End of life care interventions for people with dementia in care homes : addressing uncertainty within a framework for service delivery and evaluation

© 2015 Goodman et al. Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise statedMethods: The data from three studies on EoL care in care homes: (i) EVIDEM EoL , (ii) EPOCH , and (iii) TTT EoL were used to inform the development of the framework. All used mixed method designs and two had an intervention designed to improve how care home staff provided end of life care. The EVIDEM EoL and EPOCH studies tracked the care of older people in care homes over a period of 12 months. The TTT study collected resource use data of care home residents for three months, and surveyed decedents' notes for ten months, Results: Across the three studies, 29 care homes, 528 residents, 205 care home staff, and 44 visiting health care professionals participated. Analysis of showed that end of life interventions for people with dementia were characterised by uncertainty in three key areas; what treatment is the 'right' treatment, who should do what and when, and in which setting EoL care should be delivered and by whom? These uncertainties are conceptualised as Treatment uncertainty, Relational uncertainty and Service uncertainty. This paper proposes an emergent framework to inform the development and evaluation of EoL care interventions in care homes. Conclusion: For people with dementia living and dying in care homes, EoL interventions need to provide strategies that can accommodate or "hold" the inevitable and often unresolvable uncertainties of providing and receiving care in these settingsPeer reviewe

Effective health care for older people living and dying in care homes: A realist review

Background: Care home residents in England have variable access to health care services. There is currently no coherent policy or consensus about the best arrangements to meet these needs. The purpose of this review was to explore the evidence for how different service delivery models for care home residents support and/or improve wellbeing and health-related outcomes in older people living and dying in care homes. Methods: We conceptualised models of health care provision to care homes as complex interventions. We used a realist review approach to develop a preliminary understanding of what supported good health care provision to care homes. We completed a scoping of the literature and interviewed National Health Service and Local Authority commissioners, providers of services to care homes, representatives from the Regulator, care home managers, residents and their families. We used these data to develop theoretical propositions to be tested in the literature to explain why an intervention may be effective in some situations and not others. We searched electronic databases and related grey literature. Finally the findings were reviewed with an external advisory group. Results: Strategies that support and sustain relational working between care home staff and visiting health care professionals explained the observed differences in how health care interventions were accepted and embedded into care home practice. Actions that encouraged visiting health care professionals and care home staff jointly to identify, plan and implement care home appropriate protocols for care, when supported by ongoing facilitation from visiting clinicians, were important. Contextual factors such as financial incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support relational working to occur, but of themselves appeared insufficient to achieve change. Conclusion: How relational working is structured between health and care home staff is key to whether health service interventions achieve health related outcomes for residents and their respective organisations. The belief that either paying clinicians to do more in care homes and/or investing in training of care home staff is sufficient for better outcomes was not supported.This research was funded by National Institute of Health Research Health Service Delivery and Research programme (HSDR 11/021/02)

A high-precision near-infrared survey for radial velocity variable low-mass stars using CSHELL and a methane gas cell

We present the results of a precise near-infrared (NIR) radial velocity (RV) survey of 32 low-mass stars with spectral types K2-M4 using CSHELL at the NASA InfraRed Telescope Facility in the K band with an isotopologue methane gas cell to achieve wavelength calibration and a novel, iterative RV extraction method. We surveyed 14 members of young (≈25-150 Myr) moving groups, the young field star ϵ Eridani, and 18 nearby (<25 pc) low-mass stars and achieved typical single-measurement precisions of 8-15 m s-1with a long-term stability of 15-50 m s-1 over longer baselines. We obtain the best NIR RV constraints to date on 27 targets in our sample, 19 of which were never followed by high-precision RV surveys. Our results indicate that very active stars can display long-term RV variations as low as ∼25-50 m s-1 at ≈2.3125 μm, thus constraining the effect of jitter at these wavelengths. We provide the first multiwavelength confirmation of GJ 876 bc and independently retrieve orbital parameters consistent with previous studies. We recovered RV variabilities for HD 160934 AB and GJ 725 AB that are consistent with their known binary orbits, and nine other targets are candidate RV variables with a statistical significance of 3σ-5σ. Our method, combined with the new iSHELL spectrograph, will yield long-term RV precisions of ≲5 m s-1 in the NIR, which will allow the detection of super-Earths near the habitable zone of mid-M dwarfs

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Coastal studies in support of the Sargent Beach, Texas, Erosion Control Project

Source: https://erdc-library.erdc.dren.mil/jspui/One of the areas of highest coastal erosion along the Texas coast is located in the deltaic headland coastal segment of the Brazos River in the vicinity of Sargent Beach. Because of this erosion, a section of the Gulf Intracoastal Waterway (GIWW) from Cedar Lakes to East Matagorda Bay is in danger of intrusion from breaching of the narrow (less than 300-m-wide) shorefront. Owing to its deltaic origin, the beach is composed of cohesive fine-grained clay and silt material, overlain by a narrow layer of coastal peat and topped by a thin veneer of fine-grained quartz beach sand with a high percentage of shell fragments. Within the 24-year study period (1965-1989), the northeastern half of the study area measured an average erosion rate of 25 ftlyr (7.6 mlyr) and consisted of a thin sandy flat sloping beach over the clay deposit. The southwestern section has up to I-m-high clay bluffs outcropping into the surf zone and measured an average 36 ftlyr (1 1 m/yr) erosion rate. It is speculated that this high erosion rate is a result of intermittent wave cutting of large chunks of the clay bluff material. The overall erosion rate along this coast is due to a general lack of sand

Effectiveness of Spur Jetties at Siuslaw River, Oregon. Report 1, Prototype Monitoring Study

Source: https://erdc-library.erdc.dren.mil/jspui/In 1985, the rubble-mound jetties at the entrance to the Suislaw River, Florence, OR, were extended offshore. In addition, on the Ocen side of each jetty, one long spur oriented 45 deg to the main structure was constructed shoreward of the seaward end of each of the twin jetties. The spur system was investigated as a cost-reducing alternative to significant linear jetty length extension which would reduce sediment shoaling and dredging requirements in the channel and improve navigability. Cost reductions were expected in reduced maintenance dredging and in actual construction and material cost. Monitoring and evaluation of the jetty system were conducted through the U.S. Army Corps of Engineers, Monitoring of Completed Coastal Projects (MCCP) Program by the Coastal Engineering Research Center (CERC) in coordination with the U.S. Army Engineer District, Portland (NPP). Data collected during field monitoring of the area are related to incident wave conditions. Spur-induced current patterns and sediment deposition patterns, along with annual dredging records are analyzed to evaluate structure performance. The favorable results of this MCCP study substantiate physical model test findings and indicate potential application of spur jetties at other sites