Creating and Sustaining Interdisciplinary Guardianship Committees

Over the past two decades, guardians, advocates, and the judiciary have been working at the national level to improve guardianship law and practice. This work was set in motion by a series of more than 200 Associated Press Wire Stories about guardianship abuses that were published in the mid-1980s. Over the next decade, guardians and other interested parties built relationships and established an association dedicated to improving guardianship. In the year 2000, members of the National Guardianship Association (“NGA”) wrote and formally adopted “Standards of Practice” for guardians. In 2001, at the Wingspan Conference held at Stetson University, other national groups such as the National College of Probate Judges and the National Academy of Elder Law Attorneys recognized the NGA standards as a national model. Making progress on change can be challenging and changes in practice have not kept pace with the many changes in state statutes. Each state is different in personality and procedure. What is common among the states is that courts, social service agencies, and advocates work independently, speak different languages, and may not understand each other. This makes change even more difficult unless the parties involved are willing to develop common language and a dialogue. That dialogue is the goal of teams that adopt an “interdisciplinary” approach. This Article will describe the multiple national conferences since 1988 that have spearheaded the process of guardianship reform, filtering it through to the states. The Article will also describe efforts at the state level to implement reform, focusing on the evolution of the Ohio Interdisciplinary Guardianship Committee (“IGC”), from its precursor, the Guardianship Forum, to a permanent, established subcommittee at the Supreme Court of Ohio. In addition to examining Ohio’s state-level IGC, this Article will review a number of other interdisciplinary groups around the country with similar approaches, though the focus of the groups may be slightly different. These groups may be statewide or may be organized at the county level. All these groups are trying to serve vulnerable adult populations with limited resources, and working as an interdisciplinary team expands the resources for problem resolution. Finally, there will be a discussion of the lessons the Ohio committee has learned through the process, and recommendations will be offered to assist other states interested in implementing and maintaining reform. The goal is to encourage more states to establish IGCs, to provide them with an effective entity to implement reform, and to position states to adopt the recommended standards developed as an outcome of the 2011 Guardianship Summit in Utah. Guardianship is a responsibility of the “state” that removes rights from the individual to protect that person. Encouraging courts, guardians, and the social service community in every state to learn about and implement best practice is the goal of the interdisciplinary dialogue

The ventral epithelium of Trichoplax adhaerens deploys in distinct patterns cells that secrete digestive enzymes, mucus or diverse neuropeptides

© The Author(s), 2019. This article is distributed under the terms of the Creative Commons Attribution License. The definitive version was published in Mayorova, T. D., Hammar, K., Winters, C. A., Reese, T. S., & Smith, C. L. The ventral epithelium of Trichoplax adhaerens deploys in distinct patterns cells that secrete digestive enzymes, mucus or diverse neuropeptides. Biology Open, 8, (2019): bio045674, doi:10.1242/bio.045674.The disk-shaped millimeter-sized marine animal, Trichoplax adhaerens, is notable because of its small number of cell types and primitive mode of feeding. It glides on substrates propelled by beating cilia on its lower surface and periodically pauses to feed on underlying microorganisms, which it digests externally. Here, a combination of advanced electron and light microscopic techniques are used to take a closer look at its secretory cell types and their roles in locomotion and feeding. We identify digestive enzymes in lipophils, a cell type implicated in external digestion and distributed uniformly throughout the ventral epithelium except for a narrow zone near its edge. We find three morphologically distinct types of gland cell. The most prevalent contains and secretes mucus, which is shown to be involved in adhesion and gliding. Half of the mucocytes are arrayed in a tight row around the edge of the ventral epithelium while the rest are scattered further inside, in the region containing lipophils. The secretory granules in mucocytes at the edge label with an antibody against a neuropeptide that was reported to arrest ciliary beating during feeding. A second type of gland cell is arrayed in a narrow row just inside the row of mucocytes while a third is located more centrally. Our maps of the positions of the structurally distinct secretory cell types provide a foundation for further characterization of the multiple peptidergic cell types in Trichoplax and the microscopic techniques we introduce provide tools for carrying out these studies.The work was supported by the Intramural Research Program of the National Institute of Neurological Disorders and Stroke and the National Institutes of Health

Eat Smart Move More Weigh Less: A Community Based Weight Management Program for Adults

Describes development of a comprehensive, low cost weight management program to be delivered by local public health educators or cooperative extension agents. The program was developed by a unique partnerships of the NC Cooperative Extension Serive, the NC Division of Public Health and the Brody School of Medicine at East Carolina University

Dose-finding study of a 90-day contraceptive vaginal ring releasing estradiol and segesterone acetate.

ObjectiveTo evaluate serum estradiol (E2) concentrations during use of 90-day contraceptive vaginal rings releasing E2 75, 100, or 200 mcg/day and segesterone acetate (SA) 200 mcg/day to identify a dose that avoids hypoestrogenism.Study designWe conducted a multicenter dose-finding study in healthy, reproductive-aged women with regular cycles with sequential enrollment to increasing E2 dose groups. We evaluated serum E2 concentrations twice weekly for the primary outcome of median E2 concentrations throughout initial 30-day use (target ≥40 pg/mL). In an optional 2-cycle extension substudy, we randomized participants to 2- or 4-day ring-free intervals per 30-day cycle to evaluate bleeding and spotting based on daily diary information.ResultsSixty-five participants enrolled in E2 75 (n = 22), 100 (n = 21), and 200 (n = 22) mcg/day groups; 35 participated in the substudy. Median serum E2 concentrations in 75 and 100 mcg/day groups were <40 pg/mL. In the 200 mcg/day group, median E2 concentrations peaked on days 4-5 of CVR use at 194 pg/mL (range 114-312 pg/mL) and remained >40 pg/mL throughout 30 days; E2 concentrations were 37 pg/mL (range 28-62 pg/mL) on days 88-90 (n = 11). Among the E2 200 mcg/day substudy participants, all had withdrawal bleeding following ring removal. The 2-day ring-free interval group reported zero median unscheduled bleeding and two (range 0-16) and three (range 0-19) unscheduled spotting days in extension cycles 1 and 2, respectively. The 4-day ring-free interval group reported zero median unscheduled bleeding or spotting days.ConclusionsEstradiol concentrations with rings releasing E2 200 mcg/day and SA 200 mcg/day avoid hypoestrogenism over 30-day use.ImplicationsA 90-day contraceptive vaginal ring releasing estradiol 200 mcg/day and segesterone acetate 200 mcg/day achieves estradiol concentrations that should avoid hypoestrogenism and effectively suppresses ovulation

Energy Storage Technology Development for Space Exploration

The National Aeronautics and Space Administration is developing battery and fuel cell technology to meet the expected energy storage needs of human exploration systems. Improving battery performance and safety for human missions enhances a number of exploration systems, including un-tethered extravehicular activity suits and transportation systems including landers and rovers. Similarly, improved fuel cell and electrolyzer systems can reduce mass and increase the reliability of electrical power, oxygen, and water generation for crewed vehicles, depots and outposts. To achieve this, NASA is developing non-flow-through proton-exchange-membrane fuel cell stacks, and electrolyzers coupled with low permeability membranes for high pressure operation. The primary advantage of this technology set is the reduction of ancillary parts in the balance-of-plant fewer pumps, separators and related components should result in fewer failure modes and hence a higher probability of achieving very reliable operation, and reduced parasitic power losses enable smaller reactant tanks and therefore systems with lower mass and volume. Key accomplishments over the past year include the fabrication and testing of several robust, small-scale non-flow-through fuel cell stacks that have demonstrated proof-of-concept. NASA is also developing advanced lithium-ion battery cells, targeting cell-level safety and very high specific energy and energy density. Key accomplishments include the development of silicon composite anodes, lithiatedmixed- metal-oxide cathodes, low-flammability electrolytes, and cell-incorporated safety devices that promise to substantially improve battery performance while providing a high level of safety

Energy Storage Project

NASA's Exploration Technology Development Program funded the Energy Storage Project to develop battery and fuel cell technology to meet the expected energy storage needs of the Constellation Program for human exploration. Technology needs were determined by architecture studies and risk assessments conducted by the Constellation Program, focused on a mission for a long-duration lunar outpost. Critical energy storage needs were identified as batteries for EVA suits, surface mobility systems, and a lander ascent stage; fuel cells for the lander and mobility systems; and a regenerative fuel cell for surface power. To address these needs, the Energy Storage Project developed advanced lithium-ion battery technology, targeting cell-level safety and very high specific energy and energy density. Key accomplishments include the development of silicon composite anodes, lithiated-mixed-metal-oxide cathodes, low-flammability electrolytes, and cell-incorporated safety devices that promise to substantially improve battery performance while providing a high level of safety. The project also developed "non-flow-through" proton-exchange-membrane fuel cell stacks. The primary advantage of this technology set is the reduction of ancillary parts in the balance-of-plant--fewer pumps, separators and related components should result in fewer failure modes and hence a higher probability of achieving very reliable operation, and reduced parasitic power losses enable smaller reactant tanks and therefore systems with lower mass and volume. Key accomplishments include the fabrication and testing of several robust, small-scale nonflow-through fuel cell stacks that have demonstrated proof-of-concept. This report summarizes the project s goals, objectives, technical accomplishments, and risk assessments. A bibliography spanning the life of the project is also included

Identifying nonalcoholic fatty liver disease patients with active fibrosis by measuring extracellular matrix remodeling rates in tissue and blood.

Excess collagen synthesis (fibrogenesis) in the liver plays a causal role in the progression of nonalcoholic fatty liver disease (NAFLD). Methods are needed to identify patients with more rapidly progressing disease and to demonstrate early response to treatment. We describe here a novel method to quantify hepatic fibrogenesis flux rates both directly in liver tissue and noninvasively in blood. Twenty-one patients with suspected NAFLD ingested heavy water (2 H2 O, 50-mL aliquots) two to three times daily for 3-5 weeks prior to a clinically indicated liver biopsy. Liver collagen fractional synthesis rate (FSR) and plasma lumican FSR were measured based on 2 H labeling using tandem mass spectrometry. Patients were classified by histology for fibrosis stage (F0-F4) and as having nonalcoholic fatty liver or nonalcoholic steatohepatitis (NASH). Magnetic resonance elastography measurements of liver stiffness were also performed. Hepatic collagen FSR in NAFLD increased with advancing disease stage (e.g., higher in NASH than nonalcoholic fatty liver, positive correlation with fibrosis score and liver stiffness) and correlated with hemoglobin A1C. In addition, plasma lumican FSR demonstrated a significant correlation with hepatic collagen FSR.ConclusionUsing a well-characterized cohort of patients with biopsy-proven NAFLD, this study demonstrates that hepatic scar in NASH is actively remodeled even in advanced fibrosis, a disease that is generally regarded as static and slowly progressive. Moreover, hepatic collagen FSR correlates with established risks for fibrotic disease progression in NASH, and plasma lumican FSR correlates with hepatic collagen FSR, suggesting applications as direct or surrogate markers, respectively, of hepatic fibrogenesis in humans. (Hepatology 2017;65:78-88)

Plasma sTNFR1 and IL8 for prognostic enrichment in sepsis trials: a prospective cohort study.

BackgroundEnrichment strategies improve therapeutic targeting and trial efficiency, but enrichment factors for sepsis trials are lacking. We determined whether concentrations of soluble tumor necrosis factor receptor-1 (sTNFR1), interleukin-8 (IL8), and angiopoietin-2 (Ang2) could identify sepsis patients at higher mortality risk and serve as prognostic enrichment factors.MethodsIn a multicenter prospective cohort study of 400 critically ill septic patients, we derived and validated thresholds for each marker and expressed prognostic enrichment using risk differences (RD) of 30-day mortality as predictive values. We then used decision curve analysis to simulate the prognostic enrichment of each marker and compare different prognostic enrichment strategies.Measurements and main resultsAn admission sTNFR1 concentration > 8861 pg/ml identified patients with increased mortality in both the derivation (RD 21.6%) and validation (RD 17.8%) populations. Among immunocompetent patients, an IL8 concentration > 94 pg/ml identified patients with increased mortality in both the derivation (RD 17.7%) and validation (RD 27.0%) populations. An Ang2 level > 9761 pg/ml identified patients at 21.3% and 12.3% increased risk of mortality in the derivation and validation populations, respectively. Using sTNFR1 or IL8 to select high-risk patients improved clinical trial power and efficiency compared to selecting patients with septic shock. Ang2 did not outperform septic shock as an enrichment factor.ConclusionsThresholds for sTNFR1 and IL8 consistently identified sepsis patients with higher mortality risk and may have utility for prognostic enrichment in sepsis trials

Chronic obstructive pulmonary disease in older persons: A comparison of two spirometric definitions

SummaryBackgroundAmong older persons, we previously endorsed a two-step spirometric definition of chronic obstructive pulmonary disease (COPD) that requires a ratio of forced expiratory volume in 1sec to forced vital capacity (FEV1/FVC) below .70, and an FEV1 below the 5th or 10th standardized residual percentile (“SR-tile strategy”).ObjectiveTo evaluate the clinical validity of an SR-tile strategy, compared to a current definition of COPD, as published by the Global Initiative for Obstructive Lung Disease (GOLD-COPD), in older persons.MethodsWe assessed national data from 2480 persons aged 65–80 years. In separate analyses, we evaluated the association of an SR-tile strategy with mortality and respiratory symptoms, relative to GOLD-COPD. As per convention, GOLD-COPD was defined solely by an FEV1/FVC<.70, with severity staged according to FEV1 cut-points at 80 and 50 percent predicted (%Pred).ResultsAmong 831 participants with GOLD-COPD, the risk of death was elevated only in 179 (21.5%) of those who also had an FEV1<5th SR-tile; and the odds of having respiratory symptoms were elevated only in 310 (37.4%) of those who also had an FEV1<10th SR-tile. In contrast, GOLD-COPD staged at an FEV1 50–79%Pred led to misclassification (overestimation) in terms of 209 (66.4%) and 77 (24.6%) participants, respectively, not having an increased risk of death or likelihood of respiratory symptoms.ConclusionRelative to an SR-tile strategy, the majority of older persons with GOLD-COPD had neither an increased risk of death nor an increased likelihood of respiratory symptoms. These results raise concerns about the clinical validity of GOLD guidelines in older persons