What determines duration of palliative care before death for patients with advanced disease? A retrospective cohort study of community and hospital palliative care provision in a large UK city

Objective For patients with advanced cancer, several randomised controlled trials have shown that access to palliative care at least 6 months before death can improve symptoms, reduce unplanned hospital admissions, minimize aggressive cancer treatments and enable patients to make choices about their end of life care, including exercising the choice to die at home. This study determines in a UK population the duration of palliative care before death and explores influencing factors. Design This retrospective cohort study analysed referrals to three specialist palliative care services; a hospital based inpatient palliative care team, and two community based services (hospices). For each patient referred to any of the above services we identified the date of first referral to that team and calculated the median interval between first referral and death. We also calculated how referral time varied by age, sex, diagnosis and type of palliative care service. Participants 4,650 patients referred to specialist palliative care services in Leeds UK between April 2012 and March 2014. Results Median age of the sample was 75 years. 3,903 (84.0%) patients had a diagnosis of cancer. Age, diagnosis and place of referral were significant predictors of duration of palliative care before death. Age was independently associated (J = 2672078, z = -392046.14, r = .01) with duration of palliative care regardless of diagnosis. Patients over 75 years have 29 fewer days of palliative care than patients under 50. Patients with non-cancer diagnoses have 13 fewer days of palliative care than patients with cancer. Additionally, patients referred to hospital palliative care receive 24.5 fewer days palliative care than those referred to community palliative care services. Conclusions The current timing of referral to palliative care may limit the benefits to patient in terms of improvements in end of life care, particularly for older patients and patients with conditions other than cancer

Diagnostic Biomarkers for Alzheimer's Disease Using Non-Invasive Specimens

Studies in the field of Alzheimer's disease (AD) have shown the emergence of biomarkers in biologic fluids that hold great promise for the diagnosis of the disease. A diagnosis of AD at a presymptomatic or early stage may be the key for a successful treatment, with clinical trials currently investigating this. It is anticipated that preventative and therapeutic strategies may be stage-dependent, which means that they have a better chance of success at a very early stage-before critical neurons are lost. Several studies have been investigating the use of cerebrospinal fluid (CSF) and blood as clinical samples for the detection of AD with a number of established core markers, such as amyloid beta (Aβ), total tau (T-tau) and phosphorylated tau ( tau), being at the center of clinical research interest. The use of oral samples-including saliva and buccal mucosal cells-falls under one of the least-investigated areas in AD diagnosis. Such samples have great potential to provide a completely non-invasive alternative to current CSF and blood sampling procedures. The present work is a thorough review of the results and analytical approaches, including proteomics, metabolomics, spectroscopy and microbiome analyses that have been used for the study and detection of AD using salivary samples and buccal cells. With a few exceptions, most of the studies utilizing oral samples were performed in small cohorts, which in combination with the existence of contradictory results render it difficult to come to a definitive conclusion on the value of oral markers. Proteins such as Aβ, T-tau and tau, as well as small metabolites, were detected in saliva and have shown some potential as future AD diagnostics. Future large-cohort studies and standardization of sample preparation and (pre-)analytical factors are necessary to determine the use of these non-invasive samples as a diagnostic tool for AD

Marriage and Materialism: Actor and Partner Effects Between Materialism, Importance of Marriage, and Marital Satisfaction

Drawing upon both the incompatibility of materialism and children model and marital paradigms theory, the purpose of the current study was to examine husband-wife actor and partner effects between materialism and marital satisfaction and to explore perception of the importance of marriage as a mediator of these relationships. Using a sample of 706 couples from the RELATE dataset, wives’ materialism negatively predicted both their own marital satisfaction as well as their husbands’ marital satisfaction. However, when controlling for financial problems in marriage, these effects became non-significant. Additionally, upon adding both wives’ and husbands’ importance of marriage (as well as combined couples’ “common fate” importance of marriage) to the model as mediators, indirect effects (actor and partner) between materialism and marital satisfaction were noted. Thus, when one partner (regardless of gender) places a high value on money and possessions, both spouses are less likely to place a high value on marriage, and are subsequently less likely to be satisfied in their marriage. Implications for financial therapists are discussed

What are the Prospects of 3D Profiling Systems Applied to Firearms and Toolmark Identification?

This paper details a comparative pilot study of 3D (three dimensional) imaging technologies for potential application in forensic firearms and toolmark identification; as such it reviews the most up-to-date profiling systems. In particular, the paper focuses on the application of 3D imaging and recording technology as applied to firearm identification, being a specialised field within the discipline of toolmark identification. Each technology under test employs a different technique or scientific principle to capture topographic data i.e. focus-variation microscopy, confocal microscopy, point laser profilometry and vertical scanning interferometry. To qualitatively establish the capabilities and limitations of each technology investigated, standard reference samples were used and a set of specific operational criteria devised for successful application in this field. The reference standard crucially included and centred on was the National Institute of Standards and Technology (NIST) 'standard bullet'. This was to ensure that evaluation represented the practical examination of ballistic samples i.e. fired cartridge cases and bullets. It is concluded that focus-variation microscopy has potentially the most promising approach for a forensic laboratory instrument, in terms of functionality and 3D imaging performance, and is worthy of further investigation

Evaluating the long-term effectiveness of school-based depression, anxiety, and substance use prevention into young adulthood: Protocol for the climate school combined study

Background: Mental health and substance use disorders are the leading causes of global disability in children and youth. Both tend to first onset or escalate in adolescence and young adulthood, calling for effective prevention during this time. The Climate Schools Combined (CSC) study was the first trial of a Web-based combined universal approach, delivered through school classes, to prevent both mental health and substance use problems in adolescence. There is also limited evidence for the cost-effectiveness of school-based prevention programs. Objective: The aim of this protocol paper is to describe the CSC follow-up study, which aims to determine the long-term efficacy and cost-effectiveness of the CSC prevention program for depression, anxiety, and substance use (alcohol and cannabis use) up to 7 years post intervention. Methods: A cluster randomized controlled trial (the CSC study) was conducted with 6411 participants aged approximately 13.5 years at baseline from 2014 to 2016. Participating schools were randomized to 1 of 4 conditions: (1) control (health education as usual), (2) Climate Substance Use (universal substance use prevention), (3) Climate Mental Health (universal mental health prevention), or (4) CSC (universal substance use and mental health prevention). It was hypothesized that the CSC program would be more effective than conditions (1) to (3) in reducing alcohol and cannabis use (and related harms), anxiety, and depression symptoms as well as increasing knowledge related to alcohol, cannabis, anxiety, and depression. This long-term study will invite follow-up participants to complete 3 additional Web-based assessments at approximately 5, 6, and 7 years post baseline using multiple sources of locator information already provided to the research team. The primary outcomes include alcohol and cannabis use (and related harms) and mental health symptoms. An economic evaluation of the program will also be conducted using both data linkage as well as self-report resource use and quality of life measures. Secondary outcomes include self-efficacy, social networks, peer substance use, emotion regulation, and perfectionism. Analyses will be conducted using multilevel mixed-effects models within an intention-to-treat framework. Results: The CSC long-term follow-up study is funded from 2018 to 2022 by the Australian National Health and Medical Research Council (APP1143555). The first follow-up wave commences in August 2018, and the results are expected to be submitted for publication in 2022. Conclusions: This is the first study to provide a long-term evaluation of combined universal substance use and mental health prevention up to 7 years post intervention. Evidence of sustained benefits into early adulthood would provide a scalable, easy-to-implement prevention strategy with the potential for widespread dissemination to reduce the considerable harms, burden of disease, injury, and social costs associated with youth substance use and mental disorders

Adherence to the caffeine intake guideline during pregnancy and birth outcomes: A prospective cohort study

© 2018 by the authors. Licensee MDPI, Basel, Switzerland. The aims of this study were to identify: (i) the proportion of women exceeding the caffeine intake guideline ( > 200 mg/day) during each trimester, accounting for point of pregnancy awareness; (ii) guideline adherence trajectories across pregnancy; (iii) maternal characteristics associated with trajectories; and (iv) association between adherence and growth restriction birth outcomes. Typical and maximal intake per consumption day for the first trimester (T1; pre- and post-pregnancy awareness), second (T2), and third trimester (T3) were recorded for a prospective cohort of pregnant Australian women with singleton births (n = 1232). Birth outcomes were birth weight, small for gestational age, and head circumference. For each period, participants were classified as abstinent, within (≤200 mg), or in excess ( > 200 mg). Latent class growth analyses identified guideline adherence trajectories; regression analyses identified associations between adherence in each trimester and birth outcomes. The percentage of participants who reported caffeine use declined between T1 pre- and post-pregnancy awareness (89% to 68%), and increased in T2 and T3 (79% and 80%). Trajectories were: ‘low consumption’ (22%): low probability of any use; ‘within-guideline’ (70%): high probability of guideline adherence; and ‘decreasing heavy use’ (8%): decreasing probability of excess use. The latter two groups were more likely to report alcohol and tobacco use, and less likely to report planning pregnancy and fertility problems. Exceeding the guideline T1 pre-pregnancy awareness was associated with lower birth weight after covariate control (b = -143.16, p = 0.011). Overall, high caffeine intake pre-pregnancy awareness occurs amongst a significant minority of women, and continued excess use post-pregnancy awareness is more common where pregnancy is unplanned. Excess caffeine consumption pre-pregnancy awareness may increase the risk for lower birth weight. Increasing awareness of the guideline in pregn ancy and preconception health care may be warranted

Relative contribution of intramyocellular lipid to whole-body fat oxidation is reduced with age but subsarcolemmal lipid accumulation and insulin resistance are only associated with overweight individuals

Insulin resistance is closely related to intramyocellular lipid (IMCL) accumulation, and both are associated with increasing age. It remains to be determined to what extent perturbations in IMCL metabolism are related to the aging process per se. On two separate occasions, whole-body and muscle insulin sensitivity (euglycemic-hyperinsulinemic clamp with 2-deoxyglucose) and fat utilization during 1 h of exercise at 50% VO2max ([U-13C]palmitate infusion combined with electron microscopy of IMCL) were determined in young lean (YL), old lean (OL), and old overweight (OO) males. OL displayed IMCL content and insulin sensitivity comparable with those in YL, whereas OO were markedly insulin resistant and had more than twofold greater IMCL in the subsarcolemmal (SSL) region. Indeed, whereas the plasma free fatty acid Ra and Rd were twice those of YL in both OL and OO, SSL area only increased during exercise in OO. Thus, skeletal muscle insulin resistance and lipid accumulation often observed in older individuals are likely due to lifestyle factors rather than inherent aging of skeletal muscle as usually reported. However, age per se appears to cause exacerbated adipose tissue lipolysis, suggesting that strategies to reduce muscle lipid delivery and improve adipose tissue function may be warranted in older overweight individuals

Characteristics of individuals presenting to treatment for primary alcohol problems versus other drug problems in the Australian patient pathways study

Background: People seeking treatment for substance use disorders often have additional health and social issues. Although individuals presenting with alcohol as the primary drug of concern (PDOC) account for nearly half of all treatment episodes to the Australian alcohol and other drug (AOD) service system, previous treatment cohort studies have focused only on the profile of Australian heroin or methamphetamine users. While studies overseas indicate that clients seeking treatment primarily for their drinking are less likely to experience social and economic marginalisation than those seeking treatment primarily for illicit or pharmaceutical drug use, very little research has directly compared individuals presenting with alcohol as the PDOC to those primarily presenting with other drugs as their PDOC. Methods: Seven hundred and ninety-six participants were recruited at entry to specialist AOD treatment in Victoria and Western Australia, and completed measures of demographic and social factors, substance use, quality of life, service use, and criminal justice involvement. We compared those with alcohol as their PDOC to those with other drugs as their PDOC using Pearson chi-square and Mann–Whitney U tests. Results: Rates of social disadvantage, poor quality of life, high severity of substance dependence, and past-year AOD, mental health, acute health, and social service use were high in all groups. However, participants with alcohol as the PDOC were older; more likely to have an educational qualification; less likely to report criminal justice involvement, housing/homelessness service use, tobacco smoking, or problems with multiple substances; and reported better environmental quality of life; but were more likely to have used ambulance services, than those with other drugs as their PDOC. Conclusions: While those seeking treatment primarily for alcohol problems appear less likely to suffer some forms of social and economic disadvantage or to use multiple substances than those with a primary drug problem, they experience similarly high levels of substance dependence severity and mental health and AOD service use. These findings reinforce the need for AOD services to integrate or coordinate care with programs that address the many complexities clients frequently present with, while also acknowledging differences between those seeking treatment for alcohol versus other drug problems

'Dreamers’, (un)deserving immigrants and generational interdependence

Undocumented young people known as the ‘Dreamers’ have become the embodiment of the ‘deserving immigrant’ in US public debates on immigration. Through exploring the narratives of undocumented young organisers in California, this article examines how they came to be framed in this way and the limitations of this as a pathway to social justice. It explores their accounts of organising in the undocumented youth movement to examine how their relationships with their families have influenced their engagement with the Dreamer narrative and its contestation. It was found that the figure of the deserving Dreamer represented an overly individualised account of migrant youth experiences and trajectories. Drawing on a relational understanding of migration and life course pathways, it is argued that undocumented youth are embedded in interdependent intergenerational relationships which affect their experiences and outcomes and therefore need to be recognised in any pathway to social justice