16 loci that were previously developed for the molecular differentiation of the taxa within the complex. These six markers were first tested in silico and then used for the actual genotyping of C. quilicii and C. rosa, resulting in the correct identification of all male reference specimens. Here, we propose an integrated morphological and molecular setup for the identification of the four species of the FAR complex. The decision map relies on preliminary DNA barcoding or morphological identification (when possible) to exclude species not belonging to the complex followed by (a) morphological identification of all adult male specimens and female C. anonae, (b) molecular identification via a panel of 16 microsatellite markers for immature stages, damaged vouchers and samples potentially including adult female C. fasciventris/C. quilicii/C. rosa and (c) molecular identification via a reduced panel of six microsatellite markers for samples including only C. quilicii and C. rosa. This simplified diagnostic setup was profitably implemented in the framework of the ERAfrica fruit fly project and will help correctly identify species within the FAR complex for their early detection and monitoring.
Introduction: Aligning health systems appropriately to the needs of the elderly is an urgent global priority, according to the WHO. In Canada, ED length of stay has risen 16% for elderly patients in the last year. Agitation requiring chemical restraint is a common, high-risk problem for elderly in the ED. Improving outcomes in this heterogeneous population remain difficult due to inability to effectively identify and evaluate delirium, frailty, multi-morbidity, and incompatibility with the ED system. A data-driven approach to complex health problems is a recognized emerging tool for healthcare innovation. New opportunities for targeted quality improvement in the ED will be uncovered by identifying the clinical characteristics of elderly patients with agitation, and the system process factors that influence their outcomes. Methods: We studied 400 patients in a case-control study at two tertiary-care EDs over five years. Patients were randomly selected if age was greater than 75 years. 200 cases of patients who received an intravenous dose of haloperidol, midazolam and/or lorazepam were selected as a surrogate data marker for having agitation. Controls were randomly matched by age and ED diagnosis. Standardized clinical, systems and process variables were collected. We conducted a univariate analysis. Results: Elderly given intravenous medications for agitation had increased mortality (OR 3.8 CI: 1.6-10.7, p<0.001) and ED length of stay (27 vs. 15 hours, p<0.001). No statistical significance was found in clinical characteristics, CTAS scores, PRISMA7 frailty scores nor sentinel or return visits. There was no statistical difference in median hospital length of stay (8 vs. 6 days, p<0.70). No differences were found in median time from ED physician seeing a patient to first consultant request (73 vs. 83 mins, p=0.75). The largest time intervals contributing to ED length of stay were from first consultant request to hospital request (15 vs. 12 hours, p=0.056) and hospitalization delay (13 vs. 7 hours, p=0.45). Conclusion: Identification of high-risk elderly patients for targeted intervention through a data-driven approach is feasible and informative. Traditional clinical characteristics remain unhelpful in identifying and evaluating outcomes in elderly with agitation. We have identified a process factor that is clinically relevant and pragmatic to evaluate in our ED system. Future research focused on optimizing systems process factors to improve quality of elderly care should be prioritized.
Children with CHD and acquired heart disease have unique, high-risk physiology. They may have a higher risk of adverse tracheal-intubation-associated events, as compared with children with non-cardiac disease.
Materials and methods
We sought to evaluate the occurrence of adverse tracheal-intubation-associated events in children with cardiac disease compared to children with non-cardiac disease. A retrospective analysis of tracheal intubations from 38 international paediatric ICUs was performed using the National Emergency Airway Registry for Children (NEAR4KIDS) quality improvement registry. The primary outcome was the occurrence of any tracheal-intubation-associated event. Secondary outcomes included the occurrence of severe tracheal-intubation-associated events, multiple intubation attempts, and oxygen desaturation.
A total of 8851 intubations were reported between July, 2012 and March, 2016. Cardiac patients were younger, more likely to have haemodynamic instability, and less likely to have respiratory failure as an indication. The overall frequency of tracheal-intubation-associated events was not different (cardiac: 17% versus non-cardiac: 16%, p=0.13), nor was the rate of severe tracheal-intubation-associated events (cardiac: 7% versus non-cardiac: 6%, p=0.11). Tracheal-intubation-associated cardiac arrest occurred more often in cardiac patients (2.80 versus 1.28%; p<0.001), even after adjusting for patient and provider differences (adjusted odds ratio 1.79; p=0.03). Multiple intubation attempts occurred less often in cardiac patients (p=0.04), and oxygen desaturations occurred more often, even after excluding patients with cyanotic heart disease.
The overall incidence of adverse tracheal-intubation-associated events in cardiac patients was not different from that in non-cardiac patients. However, the presence of a cardiac diagnosis was associated with a higher occurrence of both tracheal-intubation-associated cardiac arrest and oxygen desaturation.
Characterisation of genetic diversity in a large number of European pig populations has been undertaken with EC support. The populations sampled included local (rare) breeds, national varieties of the major international breeds, commercial lines and the Chinese Meishan breed. A second phase of the project will sample a further 50 Chinese breeds. Neutral genetic markers (AFLP and microsatellites), with individual or bulk typing, were used and compared.
DNA from 59 European pig populations was extracted on samples of about 50 individuals per population. Individuals were typed for 50 microsatellites and for 148 AFLP bands. A subset of 25 populations was typed for 20 microsatellites on pools of DNA. Allele frequencies were estimated by direct allele counting for the co-dominant markers. Frequencies of AFLP negative alleles (absent bands) were obtained by taking the square root of absent band frequencies. Within-breed variability was summarised using standard statistics: expected and observed heterozygosity, mean observed and effective numbers of alleles, and F statistics. Between-breed diversity analysis was based on a bootstrapped Neighbor-Joining (NJ) tree derived from Reynolds distances (DR). The standard distance of Nei (DS) was also calculated.
Transmission of acute respiratory infections (ARI) and acute gastroenteritis (AGE) often occurs in households. The aim of this study was to assess which proportion of ARI and AGE is introduced and transmitted by children in German households with children attending child care. We recruited families with children aged 0–6 years in Braunschweig (Germany), for a 4 months prospective cohort study in the winter period 2014/2015. Every household member was included in a health diary and used nasal swabs for pathogen identification in case of ARI. We defined a transmission if two persons had overlapping periods with symptoms and used additional definitions for sensitivity analyses. In total, 77 households participated with 282 persons. We observed 277 transmission events for ARI and 23 for AGE. In most cases, the first infected person in a household was a child (ARI: 63%, AGE: 53%), and the risk of within-household transmission was two times higher when the index case was a child. In 26 ARI-transmission events, pathogens were detected for both cases; hereof in 35% (95% confidence interval (17–56%)) the pathogens were different. Thus, symptomatic infections in household members, apparently linked in time, were in 2/3 associated with the same pathogens.
Rural communities face barriers to disaster preparedness and considerable risk of disasters. Emergency preparedness among rural communities has improved with funding from federal programs and implementation of a National Incident Management System. The objective of this project was to design and implement disaster exercises to test decision making by rural response partners to improve regional planning, collaboration, and readiness. Six functional exercises were developed and conducted among three rural Nebraska (USA) regions by the Center for Preparedness Education (CPE) at the University of Nebraska Medical Center (Omaha, Nebraska USA). A total of 83 command centers participated. Six functional exercises were designed to test regional response and command-level decision making, and each 3-hour exercise was followed by a 3-hour regional after action conference. Participant feedback, single agency debriefing feedback, and regional After Action Reports were analyzed. Functional exercises were able to test command-level decision making and operations at multiple agencies simultaneously with limited funding. Observations included emergency management jurisdiction barriers to utilization of unified command and establishment of joint information centers, limited utilization of documentation necessary for reimbursement, and the need to develop coordinated public messaging. Functional exercises are a key tool for testing command-level decision making and response at a higher level than what is typically achieved in tabletop or short, full-scale exercises. Functional exercises enable evaluation of command staff, identification of areas for improvement, and advancing regional collaboration among diverse response partners.
ObaidJM, BaileyG, WheelerH, MeyersL, MedcalfSJ, HansenKF, SangerKK, LoweJJ. Utilization of Functional Exercises to Build Regional Emergency Preparedness among Rural Health Organizations in the US. Prehosp Disaster Med. 2017;32(2):224–230.
Palmer amaranth and waterhemp have become increasingly troublesome weeds throughout the United States. Both species are highly adaptable and emerge continuously throughout the summer months, presenting the need for a residual PRE application in soybean. To improve season-long control of Amaranthus spp., 19 PRE treatments were evaluated on glyphosate-resistant Palmer amaranth in 2013 and 2014 at locations in Arkansas, Indiana, Nebraska, Illinois, and Tennessee; and on glyphosate-resistant waterhemp at locations in Illinois, Missouri, and Nebraska. The two Amaranthus species were analyzed separately; data for each species were pooled across site-years, and site-year was included as a random variable in the analyses. The dissipation of weed control throughout the course of the experiments was compared among treatments with the use of regression analysis where percent weed control was described as a function of time (the number of weeks after treatment [WAT]). At the mean (i.e., average) WAT (4.3 and 3.2 WAT for Palmer amaranth and waterhemp, respectively) isoxaflutole + S-metolachlor + metribuzin had the highest predicted control of Palmer amaranth (98%) and waterhemp (99%). Isoxaflutole + S-metolachlor + metribuzin, S-metolachlor + mesotrione, and flumioxazin + pyroxasulfone had a predicted control ≥ 97% and similar model parameter estimates, indicating control declined at similar rates for these treatments. Dicamba and 2,4-D provided some, short-lived residual control of Amaranthus spp. When dicamba was added to metribuzin or S-metolachlor, control increased compared to dicamba alone. Flumioxazin + pyroxasulfone, a currently labeled PRE, performed similarly to treatments containing isoxaflutole or mesotrione. Additional sites of action will provide soybean growers more opportunities to control these weeds and reduce the potential for herbicide resistance.
Herbicide-resistant Amaranthus spp. continue to cause management difficulties in soybean. New soybean technologies under development, including resistance to various combinations of glyphosate, glufosinate, dicamba, 2,4-D, isoxaflutole, and mesotrione, will make possible the use of additional herbicide sites of action in soybean than is currently available. When this research was conducted, these soybean traits were still regulated and testing herbicide programs with the appropriate soybean genetics in a single experiment was not feasible. Therefore, the effectiveness of various herbicide programs (PRE herbicides followed by POST herbicides) was evaluated in bare-ground experiments on glyphosate-resistant Palmer amaranth and glyphosate-resistant waterhemp (both tall and common) at locations in Arkansas, Illinois, Indiana, Missouri, Nebraska, and Tennessee. Twenty-five herbicide programs were evaluated; 5 of which were PRE herbicides only, 10 were PRE herbicides followed by POST herbicides 3 to 4 wks after (WA) the PRE application (EPOST), and 10 were PRE herbicides followed by POST herbicides 6 to 7 WA the PRE application (LPOST). Programs with EPOST herbicides provided 94% or greater control of Palmer amaranth and waterhemp at 3 to 4 WA the EPOST. Overall, programs with LPOST herbicides resulted in a period of weed emergence in which weeds would typically compete with a crop. Weeds were not completely controlled with the LPOST herbicides because weed sizes were larger (≥ 15 cm) compared with their sizes at the EPOST application (≤ 7 cm). Most programs with LPOST herbicides provided 80 to 95% control at 3 to 4 WA applied LPOST. Based on an orthogonal contrast, using a synthetic-auxin herbicide LPOST improves control of Palmer amaranth and waterhemp over programs not containing a synthetic-auxin LPOST. These results show herbicides that can be used in soybean and that contain auxinic- or HPPD-resistant traits will provide growers with an opportunity for better control of glyphosate-resistant Palmer amaranth and waterhemp over a wide range of geographies and environments.
We recently showed that the mRNA expression of genes encoding for specific nutrient sensing receptors, namely the free fatty acid receptors (FFAR) 1, 2, 3, and the hydroxycarboxylic acid receptor (HCAR) 2, undergo characteristic changes during the transition from late pregnancy to lactation in certain adipose tissues (AT) of dairy cows. We hypothesised that divergent energy intake achieved by feeding diets with either high or low portions of concentrate (60% v. 30% concentrate on a dry matter basis) will alter the mRNA expression of FFAR 1, 2, 3, as well as HCAR2 in subcutaneous (SCAT) and retroperitoneal AT (RPAT) of dairy cows in the first 3 weeks postpartum (p.p.). For this purpose, 20 multiparous German Holstein cows were allocated to either the high concentrate ration (HC, n=10) or the low concentrate ration (LC, n=10) from day 1 to 21 p.p. Serum samples and biopsies of SCAT (tail head) and RPAT (above the peritoneum) were obtained at day −21, 1 and 21 relative to parturition. The mRNA abundances were measured by quantitative PCR. The concentrations of short-chain fatty acid (SCFA) in serum were measured by gas chromatography-flame ionisation detector. The FFAR1 and FFAR2 mRNA abundance in RPAT was higher at day −21 compared to day 1. At day 21 p.p. the FFAR2 mRNA abundance was 2.5-fold higher in RPAT of the LC animals compared to the HC cows. The FFAR3 mRNA abundance tended to lower values in SCAT of the LC group at day 21. The HCAR2 mRNA abundance was neither affected by time nor by feeding in both AT. On day 21 p.p. the HC group had 1.7-fold greater serum concentrations of propionic acid and lower concentrations of acetic acid (trend: 1.2-fold lower) compared with the LC group. Positive correlations between the mRNA abundance of HCAR2 and peroxisome proliferator-activated receptor γ-2 (PPARG2) indicate a link between HCAR2 and PPARG2 in both AT. We observed an inverse regulation of FFAR2 and FFAR3 expression over time and both receptors also showed an inverse mRNA abundance as induced by different portions of concentrate. Thus, indicating divergent nutrient sensing of both receptors in AT during the transition period. We propose that the different manifestation of negative EB in both groups at day 21 after parturition affect at least FFAR2 expression in RPAT.
Primiparous ewes (n=32) were assigned to dietary treatments in a 2×2 factorial arrangement to determine effects of nutrient restriction and melatonin supplementation on maternal and fetal pancreatic weight, digestive enzyme activity, concentration of insulin-containing clusters and plasma insulin concentrations. Treatments consisted of nutrient intake with 60% (RES) or 100% (ADQ) of requirements and melatonin supplementation at 0 (CON) or 5 mg/day (MEL). Treatments began on day 50 of gestation and continued until day 130. On day 130, blood was collected under general anesthesia from the uterine artery, uterine vein, umbilical artery and umbilical vein for plasma insulin analysis. Ewes were then euthanized and the pancreas removed from the ewe and fetus, trimmed of mesentery and fat, weighed and snap-frozen until enzyme analysis. In addition, samples of pancreatic tissue were fixed in 10% formalin solution for histological examination including quantitative characterization of size and distribution of insulin-containing cell clusters. Nutrient restriction decreased (P⩽0.001) maternal pancreatic mass (g) and α-amylase activity (U/g, kU/pancreas, U/kg BW). Ewes supplemented with melatonin had increased pancreatic mass (P=0.03) and α-amylase content (kU/pancreas and U/kg BW). Melatonin supplementation decreased (P=0.002) maternal pancreatic insulin-positive tissue area (relative to section of tissue), and size of the largest insulin-containing cell cluster (P=0.04). Nutrient restriction decreased pancreatic insulin-positive tissue area (P=0.03) and percent of large (32 001 to 512 000 µm2) and giant (⩾512 001 µm2) insulin-containing cell clusters (P=0.04) in the fetus. Insulin concentrations in plasma from the uterine vein, umbilical artery and umbilical vein were greater (P⩽0.01) in animals receiving 100% requirements. When comparing ewes to fetuses, ewes had a greater percentage of medium insulin-containing cell clusters (2001 to 32 000 µm2) while fetuses had more (P<0.001) pancreatic insulin-positive area (relative to section of tissue) and a greater percent of small, large and giant insulin-containing cell clusters (P⩽0.02). Larger insulin-containing clusters were observed in fetuses (P<0.001) compared with ewes. In summary, the maternal pancreas responded to nutrient restriction by decreasing pancreatic weight and activity of digestive enzymes while melatonin supplementation increased α-amylase content. Nutrient restriction decreased the number of pancreatic insulin-containing clusters in fetuses while melatonin supplementation did not influence insulin concentration. This indicated using melatonin as a therapeutic agent to mitigate reduced pancreatic function in the fetus due to maternal nutrient restriction may not be beneficial.
Production systems for fattening pigs have been characterized over the last 2 decades by rising farm sizes coupled with increasing group sizes. These developments resulted in a serious public discussion regarding animal welfare and health in these intensive production systems. Even though large farm and group sizes came under severe criticism, it is still unknown whether these factors indeed negatively affect animal welfare. Therefore, the aim of this study was to assess the effect of group size (<15 v. 15 to 30 v. >30 pigs/pen) on various animal-based measures of the Welfare Quality® protocol for growing pigs under conventional fattening conditions. A total of 60 conventional pig fattening farms with different group sizes in Germany were included. Moderate bursitis (35%) was found as the most prevalent indicator of welfare-related problems, while its prevalence increased with age during the fattening period. However, differences between group sizes were not detected (P>0.05). The prevalence of moderately soiled bodies increased from 9.7% at the start to 14.2% at the end of the fattening period, whereas large pens showed a higher prevalence (15.8%) than small pens (10.4%; P<0.05). With increasing group size, the incidence of moderate wounds with 8.5% and 11.3% in small- and medium-sized pens, respectively, was lower (P<0.05) than in large-sized ones (16.3%). Contrary to bursitis and dirtiness, its prevalence decreased during the fattening period. Moderate manure was less often found in pigs fed by a dry feeder than in those fed by a liquid feeding system (P<0.05). The human–animal relationship was improved in large in comparison to small groups. On the contrary, negative social behaviour was found more often in large groups. Exploration of enrichment material decreased with increasing live weight. Given that all animals were tail-docked, tail biting was observed at a very low rate of 1.9%. In conclusion, the results indicate that BW and feeding system are determining factors for the welfare status, while group size was not proved to affect the welfare level under the studied conditions of pig fattening.
It is well known that web-based interventions can be effective treatments for depression. However, dropout rates in web-based interventions are typically high, especially in self-guided web-based interventions. Rigorous empirical evidence regarding factors influencing dropout in self-guided web-based interventions is lacking due to small study sample sizes. In this paper we examined predictors of dropout in an individual patient data meta-analysis to gain a better understanding of who may benefit from these interventions.
A comprehensive literature search for all randomized controlled trials (RCTs) of psychotherapy for adults with depression from 2006 to January 2013 was conducted. Next, we approached authors to collect the primary data of the selected studies. Predictors of dropout, such as socio-demographic, clinical, and intervention characteristics were examined.
Data from 2705 participants across ten RCTs of self-guided web-based interventions for depression were analysed. The multivariate analysis indicated that male gender [relative risk (RR) 1.08], lower educational level (primary education, RR 1.26) and co-morbid anxiety symptoms (RR 1.18) significantly increased the risk of dropping out, while for every additional 4 years of age, the risk of dropping out significantly decreased (RR 0.94).
Dropout can be predicted by several variables and is not randomly distributed. This knowledge may inform tailoring of online self-help interventions to prevent dropout in identified groups at risk.