Level of Care Preferences Among Nursing Home Residents With Advanced Dementia

Delivering goal-directed care is a hallmark of high-quality palliative care, but requires an understanding of preferences

Patterns, Predictors, and Outcomes of Falls Trajectories in Older Adults: The MOBILIZE Boston Study with 5 Years of Follow-Up

Background: Falls may occur as unpredictable events or in patterns indicative of potentially modifiable risks and predictive of adverse outcomes. Knowing the patterns, risks, and outcomes of falls trajectories may help clinicians plan appropriate preventive measures. We hypothesized that clinically distinct trajectories of falls progression, baseline predictors and their coincident clinical outcomes could be identified. Methods: We studied 765 community-dwelling participants in the MOBILIZE Boston Study, who were aged 70 and older and followed prospectively for falls over 5 years. Baseline demographic and clinical data were collected by questionnaire and a comprehensive clinic examination. Falls, injuries, and hospitalizations were recorded prospectively on daily calendars. Group-Based Trajectory Modeling (GBTM) was used to identify trajectories. Results: We identified 4 distinct trajectories: No Falls (30.1%), Cluster Falls (46.1%), Increasing Falls (5.8%) and Chronic Recurring Falls (18.0%). Predictors of Cluster Falls were faster gait speed (OR 1.69 (95CI, 1.50–2.56)) and fall in the past year (OR 3.52 (95CI, 2.16–6.34)). Predictors of Increasing Falls were Diabetes Mellitus (OR 4.3 (95CI, 1.4–13.3)) and Cognitive Impairment (OR 2.82 (95CI, 1.34–5.82)). Predictors of Chronic Recurring Falls were multi-morbidity (OR 2.24 (95CI, 1.60–3.16)) and fall in the past year (OR 3.82 (95CI, 2.34–6.23)). Symptoms of depression were predictive of all falls trajectories. In the Chronic Recurring Falls trajectory group the incidence rate of Hospital visits was 121 (95% CI 63–169) per 1,000 person-years; Injurious falls 172 (95% CI 111–237) per 1,000 person-years and Fractures 41 (95% CI 9–78) per 1,000 person-years. Conclusions: Falls may occur in clusters over discrete intervals in time, or as chronically increasing or recurring events that have a relatively greater risk of adverse outcomes. Patients with multiple falls, multimorbidity, and depressive symptoms should be targeted for preventive measures

Fall Risk is Not Black and White

Objective: To determine whether previously reported racial differences in fall rates between White and Black/African American is explained by differences in health status and neighborhood characteristics. Design: Prospective cohort Setting: Community Participants: The study included 550 White and 116 Black older adults in the Greater Boston area (mean age: 78 years; 36% men) who were English-speaking, able to walk across a room, and without severe cognitive impairment. Measurements: Falls were prospectively reported using monthly fall calendars. The location of each fall and fall-related injuries were asked during telephone interviews. At baseline, we assessed risk factors for falls, including sociodemographic characteristics, physiologic risk factors, physical activity, and community-level characteristics. Results: Over the mean follow-up of 1,048 days, 1,539 falls occurred (incidence: 806/1,000 person-years). Whites were more likely than Blacks to experience any falls (867 versus 504 falls per 1,000 person-years; RR [95% CI]: 1.77 [1.33, 2.36]), outdoor falls (418 versus 178 falls per 1,000 person-years; 1.78 [1.08, 2.92]), indoor falls (434 versus 320 falls per 1,000 person-years; 1.44 [1.02, 2.05]), and injurious falls (367 versus 205 falls per 1,000 person-years; 1.79 [1.30, 2.46]). With exception of injurious falls, higher fall rates in Whites than Blacks were substantially attenuated with adjustment for risk factors and community-level characteristics: any fall (1.24 [0.81, 1.89]), outdoor fall (1.57 [0.86, 2.88]), indoor fall (1.08 [0.64, 1.81]), and injurious fall (1.77 [1.14, 2.74]). Conclusion: Our findings suggest that the racial differences in fall rates may be largely due to confounding by individual-level and community-level characteristics

DEVELOPMENT OF WHEAT GERMPLASM FOR STEM RUST RESISTANCE IN EASTERN AFRICA

Wheat ( Triticum aestivum ) rust outbreak is the primary production constraint in Eastern Africa. Ethiopia, Kenya and Uganda are hot spots for the epidemic of rusts, due to higher rates of evolution of new pathogen races, especially of the virulent stem rust (Puccinia graminis) race, Ug99. The objective of this study was to identify sources of resistance to the major pathotypes of stem rust prevalent in some countries of Eastern Africa. Three hundred and six elite breeding lines, selected and advanced at the Wheat Regional Centre of Excellence (WRCoE) in Ethiopia, were planted in stem rust hot spot areas of the country (Arsi-Robe) and Kenya (Njoro) under natural infections. Stem rust scores of 18, 25.8 and 56.2% of lines at Arsi-Robe; and 35, 49 and 16.7% of lines at Njoro were resistant to moderately resistant, intermediate and moderately susceptible to susceptible category, respectively. Overall coefficient of infection (ACI) at Arsi-Robe (24) was greater than that of Njoro (13), indicating higher disease pressure in Ethiopia than Kenya. Among the lines, 67% at Njoro and 49% at Arsi Robe showed good levels of resistance, with a severity less than 20%. However, only 32% of the lines showed a good level of resistance (<20% severity) in both locations. These lines could have combined resistance to the multiple stem rust races prevailing at both locations. Generally, most of the lines, which showed better resistance at Njoro were susceptible at Arsi-Robe.La rouille de la tige chez le bl\ue9 ( Triticum aestivum ) est l\u2019un des plus importants probl\ue8mes rencontres dans la production du bl\ue9 en Afrique de l\u2019Est. L\u2019Ethiopie, le Kenya et l\u2019Ouganda sont des pays \ue0 fort taux d\u2019\ue9pid\ue9mie de rouille de la tige. Ceci \ue0 cause du taux \ue9lev\ue9 de d\u2019agents pathog\ue8nes, ainsi que l\u2019apparition de nouveaux pathog\ue8nes, dont le plus redoutable (Puccinia graminis) race Ug99. L\u2019objectif de cette \ue9tude \ue9tait d\u2019identifier des sources de r\ue9sistance aux pathotypes majeurs de la rouille de tige qui sevit dans certains pays de l\u2019Afrique de l\u2019Est. Trois cent six lign\ue9es \ue9lites, s\ue9lectionn\ue9es au centre r\ue9gionale d\u2019excellence du bl\ue9 (WRCoE) en Ethiopie, ont \ue9t\ue9 plant\ue9es dans des zones a fort taux de pr\ue9valence de la rouille de tige en Ethiopie (Arsi-Robe) au Kenya (Njoro). Respectivement, 18, 25.8 et 56.2% des lign\ue9es a Arsi-Robe; et 35, 49 et 16.7% des lign\ue9es a Njoro se sont r\ue9v\ue9l\ue9es r\ue9sistantes ou mod\ue9r\ue9ment r\ue9sistantes, interm\ue9diaires, mod\ue9r\ue9ment susceptibles a susceptibles. En somme, le coefficient d\u2019infection (ACI) \ue0 Arsi-Robe (24) \ue9tait plus \ue9lev\ue9 qu\u2019\ue0 Njoro (13), ceci indique que la pression de la rouille de tige est plus \ue9lev\ue9e en Ethiopie qu\u2019au Kenya. Parmi les lign\ue9es \ue9valu\ue9es, 67% \ue0 Njoro et 49% a Arsi Robe sont exhibe des bons niveaux de r\ue9sistance, avec 20% de s\ue9v\ue9rit\ue9. N\ue9anmoins, seul 32% des lign\ue9es ont exhibe une bonne r\ue9sistance (<20% s\ue9v\ue9rit\ue9) dans les deux localit\ue9s. Ces lign\ue9es porteraient surement des g\ue8nes de r\ue9sistance multiple contre les diff\ue9rentes races de champignon pr\ue9sents dans les deux localit\ue9s. G\ue9n\ue9ralement, la plupart des lign\ue9es ayant exhibe une bonne r\ue9sistance a Njoro \ue9taient susceptible a Arsi-Robe

A Mobile App For Delirium Screening

Objective: The objective of this study is to describe the algorithm and technical implementation of a mobile app that uses adaptive testing to assess an efficient mobile app for the diagnosis of delirium. Materials and Methods: The app was used as part of a NIH-funded project to assess the feasibility, effectiveness, administration time, and costs of the 2-step delirium identification protocol when performed by physicians and nurses, and certified nursing assistants (CNA). The cohort included 535 hospitalized patients aged 79.7 (SD¼6.6) years enrolled at 2 different sites. Each patient was assessed on 2 consecutive days by the research associate who performed the reference delirium assessment. Thereafter, physicians, nurses, and CNAs performed adaptive delirium assessments using the app. Qualitative data to assess the experience of administering the 2-step protocol, and the app usability were also collected and analyzed from 50 physicians, 189 nurses, and 83 CNAs. We used extensible hypertext markup language (XHTML) and JavaScript to develop the app for the iOS–based iPad. The App was linked to Research Electronic Data Capture (REDCap), a relational database system, via a REDCap application programming interface (API) that sent and received data from/to the app. The data from REDCap were sent to the Statistical Analysis System for statistical analysis. Results: The app graphical interface was successfully implemented by XHTML and JavaScript. The API facilitated the instant updating and retrieval of delirium status data between REDCap and the app. Clinicians performed 881 delirium assessments using the app for 535 patients. The transmission of data between the app and the REDCap system showed no errors. Qualitative data indicated that the users were enthusiastic about using the app with no negative comments, 82% positive comments, and 18% suggestions of improvement. Delirium administration time for the 2-step protocol showed similar total time between nurses and physicians (103.9 vs 106.5 seconds). Weekly enrollment reports of the app data were generated for study tracking purposes, and the data are being used for statistical analyses for publications. Discussion: The app developed using iOS could be easily converted to other operating systems such as Android and could be linked to other relational databases beside REDCap, such as electronic health records to facilitate better data retrieval and updating of patient’s delirium status

Combatting AMR : photoactivatable ruthenium(ii)-isoniazid complex exhibits rapid selective antimycobacterial activity

The novel photoactive ruthenium(II) complex cis-[Ru(bpy)2(INH)2][PF6]2 (1·2PF6, INH = isoniazid) was designed to incorporate the anti-tuberculosis drug, isoniazid, that could be released from the Ru(II) cage by photoactivation with visible light. In aqueous solution, 1 rapidly released two equivalents of isoniazid and formed the photoproduct cis-[Ru(bpy)2(H2O)2]2+ upon irradiation with 465 nm blue light. We screened for activity against bacteria containing the three major classes of cell envelope: Gram-positive Bacillus subtilis, Gram-negative Escherichia coli, and Mycobacterium smegmatis in vitro using blue and multi-colored LED multi-well arrays. Complex 1 is inactive in the dark, but when photoactivated is 5.5× more potent towards M. smegmatis compared to the clinical drug isoniazid alone. Complementary pump-probe spectroscopy measurements along with density functional theory calculations reveal that the mono-aqua product is formed in <500 ps, likely facilitated by a 3MC state. Importantly, complex 1 is highly selective in killing mycobacteria versus normal human cells, towards which it is relatively non-toxic. This work suggests that photoactivatable prodrugs such as 1 are potentially powerful new agents in combatting the global problem of antibiotic resistance

Association of Prognostic Estimates With Burdensome Interventions in Nursing Home Residents With Advanced Dementia

Importance: Prognostication in advanced dementia is challenging but may influence care. Objectives: To determine the accuracy of proxies' prognostic estimates for nursing home residents with advanced dementia, identify factors associated with those estimates, and examine the association between their estimates and use of burdensome interventions. Design, Setting, and Participants: Data were combined from 2 studies that prospectively followed 764 residents with advanced dementia and their proxies in Boston-area nursing homes for 12 months: (1) the Study of Pathogen Resistance and Exposure to Antimicrobials in Dementia, conducted from September 2009 to November 2012 (362 resident/proxy dyads; 35 facilities); and (2) the Educational Video to Improve nursing home Care in End-Stage Dementia, conducted from March 2013 to July 2017 (402 resident/proxy dyads; 62 facilities). Proxies were the residents' formally or informally designated medical decision makers. Main Outcomes and Measures: During quarterly telephone interviews, proxies stated whether they believed the resident would live less than 1 month, 1 to 6 months, 7 to 12 months, or more than 12 months. Prognostic estimates were compared with resident survival. Resident and proxy characteristics associated with proxy prognostic estimates were determined. The association between prognostic estimates and whether residents experienced any of the following was determined: hospital transfers, parenteral therapy, tube feeding, venipunctures, and bladder catheterizations. Results: The residents' mean (SD) age was 86.6 (7.3) years; 631 (82.6%) were women and 133 (17.4%) were men. Of the 764 residents, 310 (40.6%) died later than 12 months. Proxies estimated survival with moderate accuracy (C statistic, 0.67). When proxies perceived the resident would die within 6 months, they were more likely to report being asked (183 [7.2%] of 2526) vs not being asked (126 [5.0%] of 2526) about goals of care by nursing home clinicians (adjusted odds ratio [AOR], 1.94; 95% CI, 1.50-2.52). Residents were less likely to experience burdensome interventions when the proxy prognostic estimate was less than 6 months (89 [4.4%] of 2031) vs greater than 6 months (1008 [49.6%] of 2031) (AOR, 0.46; 95% CI, 0.34-0.62). Conclusions and Relevance: Proxies estimated the prognosis of nursing home residents with advanced dementia with moderate accuracy. Having been asked about their opinion about the goal of care was associated with the proxies' perception that the resident had less than 6 months to live and that perception was associated with a lower likelihood the resident experienced burdensome interventions

Spin-labelled photo-cytotoxic diazido platinum(iv) anticancer complex

We report the synthesis and characterisation of the nitroxide spin-labelled photoactivatable Pt(IV) prodrug trans,trans,trans-[Pt(N3)2(OH)(OCOCH2CH2CONH-TEMPO)(Py)2] (Pt-TEMPO, where TEMPO = 2,2,6,6-tetramethylpiperidine 1-oxyl). Irradiation with blue visible light gave rise to Pt(II) and azidyl as well as nitroxyl radicals. Pt-TEMPO exhibited low toxicity in the dark, but on photoactivation was as active towards human ovarian cancer cells as the clinical photosensitizer chlorpromazine and much more active than the anticancer drug cisplatin under the conditions used

Cognitive and Physical Demands of Activities of Daily Living In Older Adults: Validation of Expert Panel Ratings: The SAGES Functional Measures Working Group

Background: Difficulties with performance of functional activities may result from cognitive and/or physical impairments. To date, there has not been a clear delineation of the physical and cognitive demands of activities of daily living. Objectives: To quantify the relative physical and cognitive demands required to complete typical functional activities in older adults. Design: Expert panel survey. Setting: Web-based platform. Participants: Eleven experts from eight academic medical centers and 300 community dwelling elderly adults age 70 and older scheduled for elective non-cardiac surgery from two academic medical centers. Methods: Sum scores of expert ratings were calculated and then validated against objective data collected from a prospective longitudinal study. Main Outcome Measurements Correlation between expert ratings and objective neuropsychological tests (memory, language, complex attention) and physical measures (gait speed and grip strength) for performance-based tasks. Results: Managing money, self-administering medications, using the telephone, and preparing meals were rated as requiring significantly more cognitive demand, while walking and transferring, moderately strenuous activities, and climbing stairs were assessed as more physically demanding. Largely cognitive activities correlated with objective neuropsychological performance (r=0.13–0.23, p<.05) and largely physical activities correlated with physical performance (r=0.15–0.46, p<.05). Conclusions: Quantifying the degree of cognitive and/or physical demand for completing a specific task adds an additional dimension to standard measures of functional assessment. This additional information may significantly influence decisions about rehabilitation, post-acute care needs, treatment plans, and caregiver education