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COVID-19 as a pandemic has disproportionately affected older adults, including those with dementia. The effects on health and social care systems has necessitated a rapid-response approach to care planning and decision-making in this population, with reflexivity and responsiveness to changing individual and system needs at its core. In light of this, a decision-making tool to help families of persons with dementia was developed using a combination of qualitative data and evidence synthesis.
Objectives
To develop a decision-aid using a combination of assessment and evidence-gathering methods for families of persons with dementia.
Methods
Semi-structured interviews with helpline staff from national end-of-life and supportive care organisations formed the basis of the tool design. Co-design with people living with dementia, current and former carers and experts in general practice and social care shaped the next stage. Simultaneously, a rapid review of current evidence on making decisions with older people at the end of life was undertaken.
Results
Output from interviews covered many topics, including trust, agency and confusion in making decisions in the context of COVID-19. The rapid review of existing evidence highlighted the need to consider both process and outcome elements of decision-making.
Conclusions
Combining different sources and forms of evidence was efficient and valuable in creating a novel decision-making tool for persons with dementia and their families within the context of COVID-19. The decision-aid covered care planning, caregiver support systems, access to information and contingency considerations. Upon publication, the tool was adopted by NHS England and other leading healthcare organisations.
The coronavirus pandemic (COVID-19) has affected the functioning and capacity of healthcare systems worldwide. COVID-19 has also disproportionately affected older adults, including those living with dementia. In the context of COVID-19, decision-making surrounding place of care and place of death in this population involves significant new challenges.
Objectives
To explore key factors that influence place of care and place of death decisions in older adults. A secondary aim was to investigate key factors that influence the process and outcome of these decisions in older adults. To apply findings from current evidence to the context of COVID-19.
Methods
Rapid review of reviews, undertaken using WHO guidance for rapid reviews. Ten papers were included for full data extraction. These papers were published between 2005-2020. Data extracted was synthesised using narrative synthesis, with thematic analysis and tabulation.
Results
Papers included discussed actual place of death, as well as preferred. Results were divided into papers that explored the process of decision-making, and those that explored decision-making outcomes. Factors such as caregiver capacity, the availability of multidisciplinary teams, cultural appropriateness of care packages and advanced care planning were found to be key.
Conclusions
The process and outcomes of decision-making for older people are affected by many factors – all of which have the potential to influence both patients and caregivers experience of illness and dying. Within the context of COVID-19, such decisions may have to be made rapidly and be reflexive to changing needs of systems and of families and patients.
We present the first Faraday rotation measure (RM) grid study of an individual low-mass cluster—the Fornax cluster—which is presently undergoing a series of mergers. Exploiting commissioning data for the POlarisation Sky Survey of the Universe’s Magnetism (POSSUM) covering a ${\sim}34$ square degree sky area using the Australian Square Kilometre Array Pathfinder (ASKAP), we achieve an RM grid density of ${\sim}25$ RMs per square degree from a 280-MHz band centred at 887 MHz, which is similar to expectations for forthcoming GHz-frequency ${\sim}3\pi$-steradian sky surveys. These data allow us to probe the extended magnetoionic structure of the cluster and its surroundings in unprecedented detail. We find that the scatter in the Faraday RM of confirmed background sources is increased by $16.8\pm2.4$ rad m−2 within 1$^\circ$ (360 kpc) projected distance to the cluster centre, which is 2–4 times larger than the spatial extent of the presently detectable X-ray-emitting intracluster medium (ICM). The mass of the Faraday-active plasma is larger than that of the X-ray-emitting ICM and exists in a density regime that broadly matches expectations for moderately dense components of the Warm-Hot Intergalactic Medium. We argue that forthcoming RM grids from both targeted and survey observations may be a singular probe of cosmic plasma in this regime. The morphology of the global Faraday depth enhancement is not uniform and isotropic but rather exhibits the classic morphology of an astrophysical bow shock on the southwest side of the main Fornax cluster, and an extended, swept-back wake on the northeastern side. Our favoured explanation for these phenomena is an ongoing merger between the main cluster and a subcluster to the southwest. The shock’s Mach angle and stand-off distance lead to a self-consistent transonic merger speed with Mach 1.06. The region hosting the Faraday depth enhancement also appears to show a decrement in both total and polarised radio emission compared to the broader field. We evaluate cosmic variance and free-free absorption by a pervasive cold dense gas surrounding NGC 1399 as possible causes but find both explanations unsatisfactory, warranting further observations. Generally, our study illustrates the scientific returns that can be expected from all-sky grids of discrete sources generated by forthcoming all-sky radio surveys.
The effect of minor orthopaedic day surgery (MiODS) on patient's mood.
Methods:
A prospective population-based cohort study of 148 consecutive patients with age above 18 and less than 65, an American Society of Anaesthesiology (ASA) score of 1, and the requirement of General Anaesthesia (GA) were included. The Medical Outcomes Study-Short Form 36 (SF-36), Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) were used pre- and postoperatively.
Results:
The mean physical component score of SF-36 before surgery was 45.3 (SD = ±10.1) and 8 weeks following surgery was 44.9 (SD = ±11.04) [n = 148, p = 0.51, 95%CI = (-1.03 -1.52)]. For the measurement of the changes in mood using BDI, BAI and SF-36, latent construct modelling was employed to increase validity. The covariance between mood pre- and post-operatively (cov = 69.44) corresponded to a correlation coefficient, r = 0.88 indicating that patients suffering a greater number of mood symptoms before surgery continue to have a greater number of symptoms following surgery. When the latent mood constructs were permitted to have different means the model fitted well with χ2 (df = 1) = 0.86 for which p = 0.77, thus the null hypothesis that MiODS has no effect on patient mood was rejected.
Conclusions:
MiODS affects patient mood which deteriorates at 8 weeks post-operatively regardless of the pre-operative patient mood state. More importantly patients suffering a greater number of mood symptoms before MiODS continue to have a greater number of symptoms following surgery.
To describe an investigation into 5 clinical cases of carbapenem-resistant Acinetobacter baumannii (CRAB).
Design:
Epidemiological investigation supplemented by whole-genome sequencing (WGS) of clinical and environmental isolates.
Setting:
A tertiary-care academic health center in Boston, Massachusetts.
Patients or participants:
Individuals identified with CRAB clinical infections.
Methods:
A detailed review of patient demographic and clinical data was conducted. Clinical isolates underwent phenotypic antimicrobial susceptibility testing and WGS. Infection control practices were evaluated, and CRAB isolates obtained through environmental sampling were assessed by WGS. Genomic relatedness was measured by single-nucleotide polymorphism (SNP) analysis.
Results:
Four clinical cases spanning 4 months were linked to a single index case; isolates differed by 1–7 SNPs and belonged to a single cluster. The index patient and 3 case patients were admitted to the same room prior to their development of CRAB infection, and 2 case patients were admitted to the same room within 48 hours of admission. A fourth case patient was admitted to a different unit. Environmental sampling identified highly contaminated areas, and WGS of 5 environmental isolates revealed that they were highly related to the clinical cluster.
Conclusions:
We report a cluster of highly resistant Acinetobacter baumannii that occurred in a burn ICU over 5 months and then spread to a separate ICU. Two case patients developed infections classified as community acquired under standard epidemiological definitions, but WGS revealed clonality, highlighting the risk of burn patients for early-onset nosocomial infections. An extensive investigation identified the role of environmental reservoirs.
Respiratory syncytial virus infection is the most frequent cause of acute lower respiratory tract disease in infants. A few reports have suggested that pulmonary hypertension is associated with increased severity of respiratory syncytial virus infection. We sought to determine the association between the pulmonary hypertension detected by echocardiography during respiratory syncytial virus bronchiolitis and clinical outcomes.
Methods:
We retrospectively reviewed 154 children admitted with respiratory syncytial virus bronchiolitis who had an echocardiography performed during the admission. The association between pulmonary hypertension and clinical outcomes including mortality, intensive care unit (ICU) admission, prolonged ICU stay (>10 days), tracheal intubation, and need of high frequency oscillator ventilation was evaluated.
Results:
Echocardiography detected pulmonary hypertension in 29 patients (18.7%). Pulmonary hypertension was observed more frequently in patients with congenital heart disease (CHD) (n = 11/33, 33%), chronic lung disease of infancy (n = 12/25, 48%), prematurity (<37 weeks gestational age, n = 17/59, 29%), and Down syndrome (n = 4/10, 40%). The presence of pulmonary hypertension was associated with morbidity (p < 0.001) and mortality (p = 0.02). However, in patients without these risk factors (n = 68), pulmonary hypertension was detected in five patients who presented with shock or poor perfusion. Chronic lung disease was associated with pulmonary hypertension (OR = 5.9, 95% CI 2.2–16.3, p = 0.0005). Multivariate logistic analysis demonstrated that pulmonary hypertension is associated with ICU admission (OR = 6.4, 95% CI 2.2–18.8, p = 0.0007), intubation (OR = 4.7, 95% CI 1.8–12.3, p = 0.002), high frequency oscillator ventilation (OR = 8.4, 95% CI 2.95–23.98, p < 0.0001), and prolonged ICU stay (OR = 4.9, 95% CI 2.0–11.7, p = 0.0004).
Conclusions:
Pulmonary hypertension detected by echocardiography during respiratory syncytial virus infection was associated with increased morbidity and mortality. Chronic lung disease was associated with pulmonary hypertension detected during respiratory syncytial virus bronchiolitis. Routine echocardiography is not warranted for previously healthy, haemodynamically stable patients with respiratory syncytial virus bronchiolitis.
Psychopathic traits predispose individuals toward antisocial behavior. Such antagonistic acts often result in “unsuccessful” outcomes such as incarceration. What mechanisms allow some people with relatively high levels of psychopathic traits to live “successful”, unincarcerated lives, in spite of their antisocial tendencies? Using neuroimaging, we investigated the possibility that “successful” psychopathic individuals exhibited greater development of neural structures that promote “successful” self-regulation, focusing on the ventrolateral prefrontal cortex (VLPFC). Across two structural magnetic resonance imaging studies of “successful” participants (Study 1: N = 80 individuals in long-term romantic relationships; Study 2: N = 64 undergraduates), we observed that gray matter density in the left and right VLPFC was positively associated with psychopathic traits. These preliminary results support a compensatory model of psychopathy, in which “successful” psychopathic individuals develop inhibitory mechanisms to compensate for their antisocial tendencies. Traditional models of psychopathy that emphasize deficits may be aided by such compensatory models that identify surfeits in neural and psychological processes.
The longevity of Cassini’s exploration of Saturn’s atmosphere (a third of a Saturnian year) means that we have been able to track the seasonal evolution of atmospheric temperatures, chemistry and cloud opacity over almost every season, from solstice to solstice and from perihelion to aphelion. Cassini has built upon the decades-long ground-based record to observe seasonal shifts in atmospheric temperature, finding a thermal response that lags behind the seasonal insolation with a lag time that increases with depth into the atmosphere, in agreement with radiative climate models. Seasonal hemispheric contrasts are perturbed at smaller scales by atmospheric circulation, such as belt/zone dynamics, the equatorial oscillations and the polar vortices. Temperature asymmetries are largest in the middle stratosphere and become insignificant near the radiative-convective boundary. Cassini has also measured southern-summertime asymmetries in atmospheric composition, including ammonia (the key species forming the topmost clouds), phosphine and para-hydrogen (both disequilibrium species) in the upper troposphere; and hydrocarbons deriving from the UV photolysis of methane in the stratosphere (principally ethane and acetylene). These chemical asymmetries are now altering in subtle ways due to (i) the changing chemical efficiencies with temperature and insolation and (ii) vertical motions associated with large-scale overturning in response to the seasonal temperature contrasts. Similarly, hemispheric contrasts in tropospheric aerosol opacity and coloration that were identified during the earliest phases of Cassini’s exploration have now reversed, suggesting an intricate link between the clouds and the temperatures. Finally, comparisons of observations between Voyager and Cassini (both observing in early northern spring, one Saturn year apart) show tantalizing suggestions of non-seasonal variability. Disentangling the competing effects of radiative balance, chemistry and dynamics in shaping the seasonal evolution of Saturn’s temperatures, clouds and composition remains the key challenge for the next generation of observations and numerical simulations.
This chapter reviews the state of our knowledge about Saturn’s polar atmosphere that has been revealed through Earth- and space-based observation as well as theoretical and numerical modeling. In particular, the Cassini mission to Saturn, which has been in orbit around the ringed planet since 2004, has revolutionized our understanding of the planet. The current review updates a previous review by Del Genio et al. (2009), written after Cassini’s primary mission phase that ended in 2008, by focusing on the north polar region of Saturn and comparing it to the southern high latitudes. Two prominent features in the northern high latitudes are the northern hexagon and the north polar vortex; we extensively review observational and theoretical investigations to date of both features. We also review the seasonal evolution of the polar regions using the observational data accumulated during the Cassini mission since 2004 (shortly after the northern winter solstice in 2002), through the equinox in 2009, and approaching the next solstice in 2017. We conclude the current review by listing unanswered questions and describing the observations of the polar regions planned for the Grand Finale phase of the Cassini mission between 2016 and 2017.
Whole apples have not been previously implicated in outbreaks of foodborne bacterial illness. We investigated a nationwide listeriosis outbreak associated with caramel apples. We defined an outbreak-associated case as an infection with one or both of two outbreak strains of Listeria monocytogenes highly related by whole-genome multilocus sequence typing (wgMLST) from 1 October 2014 to 1 February 2015. Single-interviewer open-ended interviews identified the source. Outbreak-associated cases were compared with non-outbreak-associated cases and traceback and environmental investigations were performed. We identified 35 outbreak-associated cases in 12 states; 34 (97%) were hospitalized and seven (20%) died. Outbreak-associated ill persons were more likely to have eaten commercially produced, prepackaged caramel apples (odds ratio 326·7, 95% confidence interval 32·2–3314). Environmental samples from the grower's packing facility and distribution-chain whole apples yielded isolates highly related to outbreak isolates by wgMLST. This outbreak highlights the importance of minimizing produce contamination with L. monocytogenes. Investigators should perform single-interviewer open-ended interviews when a food is not readily identified.
There are two questions that we need to answer when embarking on a discussion of global duties to aid. First, ‘What do we need to do to discharge our obligations to people in other countries?’, which is a question about what needs to be done as much as it is about what duties we actually have.
The second, and more philosophically interesting, question is ‘Why do we have these obligations?’ This relates to the reasons we have such duties and the justifications that exist for our global duties to aid. This is a prior question because the way in which we answer it will affect the way that we can answer the first question posed. Without an adequate definition of the reasons for our duties, we will struggle to provide a comprehensive description of what those duties are.
In this chapter I focus on three cosmopolitan approaches to answering this second question in the context of global health care justice: Pogge's negative duties based approach (Pogge 2008: 15), Brock's minimal needs view (Brock 2009: 54–5) and Henry Shue's model of basic rights (Shue 1980: 18). While these approaches share a common focus on attempting to justify the existence of global duties to aid, held by the wealthy and owed to the global poor, each offers a distinct interpretation of why such duties exist and suggests a range of options for fulfilling them. Importantly, while I argue that Shue's approach to our global duties is the most effective of the three, I consider they all offer important insight into the problem of global poverty and provide a variety of possible practical solutions to this problem.
I will argue that Shue's model offers the most comprehensive justification of global duties and in fact can be seen as accommodating or incorporating the other two approaches. The efficacy of Shue's approach can be seen to have its foundation in his rejection of the positive/negative rights dichotomy. Shue's rejection of this widely, and mistakenly, held view of rights and duties is central to his argument for global duties to aid, as I discuss below.
Virtual reality surgical simulation of mastoidectomy is a promising training tool for novices. Final-product analysis for assessing novice mastoidectomy performance could be limited by a peak or ceiling effect. These may be countered by simulator-integrated tutoring.
Methods:
Twenty-two participants completed a single session of self-directed practice of the mastoidectomy procedure in a virtual reality simulator. Participants were randomised for additional simulator-integrated tutoring. Performances were assessed at 10-minute intervals using final-product analysis.
Results:
In all, 45.5 per cent of participants peaked before the 60-minute time limit. None of the participants achieved the maximum score, suggesting a ceiling effect. The tutored group performed better than the non-tutored group but tutoring did not eliminate the peak or ceiling effects.
Conclusion:
Timing and adequate instruction is important when using final-product analysis to assess novice mastoidectomy performance. Improved real-time feedback and tutoring could address the limitations of final product based assessment.
Environmental specimens lining seawater blowholes of Whale Point, Ascension Island in the South Atlantic Ocean were collected (August 2012) and investigated by morphological and molecular techniques. Reported here, Acremonium stroudii (Ascomycota) sp. nov., a filamentous conidia-forming fungus, was the only fungus isolated from the samples collected. Molecular analysis of the material also indicates the presence of a novel species of green algae being present, however, isolation of this alga has not been possible. Instead it appears that this specimen, which belongs to a novel lineage within the Ulvales, sister to the Dilabifilum species, encourages fungal growth in culture and has been shown to form a symbiotic relationship on low nutrition agar plates, supported by investigation through electron microscopy. As no holotype of this species could be isolated in an axenic culture it was not suitable at this point to try to define this alga, especially as no established genus could be attributed. We recommend trying to further sample areas of Ascension Island looking for other members of this green algal lineage, both investigating free-living green algae and those which are found as lichenized photobionts.
Introduction: Ketamine, an N-methyl D-aspartate (NMDA) receptor antagonist, carries potential benefit in patients with neurological illness. The cerebrovascular/cerebral blood flow (CBF) response to ketamine has been poorly outlined in the literature. Methods: We performed a systematic review of the literature on the cerebrovascular/CBF effects of ketamine in both animal and human subjects. Results: We identified 38 animal studies, and 20 human studies. Within the animal studies, a variety of different models were utilized with the majority focusing changes in global CBF or regional cerebral blood flow (rCBF). Overall, ketamine led to an increase in either global CBF or rCBF, with a vasodilatory effect in medium cerebral vessels. With the human studies a total of 379 patients, 107 of which were control subjects, were studied. Most studies focused on either 131Xe CT or PET imaging with ketamine administration. There was a trend to an increase in global CBF and rCBF with ketamine administration. Conclusions: Animal models indicate an increase in global CBF and rCBF with ketamine administration. Human studies display an Oxford 2b, GRADE C, level of evidence to support an increase in global CBF and rCBF with ketamine administration in both healthy volunteers and elective surgical patients without neurological illness.
Background: There exists the role for novel agents in the management of refractory intracranial pressure (ICP) via targeting cerebral acidosis, hyperemia, and excitotoxicity. Objective: We performed 4 separate systematic reviews to determine the effect of tromethamine (THAM), indomethacin, and ketamine on ICP. Methods: All articles from MEDLINE, BIOSIS, EMBASE, Global Health, HealthStar, Scopus, Cochrane Library, the International Clinical Trials Registry Platform (inception to: February 2014 – THAM, July 2014 – Indomethacin, November 2013 - Ketamine), and gray literature were searched. The strength of evidence was adjudicated using both the Oxford and GRADE methodology. Results: Twelve articles were reviewed utilizing THAM while documenting ICP in neurosurgical patients. All but one study documented a decrease in ICP. Twelve original articles were reviewed utilizing indomethacin for ICP in neurological patients. All but one study documented a decrease in ICP. Seven articles were reviewed utilizing ketamine, documenting ICP in TBI patients, with 16 in non-trauma neurological patients. ICP did not increase in the studies during ketamine administration, and trended to decrease ICP. Conclusion: There exists Oxford level 2b, GRADE B evidence that THAM reduces ICP in the TBI and malignant ischemic infarct population. There exists Oxford level 2b, GRADE C evidence that indomethacin and ketamine reduce ICP in the adult severe TBI population.
Endothelial dysfunction and arterial stiffness are early predictors of CVD. Intervention studies have suggested that diet is related to vascular health, but most prior studies have tested individual foods or nutrients and relied on small samples of younger adults. The purpose of the present study was to examine the relationships between adherence to the 2010 Dietary Guidelines for Americans and vascular health in a large cross-sectional analysis. In 5887 adults in the Framingham Heart Study Offspring and Third Generation cohorts, diet quality was quantified with the 2010 Dietary Guidelines Adherence Index (DGAI-2010). Endothelial function was assessed via brachial artery ultrasound and arterial stiffness via arterial tonometry. In age-, sex- and cohort-adjusted analyses, a higher DGAI-2010 score (greater adherence) was modestly associated with a lower resting flow velocity, hyperaemic response, mean arterial pressure, carotid–femoral pulse wave velocity (PWV), and augmentation index, but not associated with resting arterial diameter or flow-mediated dilation (FMD). In multivariable models adjusting for cardiovascular risk factors, only the association of a higher DGAI-2010 score with a lower baseline flow velocity and augmentation index persisted (β = − 0·002, P= 0·003 and β = − 0·05 ± 0·02, P< 0·001, respectively). Age-stratified multivariate-adjusted analyses suggested that the relationship of higher DGAI-2010 scores with lower mean arterial pressure, PWV and augmentation index was more pronounced among adults younger than 50 years. Better adherence to the 2010 Dietary Guidelines for Americans, particularly in younger adults, is associated with a lower peripheral blood flow velocity and arterial wave reflection, but not FMD. The present results suggest a link between adherence to the Dietary Guidelines and favourable vascular health.
Radiocarbon dates (n = 18) from three archaeological sites on Adak Island, Alaska, were analyzed to understand the marine reservoir offset. Samples of marine and terrestrial origins recovered from the same archaeological context were compiled in nine pairs. The mean ΔR value calculated for them totaled 545 ± 10 yr. This value can be regarded as a sound estimate of the marine reservoir offset in the central Aleutians.