TREATMENT DECISIONS FOR PEOPLE WITH LIFE LIMITING ILLNESSES: AN ANALYSIS OF TREATMENT VARIATION IN SECONDARY PREVENTIVE CARE FOR CARDIOVASCULAR DISEASE AMONG ELDERLY MEDICARE PATIENTS WITH DEMENTIA

This dissertation examines the effect of dementia on the treatment of coronary heart disease (CHD) in elderly Medicare beneficiaries. It specifically tests whether rates of utilization of evidence-based secondary preventive medication treatment (chemoprophylaxis) for CHD are different in patients with dementia compared to those without dementia. Data from the Cardiovascular Health Study were used to investigate the long-term effect of dementia on the use of four types of low burden and low risk chemoprophylaxis for CHD over time (ACE inhibitors, beta-blockers, lipoid-lowering medications and antiplatelet medications). The multivariate analyses employed a range of predictors including predisposing patient characteristics such as age, race, sex, education and the interaction of age and dementia status. Enabling variables included in the analyses are study site, income, supplemental insurance status, and residence in a nursing home. The care need variables include functional status, measured by activities of daily living, and comorbidites. The main findings reveal that the presence of any type of dementia, comorbid with CHD, has an effect on the use of beta-blockers and lipid-lowering medications. Additionally, patients with CHD and vascular type dementia are less likely to report taking beta-blockers, lipid-lowering medications, and antiplatelet medications, but more likely to report using ACE inhibitors. The results are mixed regarding the effect of timing of dementia onset of the use of chemoprophylaxis. Those who developed dementia before CHD were less likely to report using a beta-blocker and lipid-lowering mediation, yet, those who developed dementia after CHD did not discontinue use of chemoprophylaxis after the onset of dementia. The results of this dissertation provide new empirical evidence of the difference in the rate of secondary chemoprophylaxis for CHD among elderly patients with dementia compared to those without dementia. Information about the effect of dementia on the treatment of CHD, as well as factors that predict utilization, could inform health policy to improve care for the millions of Americans living with dementia and CHD

Deliver Me From The Days Of Old: Rock And Roll, Youth Culture, And The Civil Rights Movement

The U.S. civil rights movement is almost always presented as an undisputed success in mainstream culture and educational curricula, but scholars continue to question whether the widespread protests against racial segregation and inequality that swept the nation in the 1950s and 1960s led to meaningful economic, or social change. These criticisms extend to shifts in popular culture and the emergence of rock and roll music, which, as many contemporary critics noted, were areas where racial integration had already occurred. Since rock and roll emerged from both African-American and European-American cultural traditions, it introduced both black and white listeners to sounds and styles indicative of different racial backgrounds that were simultaneously integrated with musical elements that were still familiar to them. This new genre helped to encourage cross-racial identification among some young listeners. In Deliver Me From the Days of Old: Rock and Roll Music, Youth Culture, and the Civil Rights Movement, I argue that rock and roll music converged with widespread media coverage of civil rights activism to encourage support for the desegregation of public spaces and moderate racial equality among certain groups of middle-class white and black teenagers during the 1950s and 1960s. Many historians agree that rock and roll had the potential to disrupt racial divisions, but that music industry exploitation, as well as persistent political and economic oppression that overtook cultural integration, prevented it from doing so. Others note a correlation between changing racial politics and the birth of rock and roll, but do not explicitly show how this genre, and the decisions teenagers made to embrace it, emerged within a civil rights context that promoted integration as a positive change. While all of these historians offer insight into the origins of rock and roll, their accounts ignore the fact that teenage rock and roll fans made their own decisions about music and culture that were informed by, and contributed to, the emergence of a national movement for racial integration. When these decisions are ignored, the origin story of rock and roll music becomes one of exploitation rather than one of cultural integration. Although many rock and roll fans did not become politically active in the civil rights movement, they were not the passive consumers of popular culture that they are often depicted as. The choices they made to listen to and embrace this music and the artists who performed it constitute a form of political consciousness in light of the strict censures that existed in both the North and the South against racial integration. Since most rock and roll fans did not flock to sit-ins or voter registration drives, many scholars have assumed that the music\u27s appeal was mostly aesthetic, and that teenagers who did not explicitly participate in movement activities were fairly apolitical. And yet, the ways they acted and communicated in both public and private spaces during this period indicates a shift in thinking that is in keeping with moderate civil rights goals. But this viewpoint ignores the changing attitudes and behaviors exhibited by many people born during and after World War Two, which ultimately led to at least tacit support for the desegregation of public spaces and moderate racial equality among black and white youth. Black teenagers usually supported actions against segregation, and often suffered the direct repercussions when entering previously all-white schools or breaking racial barriers at concert halls. Most stated that they would only work for integration if they were treated with full respect and dignity, not if they were expected to adjust to white norms. White youth were not as aware of the challenges facing their black contemporaries, but many were eager to resist conformist Cold War culture and politics, the expansion of the military-industrial complex, unregulated capitalist development, and overt racial segregation and discrimination, even outside of traditional Southern boundaries. Rock and roll music therefore helped young people to talk about race relations and discrimination in both public and private spaces, and to challenge racial norms during the civil rights movement. Even though racial discrimination and structural racism did not disappear, this new middle ground, shaped by a popular new art form, helped young people of both races find ways to communicate across supposedly rigid racial lines

Natural rubber modified clay nanocomposite pressure sensitive adhesive

Orientador: Julio Roberto BartoliDissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Engenharia QuimicaResumo: Adesivo Sensíveis à Pressão (PSA) são adesivos poliméricos usados principalmente em fitas e etiquetas. De modo geral, existem três tipos de adesivos PSA: a base de solvente, a base d'água e "hot melt". Os adesivos a base de solvente apresentam algumas limitações como flamabilidade e toxicidade, mas ainda são amplamente usados, devido às propriedades finais que apresentam, como boa adesividade a substratos polares c boa adesão com alguns plásticos. Geralmente, os compostos poliméricos para PSA utilizam cargas minerais devido à redução de custo e às propriedades finais que os PSA podem apresentar, como propriedades dielétricas, resistência à umidade e tensão na ruptura. Por outro lado, nanocompósitos estão mostrando grandes vantagens em várias aplicações poliméricas, melhorando suas propriedades térmicas, mecânicas e retardância à chama. Adesivos PSA nanocompósitos a base de solvente foram preparados pelo processo de esfoliação-solução de compostos a base de borracha natural e argilas organicamente modificadas. Um planejamento fatorial de experimentos, 22 com replicata, foi utilizado para verificar a influência dos fatores da composição: concentração e tipos de argilas modificadas, nas propriedades físicas dos adesivos. Um composto adesivo de referencia (PSA convencional) foi também preparado utilizando CaCOH3, carga de uso comum nessas formulações. Os adesivos foram caracterizados através das suas propriedades adesivas (coesão ou "shear", adesão ao aço ou "peel" ,tlato à superfície ou "tack") gel e resistência à propagação de chama. A maioria dessas propriedades apresentou significância estatística em ao menos um dos fatores de composição estudados, tipo ou concentração de nanoargila. Os ensaios de resistência á propagação de chama mostraram melhoria nas propriedades de resistência à propagação da chama em todos os adesivos com argilas modificadas, comparados ao composto de referência. Análises TGA indicaram o mesmo comportamento de variação de massa em função da temperatura para lodos os adesivos. As análises DMTA dos adesivos mostraram diferenças entre os dois tipos de argilas modificadas quanto às suas Tg. Nas análises XRD dos adesivos não foram identificados picos de difração característicos das argilas, talvez devido à diluição das amostras ou até à desejada esfoliação. Nas análises de SEM dos compostos adesivos observou-se uma tênue forma lamelar devido às argilas e as análises EDS dos compostos indicaram a presença de Si e Al, constituintes da argila modificadaAbstract: Pressure sensitive adhesives (PSA) are polymeric adhesives used for mainly in tapes and labels. Usually, there are 3 types of PSA: solvent based, water based and hot melt. Solvent based adhesives have few limitations, like flammability and toxicity, but they are still often used, due to their properties as good adhesion to polar substrates and good bonding with some plastics. The compounds for pressure sensitive adhesives, in general, use fillers due to cost reduction and properties they can give, like dielectric properties, water resistance and tensile strength. On the other side, nanocomposites are showing great advantages on several polymers applications improving thermal resistance, flame retardancy and mechanical properties. Nanocomposites for solvent-based adhesives were prepared by an exfoliation-solution process of natural rubber and organically modified clay compounds. A Design of Experiment (DOE). 22 with replication, was used to verify the influence of compounding factors; concentration and grades of nanoclays.A control adhesive compound was prepared using CaCO3, very common filler for adhesive fonnulations. The PSA were characterized by their adhesive properties (cohesion or shear, adhesion to steel or peel test, tack), gel and flammability. Almost all these properties showed statistical significance at least for one of the compounding factors, grade or concentration of nanociay. The flammability tests showed an improvement on the flame retardancy properties for all the nanoclays adhesives compared to the control compound. TGA analyses showed the same pattern of mass reduction as a function of temperature for all the adhesives. DMTA showed differences between the 2 kinds of nanoclays regarding Tg. XRD analyses did not show any diffraction peak related to the clays, likely due to the diluted samples or even to an exfoliation. SEM analyses showed a slightly lamellar pattern of clays and EDS analyses of the compounds confirmed the presence of Si and Al, elements of the nanoclaysMestradoCiencia e Tecnologia de MateriaisMestre em Engenharia Químic

Examining the benefits and harms of Alzheimer's disease screening for family members of older adults: study protocol for a randomized controlled trial

BACKGROUND: Multiple national expert panels have identified early detection of Alzheimer's disease and related dementias (ADRD) as a national priority. However, the United States Preventive Services Task Force (USPSTF) does not currently support screening for ADRD in primary care given that the risks and benefits are unknown. The USPSTF stresses the need for research examining the impact of ADRD screening on family caregiver outcomes. METHODS: The Caregiver Outcomes of Alzheimer's Disease Screening (COADS) is a randomized controlled trial that will examine the potential benefits or harms of ADRD screening on family caregivers. It will also compare the effectiveness of two strategies for diagnostic evaluation and management after ADRD screening. COADS will enroll 1800 dyads who will be randomized into three groups (n = 600/group): the 'Screening Only' group will receive ADRD screening at baseline and disclosure of the screening results, with positive-screen participants receiving a list of local resources for diagnostic follow-up; the 'Screening Plus' group will receive ADRD screening at baseline coupled with disclosure of the screening results, with positive-screen participants referred to a dementia collaborative care program for diagnostic evaluation and potential care; and the control group will receive no screening. The COADS trial will measure the quality of life of the family member (the primary outcome) and family member mood, anxiety, preparedness and self-efficacy (the secondary outcomes) at baseline and at 6, 12, 18 and 24 months. Additionally, the trial will examine the congruence of depressive and anxiety symptoms between older adults and family members at 6, 12, 18 and 24 months and compare the effectiveness of two strategies for diagnostic evaluation and management after ADRD screening between the two groups randomized to screening (Screening Only versus Screening Plus). DISCUSSION: We hypothesize that caregivers in the screening arms will express higher levels of health-related quality of life, lower depressive and anxiety symptoms, and better preparation for caregiving with higher self-efficacy at 24 months. Results from this study will directly inform the National Plan to Address Alzheimer's Disease, the USPSTF and other organizations regarding ADRD screening and early detection policies

Adherence and Tolerability of Alzheimer's Disease Medications: A Pragmatic Randomized Trial

BACKGROUND/OBJECTIVES: Post-marketing comparative trials describe medication use patterns in diverse, real-world populations. Our objective was to determine if differences in rates of adherence and tolerability exist among new users to acetylcholinesterase inhibitors (AChEI's). DESIGN: Pragmatic randomized, open label comparative trial of AChEI's currently available in the United States. SETTING: Four memory care practices within four healthcare systems in the greater Indianapolis area. PARTICIPANTS: Eligibility criteria included older adults with a diagnosis of possible or probable Alzheimer's disease (AD) who were initiating treatment with an AChEI. Participants were required to have a caregiver to complete assessments, access to a telephone, and be able to understand English. Exclusion criteria consisted of a prior severe adverse event from AChEIs. INTERVENTION: Participants were randomized to one of three AChEIs in a 1:1:1 ratio and followed for 18 weeks. MEASUREMENTS: Caregiver-reported adherence, defined as taking or not taking study medication, and caregiver-reported adverse events, defined as the presence of an adverse event. RESULTS: 196 participants were included with 74.0% female, 30.6% African Americans, and 72.9% who completed at least twelfth grade. Discontinuation rates after 18 weeks were 38.8% for donepezil, 53.0% for galantamine, and 58.7% for rivastigmine (P = .063) in the intent to treat analysis. Adverse events and cost explained 73.1% and 25.4% of discontinuation. No participants discontinued donepezil due to cost. Adverse events were reported by 81.2% of all participants; no between-group differences in total adverse events were statistically significant. CONCLUSIONS: This pragmatic comparative trial showed high rates of adverse events and cost-related non-adherence with AChEIs. Interventions improving adherence and persistence to AChEIs may improve AD management. TRIAL REGISTRATION: Clinicaltrials.gov: NCT01362686 (https://clinicaltrials.gov/ct2/show/NCT01362686)

Engaging Persons Living With Dementia in the Research Process: Best Practice Considerations From a National Dementia Meeting

Today more than 35 million people and families worldwide live with dementia. 1 Although there is no cure for dementia, years of investment have yielded many behavioral and other nonpharmacologic programs and interventions aimed at helping people live better with dementia 2 and to support dementia caregivers. 3 Despite promising evidence about these interventions’ statistical and clinical significance, there is a lack of impact from this evidence. 4 It is not clear whether this reflects genuine ineffectiveness in “the real word” or a failure in implementing this evidence

Synergistic Activation of ENaC by Three Membrane-bound Channel-activating Serine Proteases (mCAP1, mCAP2, and mCAP3) and Serum- and Glucocorticoid-regulated Kinase (Sgk1) in Xenopus Oocytes

Sodium balance is maintained by the precise regulation of the activity of the epithelial sodium channel (ENaC) in the kidney. We have recently reported an extracellular activation of ENaC-mediated sodium transport (INa) by a GPI-anchored serine protease (mouse channel–activating protein, mCAP1) that was isolated from a cortical collecting duct cell line derived from mouse kidney. In the present study, we have identified two additional membrane-bound serine proteases (mCAP2 and mCAP3) that are expressed in the same cell line. We show that each of these proteases is able to increase INa 6–10-fold in the Xenopus oocyte expression system. INa and the number (N) of channels expressed at the cell surface (measured by binding of a FLAG monoclonal I125-radioiodinated antibody) were measured in the same oocyte. Using this assay, we show that mCAP1 increases INa 10-fold (P < 0.001) but N remained unchanged (P = 0.9), indicating that mCAP1 regulates ENaC activity by increasing its average open probability of the whole cell (wcPo). The serum- and glucocorticoid-regulated kinase (Sgk1) involved in the aldosterone-dependent signaling cascade enhances INa by 2.5-fold (P < 0.001) and N by 1.6-fold (P < 0.001), indicating a dual effect on N and wcPo. Compared with Sgk1 alone, coexpression of Sgk1 with mCAP1 leads to a ninefold increase in INa (P < 0.001) and 1.3-fold in N (P < 0.02). Similar results were observed for mCAP2 and mCAP3. The synergism between CAPs and Sgk1 on INa was always more than additive, indicating a true potentiation. The synergistic effect of the two activation pathways allows a large dynamic range for ENaC-mediated sodium regulation crucial for a tight control of sodium homeostasis

Toward a better understanding of the effects of endocrine disrupting compounds on health : Human-relevant case studies from sheep models

The 3 case studies reviewed in this article were supported by funders including: SRF Academic Scholarship Award 2013, the Wellcome Trust (080388), the European Community’s Seventh Framework Programme under grant agreement no 212885 and French Region Midi-Pyrénées [31000642] the French National Research Program for Environmental and Occupational Health of Anses [grant number 2015/1/112, 2015] and the French National Research Agency [ANR-13-CESA0007-1].Peer reviewedPostprin

Effects of potassium depletion on renal tubular chloride transport in the rat

Effects of potassium depletion on renal tubular chloride transport in the rat. Potassium depletion (KD) causes renal chloride-wasting. To investigate the effects of KD on renal tubular reabsorption of chloride, balance, clearance, micropuncture, and microinjection studies were performed on potassium-depleted rats. KD was produced by omitting potassium from the diet and by administration of DOC A on days 2 and 3; rats were studied on days 9 to 12. Diets were chloride-free in both control and KD groups. In the KD group, balance experiments confirmed greater chloride depletion and continued chloride-wasting, and clearance studies showed an increased FECl. Muscle potassium was reduced by 27% as compared to control. Whole kidney and single nephron GFR were reduced in KD rats to 72 and 74% of control. Fractional (6 ± 6% vs. 22 ± 4%, P < 0.05) and absolute chloride reabsorption in the proximal tubule were reduced in KD, and chloride delivery out of the proximal tubule was not different. Fractional reabsorption of delivered chloride was reduced in the loop of Henle (92 ± 0.8% in KD vs. 95 ± 0.7% in control, P < 0.02). Transtubular chloride ratio (0.28 ± 0.02 vs. 0.21 ± 0.02, P < 0.02) was increased at the early distal tubule. Fractional delivery of chloride (8 ± 0.9 vs. 5 ± 0.5%, P < 0.02), and fluid (26 ± 1 vs. 22 ± 1%, P < 0.05) were also increased in KD at the early distal tubule. Recovery of chloride 36 injected into late distal tubules was 88 ± 1% on a normal chloride intake, 62 ± 2% in chloride depletion, and 88 ± 2% in potassium and chloride depletion. Thus, KD depresses chloride reabsorption in the proximal tubule and in the loop of Henle, and it decreases chloride 36 efflux from the collecting duct