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

Racial Differences in Outcomes of an Advance Care Planning Intervention for Dialysis Patients and Their Surrogates

Background: African Americans' beliefs about end-of-life care may differ from those of whites, but racial differences in advance care planning (ACP) outcomes are unknown

Effect of Palliative Care–Led Meetings for Families of Patients With Chronic Critical Illness: A Randomized Clinical Trial

Family caregivers of patients with chronic critical illness experience significant psychological distress

Triggered Palliative Care for Late-stage Dementia: a Pilot Randomized Trial

Context Persons with late-stage dementia have limited access to palliative care. Objective To test dementia-specific specialty palliative care triggered by hospitalization. Methods This pilot randomized controlled trial enrolled 62 dyads of persons with late-stage dementia and family decision-makers on admission to hospital. Intervention dyads received dementia-specific specialty palliative care consultation plus post-acute transitional care. Control dyads received usual care and educational information. The primary outcome was 60-day hospital or emergency department visits. Secondary patient and family-centered outcomes were patient comfort, family distress, palliative care domains addressed in the treatment plan, and access to hospice or community-based palliative care. Secondary decision-making outcomes were discussion of prognosis, goals of care, completion of Medical Orders for Scope of Treatment (MOST), and treatment decisions. Results Of 137 eligible dyads, 62 (45%) enrolled. The intervention proved feasible, with protocol completion ranging from 77% (family 2-week call) to 93% (initial consultation). Hospital and emergency department visits did not differ (intervention vs control, 0.68 vs 0.53 transfers per 60 days, p=0.415). Intervention patients had more palliative care domains addressed, and were more likely to receive hospice (25% vs 3%, p<0.019). Intervention families were more likely to discuss prognosis (90% vs 3%, p<0.001) and goals of care (90% vs 25%, p<0.001), and to have a MOST at 60-day follow-up (79% vs 30%, p<0.001). More intervention families made decisions to avoid re-hospitalization (13% vs 0%, p=0.033). Conclusion Specialty palliative care consultation for hospitalized patients with for late-stage dementia is feasible and promising to improve decision-making and some treatment outcomes

Availability of Advance Care Planning Documentation for Older Emergency Department Patients: A Cross-Sectional Study

Introduction: Increasing advance care planning (ACP) among older adults is a national priority. Documentation of ACP in the electronic health record (EHR) is particularly important during emergency care

Estimating global mortality from potentially foodborne diseases: an analysis using vital registration data

<p>Abstract</p> <p>Background</p> <p>Foodborne diseases (FBD) comprise a large part of the global mortality burden, yet the true extent of their impact remains unknown. The present study utilizes multiple regression with the first attempt to use nonhealth variables to predict potentially FBD mortality at the country level.</p> <p>Methods</p> <p>Vital registration (VR) data were used to build a multiple regression model incorporating nonhealth variables in addition to traditionally used health indicators. This model was subsequently used to predict FBD mortality rates for all countries of the World Health Organization classifications AmrA, AmrB, EurA, and EurB.</p> <p>Results</p> <p>Statistical modeling strongly supported the inclusion of nonhealth variables in a multiple regression model as predictors of potentially FBD mortality. Six variables were included in the final model: <it>percent irrigated land, average calorie supply from animal products, meat production in metric tons, adult literacy rate, adult HIV/AIDS prevalence</it>, and <it>percent of deaths under age 5 caused by diarrheal disease</it>. Interestingly, nonhealth variables were not only more robust predictors of mortality than health variables but also remained significant when adding additional health variables into the analysis. Mortality rate predictions from our model ranged from 0.26 deaths per 100,000 (Netherlands) to 15.65 deaths per 100,000 (Honduras). Reported mortality rates of potentially FBD from VR data lie within the 95% prediction interval for the majority of countries (37/39) where comparison was possible.</p> <p>Conclusions</p> <p>Nonhealth variables appear to be strong predictors of potentially FBD mortality at the country level and may be a powerful tool in the effort to estimate the global mortality burden of FBD.</p> <p>Disclaimer</p> <p>The views expressed in this document are solely those of the authors and do not represent the views of the World Health Organization.</p

The X-ray spectra and spectral variability of intermediate type Seyfert galaxies: ASCA observations of NGC 4388 and ESO 103-G35

The X-ray spectra of two intermediate type Seyfert galaxies are investigated using ASCA observations separated by more than a year. Both NGC 4388 and ESO 103-G35 exhibit strong, narrow Fe K alpha line emission and absorption by cold neutral gas with a column density ~ 10^23 cm^-2, characteristic of the X-ray spectra of type 2 Seyfert galaxies. The power law continuum flux has changed by a factor of 2 over a time-scale of ~ 2 years for both objects, declining in the case of NGC 4388 and rising in ESO 103-G35. No variation was observed in the equivalent width of the Fe K alpha line in the spectra of NGC 4388, implying that the line flux declined with the continuum. We find that the strength of the line cannot be accounted for by fluorescence in line-of-sight material with the measured column density unless a `leaky-absorber' model of the type favored for IRAS 04575-7537 is employed. The equivalent width of the Fe K alpha emission line is seen to decrease between the observations of ESO 103-G35 while the continuum flux increased. The 1996 observation of ESO 103-G35 can also be fitted with an absorption edge at 7.4 $\pm$ 0.2 keV due to partially ionized iron, and when an ionized absorber model is fitted to the data it is found that the equivalent column of neutral hydrogen rises to 3.5 x 10^23 cm^-2. The Fe K alpha line flux can be accounted by fluorescence in this material alone and this model is also a good representation of the 1988 and 1991 Ginga observations. There is then no requirement for a reflection component in the ASCA spectra of ESO 103-G35 or NGC 4388.Comment: 45 pages, 5 tables, 11 figures. Accepted for publication in the Astrophysical Journa

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

Binational reflections on pathways to groundwater security in the Mexico-United States borderlands

Shared groundwater resources between Mexico and the United States are facing unprecedented stressors. We reflect on how to improve water security for groundwater systems in the border region. Our reflection begins with the state of groundwater knowledge, and the challenges groundwater resources face from a physical, societal and institutional perspective. We conclude that the extent of ongoing cooperation frameworks, joint and remaining research efforts, from which alternative strategies can emerge, still need to be developed. The way forward offers a variety of cooperation models as the future offers rather complex, shared and multidisciplinary water challenges to the Mexico–US borderlands