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The objectives of this study were to develop and refine EMPOWER (Enhancing and Mobilizing the POtential for Wellness and Resilience), a brief manualized cognitive-behavioral, acceptance-based intervention for surrogate decision-makers of critically ill patients and to evaluate its preliminary feasibility, acceptability, and promise in improving surrogates’ mental health and patient outcomes.
Part 1 involved obtaining qualitative stakeholder feedback from 5 bereaved surrogates and 10 critical care and mental health clinicians. Stakeholders were provided with the manual and prompted for feedback on its content, format, and language. Feedback was organized and incorporated into the manual, which was then re-circulated until consensus. In Part 2, surrogates of critically ill patients admitted to an intensive care unit (ICU) reporting moderate anxiety or close attachment were enrolled in an open trial of EMPOWER. Surrogates completed six, 15–20 min modules, totaling 1.5–2 h. Surrogates were administered measures of peritraumatic distress, experiential avoidance, prolonged grief, distress tolerance, anxiety, and depression at pre-intervention, post-intervention, and at 1-month and 3-month follow-up assessments.
Part 1 resulted in changes to the EMPOWER manual, including reducing jargon, improving navigability, making EMPOWER applicable for a range of illness scenarios, rearranging the modules, and adding further instructions and psychoeducation. Part 2 findings suggested that EMPOWER is feasible, with 100% of participants completing all modules. The acceptability of EMPOWER appeared strong, with high ratings of effectiveness and helpfulness (M = 8/10). Results showed immediate post-intervention improvements in anxiety (d = −0.41), peritraumatic distress (d = −0.24), and experiential avoidance (d = −0.23). At the 3-month follow-up assessments, surrogates exhibited improvements in prolonged grief symptoms (d = −0.94), depression (d = −0.23), anxiety (d = −0.29), and experiential avoidance (d = −0.30).
Significance of results
Preliminary data suggest that EMPOWER is feasible, acceptable, and associated with notable improvements in psychological symptoms among surrogates. Future research should examine EMPOWER with a larger sample in a randomized controlled trial.
The 2020 update of the Canadian Stroke Best Practice Recommendations (CSBPR) for the Secondary Prevention of Stroke includes current evidence-based recommendations and expert opinions intended for use by clinicians across a broad range of settings. They provide guidance for the prevention of ischemic stroke recurrence through the identification and management of modifiable vascular risk factors. Recommendations address triage, diagnostic testing, lifestyle behaviors, vaping, hypertension, hyperlipidemia, diabetes, atrial fibrillation, other cardiac conditions, antiplatelet and anticoagulant therapies, and carotid and vertebral artery disease. This update of the previous 2017 guideline contains several new or revised recommendations. Recommendations regarding triage and initial assessment of acute transient ischemic attack (TIA) and minor stroke have been simplified, and selected aspects of the etiological stroke workup are revised. Updated treatment recommendations based on new evidence have been made for dual antiplatelet therapy for TIA and minor stroke; anticoagulant therapy for atrial fibrillation; embolic strokes of undetermined source; low-density lipoprotein lowering; hypertriglyceridemia; diabetes treatment; and patent foramen ovale management. A new section has been added to provide practical guidance regarding temporary interruption of antithrombotic therapy for surgical procedures. Cancer-associated ischemic stroke is addressed. A section on virtual care delivery of secondary stroke prevention services in included to highlight a shifting paradigm of care delivery made more urgent by the global pandemic. In addition, where appropriate, sex differences as they pertain to treatments have been addressed. The CSBPR include supporting materials such as implementation resources to facilitate the adoption of evidence into practice and performance measures to enable monitoring of uptake and effectiveness of recommendations.
Consumption is driven by children’s sensory acceptance, but little is known about the sensory characteristics of vegetables that children commonly eat. A greater understanding could help design more effective interventions to help raise intakes, thus realising beneficial health effects. This study sought to: (1) Understand the vegetable consumption patterns in children, with and without potatoes, using the Australian and WHO definitions. (2) Describe the sensory characteristics of vegetables consumed by children by age group, level of intake and variety. (3) Determine the vegetable preferences of children, by age group, level of intake and variety.
Analysis of National Nutrition Survey data, combining reported vegetable intake with sensory characteristics described by a trained panel.
A nationally representative sample of Australian children and adolescents aged 2–17·9 years (n 2812).
While consumption increased in older age groups, variety remained constant. Greater variety, however, was associated with higher vegetable consumption. Potato intake increased with consumption, contributing over one-third of total vegetable intake for highest vegetable consumption and for older age groups. Children favoured relatively sweet vegetables and reported lower consumption of bitter vegetables. There were no differences in the sensory properties of vegetables consumed by children in different age groups. After potatoes, carrots, sweetcorn, mixtures, fruiting and cruciferous types were preferred vegetables.
Children tend to prefer vegetables with sensory characteristics consistent with innate taste preferences (sweet and low bitterness). Increasing exposure to a variety of vegetables may help increase the persistently low vegetable consumption patterns of children.
A 10% prevalence of intracranial aneurysms in patients with coarctation of the aorta has been described in a few studies. Our objective is to describe the rate of intracranial aneurysm detection in patients with coarctation of the aorta in the current era. We hypothesise that, with earlier detection and coarctation of the aorta intervention, the rate of intracranial aneurysm is lower than previously reported and screening imaging may only be warranted in older patients or patients with certain risk factors.
This is a retrospective study of 102 patients aged 13 years and older with coarctation who underwent brain computed tomography angiography, magnetic resonance imaging (MRI), or magnetic resonance angiography between January, 2000 and February, 2018.
The median age of coarctation repair was 4.4 months (2 days–47 years) and the initial repair was primarily surgical (90.2%). There were 11 former smokers, 4 current smokers, and 13 patients with ongoing hypertension. Imaging modalities included computed tomography angiography (13.7%), MRI (41.2%), and magnetic resonance angiography (46.1%), performed at a median age of 33.3 years, 22.4 years, and 25 years, respectively. There were 42 studies performed for screening, 48 studies performed for neurologic symptoms, and 12 studies performed for both screening and symptoms. There were no intracranial aneurysms detected in this study.
These results suggest that the rate of intracranial aneurysms may be lower than previously reported and larger studies should explore the risk of intracranial aneurysms in coarctation of the aorta in the current era.
The concept of electoral competition plays a central role in many subfields of political science, but no consensus exists on how to measure it. One key challenge is how to conceptualize and measure electoral competitiveness at the district level across alternative electoral systems. Recent efforts to meet this challenge have introduced general measures of competitiveness which rest on explicit calculations about how votes translate into seats, but also implicit assumptions about how effort maps into votes (and how costly effort is). We investigate how assumptions about the effort-to-votes mapping affect the units in which competitiveness is best measured, arguing in favor of vote-share-denominated measures and against vote-share-per-seat measures. Whether elections under multimember proportional representation systems are judged more or less competitive than single-member plurality or runoff elections depends directly on the units in which competitiveness is assessed (and hence on assumptions about how effort maps into votes).
High-SiO2 rocks referred to as oceanic plagiogranites are common within the crustal sequences of ophiolites; however, their mode of petrogenesis is controversial with both late-stage fractional crystallization and partial melting models being proposed. Here, we present new whole-rock data from plagiogranitic dyke-like bodies and lenses from the lower and middle sections of the sheeted dyke complex of the Cretaceous Muslim Bagh Ophiolite, northwestern Pakistan. The plagiogranites have similar geochemical signatures that are inconsistent with them being the fractionation products of the mafic units of the Muslim Bagh Ophiolite. However, the plagiogranites all display very low TiO2 contents (<0.4 wt%), implying that they formed by partial melting of mafic rocks. Melt modelling of a crustal gabbro from the Muslim Bagh Ophiolite shows that the trace-element signature of the plagiogranites can be replicated by 5–10% melting of a crustal hornblende gabbro with amphibole as a residual phase, resulting in a concave-up middle rare Earth element pattern. Compositional similarities between the Muslim Bagh Ophiolite plagiogranites and Archaean TTG (trondhjemite–tonalite–granodiorite) has implications for the generation of juvenile Archaean continental crust. As the Muslim Bagh Ophiolite was derived in a supra-subduction zone, it is suggested that some Archaean TTG may have been derived from melting of mafic upper crust in early subduction-like settings. However, due to the small volume of Muslim Bagh Ophiolite plagiogranites, it is inferred that they can be instructive on the petrogenesis of some, but not all, Archaean TTG.
Embryo splitting might be used to increase offspring yield and for molecular analysis of embryo competence. How splitting affects developmental potential of embryos is unknown. This research aimed to study the effect of bovine blastocyst splitting on morphological and gene expression homogeneity of demi-embryos and on embryo competence during elongation. Grade I bovine blastocyst produced in vitro were split into halves and distributed in nine groups (3 × 3 setting according to age and stage before splitting; age: days 7–9; stage: early, expanded and hatched blastocysts). Homogeneity and survival rate in vitro after splitting (12 h, days 10 and 13) and the effect of splitting on embryo development at elongation after embryo transfer (day 17) were assessed morphologically and by RT-qPCR. The genes analysed were OCT4, SOX2, NANOG, CDX2, TP1, TKDP1, EOMES, and BAX. Approximately 90% of split embryos had a well conserved defined inner cell mass (ICM), 70% of the halves had similar size with no differences in gene expression 12 h after splitting. Split embryos cultured further conserved normal and comparable morphology at day 10 of development; this situation changes at day 13 when embryo morphology and gene expression differed markedly among demi-embryos. Split and non-split blastocysts were transferred to recipient cows and were recovered at day 17. Fifty per cent of non-split embryos were larger than 100 mm (33% for split embryos). OCT4, SOX2, TP1 and EOMES levels were down-regulated in elongated embryos derived from split blastocysts. In conclusion, splitting day-8 blastocysts yields homogenous demi-embryos in terms of developmental capability and gene expression, but the initiation of the filamentous stage seems to be affected by the splitting.
Describe the epidemiology of healthcare-related (ie, healthcare-associated and hospital-acquired) pneumonia due to methicillin-resistant Staphylococcus aureus (MRSA) among hospitalized patients in community hospitals.
Retrospective cohort study.
Twenty-four community hospitals in the southeastern United States affiliated with the Duke Infection Control Outreach Network (median size, 211 beds; range, 103–658 beds).
Adult patients with healthcare-related MRSA pneumonia admitted to study hospitals from January 1, 2008, to December 31, 2012, were identified using surveillance data. Seasonal and annual incidence rates (cases per 100,000 patient-days) were estimated using generalized estimating equation models. Characteristics of community-onset and hospital-onset cases were compared.
A total of 1,048 cases of healthcare-related pneumonia due to MRSA were observed during 5,863,941 patient-days. The annual incidence rate of healthcare-related MRSA pneumonia increased from 11.3 cases per 100,000 patient-days (95% confidence interval [CI], 6.8–18.7) in 2008 to 15.5 cases per 100,000 patient-days (95% CI, 8.4–28.5) in 2012 (P = .055). The incidence rate was highest in winter months and lowest in summer months (15.4 vs 11.1 cases per 100,000 patient-days; incidence rate ratio, 1.39 [95% CI, 1.06–1.82]; P = .016). A total of 814 cases (77.7%) were community-onset healthcare-associated pneumonia cases; only 49 cases (4.7%) were ventilator-associated cases. Of 811 patients whose disposition was known, 240 (29.6%) died during hospitalization or were discharged to hospice.
From 2008 through 2012, the incidence of healthcare-related MRSA pneumonia among patients who were admitted to a large network of community hospitals increased, despite the decreasing incidence of invasive MRSA infections nationwide. Additional study is warranted to evaluate trends in this important and potentially modifiable public health problem.
Infect Control Hosp Epidemiol 2014;35(12):1452–1457
Patients with Fontan palliation and single-ventricle physiology encounter multiple comorbidities including plastic bronchitis, a disease characterised by the plugging of small and large airways by rubbery, white casts. To date, no controlled clinical trials have demonstrated effective treatment of plastic bronchitis. We report the application of aerosolised heparin, which has published success in non-cardiac-related pulmonary disease, for this complication in a Fontan patient.
In the study of matter, both living and inanimate, the breakthrough discoveries and most scientists' intellectual obsessions often flow from what we call emergent behavior: phenomena not readily predictable from a detailed knowledge of the material subunits alone. We call systems that display emergent behavior complex adaptive matter, and their relevant organizing principles are unique to their scales of length and time. This issue of MRS Bulletin provides an overview of the aggregate of research on complex adaptive matter through a survey of five examples, ranging from intrinsically disordered electron matter in high-temperature superconductors to protein aggregates in amyloid diseases like Alzheimer's. We explain the philosophy and motivation for this research, noting that the study of emergent phenomena complements a globally reductionist scientific approach by seeking to identify, with intellectual precision, the relevant organizing principles governing the behavior. Our authors focus on the character of emergence for their particular systems, the role of materials research approaches to the problems, and the efforts to identify the organizing principles at work.
Many of the key challenges and opportunities in the study of matter involve complex and collective phenomena in which many parts exhibit organization without a central instruction set or clock. At the core of this enterprise in the study of matter is the search for an understanding of “emergent behavior”—that is, phenomena whose ultimate cause involves interactions between many simple units but which cannot be easily predicted from knowledge of the component parts alone. Examples of emergence are ordered convection cells in fluids, metabolic processes in cells, cognition, and stripes in superconductors. Our shorthand designation for soft, hard, and living matter exhibiting emergent behavior is “complex adaptive matter.”
Recent studies of capital budgeting procedures used by business executives suggest increasing use of present value methods. This study compares Massachusetts greenhouse business managers use of capital budgeting procedures to those of Fortune 1000 firms. Results indicate that different capital budgeting procedures are used and that the payback criterion remains the most popular for the farm firms studied. Some implications for Extension finance educators are drawn.
We examined the within-crown distributions of male and female bagworm, Thyridopteryx ephemeraeformis (Haworth), pupae on Juniperus virginiana L. as a function of prior defoliation. This was to evaluate the hypothesis that the differential movement of females to the upper crown before pupation would be strongest on heavily defoliated trees. Differential stratification of the sexes occurred irrespective of degree of defoliation, and despite the fact that competition, as evidenced by higher mortality of pupae and reduced weight of egg masses, was apparently greatest at the top of moderately and severely defoliated hosts. There was no relationship between height of pupation and risk of parasitism for either sex. Female larvae were ca. 4-fold more likely than males to abandon a low-lying host upon which they had fed and to ascend the trunks of nearby trees before pupating. Enhancement of larval dispersal by females is the most plausible explanation for the stratified distribution of bagworm pupae within trees.
Seasonal and daily patterns of ballooning, and behavioral processes involved in aerial dispersal of the bagworm, Thyridopteryx ephemeraeformis (Haworth), were studied on Juniperus virginiana L. in Kentucky. The aerial dispersal period began in mid-May 1983 and lasted ca. 1 month. About 75% of dispersing larvae ballooned after making a bag. Settling velocities were determined for larvae with and without bags and trailing varying lengths of silk; a model was then developed that predicts dispersal distance for a particular wind speed and departure height. Most aerial dispersal is probably short-range. The bag reduced potential dispersal distance, but larvae with bags survived ca. 2 days longer than those without bags when exposed to abiotic factors off of a host. Larvae without bags ballooned mostly in morning, whereas 80% of the larvae dispersing with a bag ballooned in the afternoon. These patterns may be related to the diel periodicity of emergence of neonate larvae from old female bags, and the subsequent behavior of 1st instars prior to dispersal. A large proportion of each cohort emigrates regardless of host condition.
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