bluuebunny/crossref_metadata_2025 huggingface dataset:
Drought‐induced defoliation and long periods of near‐zero gas exchange play a key role in accentuating metabolic decline of Scots pine
Authors: Poyatos Rafael , Aguadé David , Galiano Lucía , Mencuccini Maurizio , Martínez‐Vilalta Jordi
Published: April 2013

Drought‐induced defoliation has recently been associated with the depletion of carbon reserves and increased mortality risk in Scots pine (Pinus sylvestris). We hypothesize that defoliated individuals are more sensitive to drought, implying that potentially higher gas exchange (per unit of leaf area) during wet periods may not compensate for their reduced photosynthetic area.

We measured sap flow, needle water potentials and whole‐tree hydraulic conductance to analyse the drought responses of co‐occurring defoliated and nondefoliated Scots pines in northeast Spain during typical (2010) and extreme (2011) drought conditions.

Defoliated Scots pines showed higher sap flow per unit leaf area during spring, but were more sensitive to summer drought, relative to nondefoliated pines. This pattern was associated with a steeper decline in soil‐to‐leaf hydraulic conductance with drought and an enhanced sensitivity of canopy conductance to soil water availability. Near‐homeostasis in midday water potentials was observed across years and defoliation classes, with minimum values of −2.5 MPa. Enhanced sensitivity to drought and prolonged periods of near‐zero gas exchange were consistent with low levels of carbohydrate reserves in defoliated trees.

Our results support the critical links between defoliation, water and carbon availability, and their key roles in determining tree survival and recovery under drought.
Dysregulation of miR‐31 and miR‐375 expression is associated with clinical outcomes in oral carcinoma
Authors: Siow MY , Karen Ng LP , Vincent Chong VK , Jamaludin M , Abraham MT , Abdul Rahman ZA , Kallarakkal TG , Yang Y‐H , Cheong SC , Zain RB
Published: April 2013

Objectives

To identify differentially expressed miRNA between oral squamous cell carcinoma (OSCC) and non‐cancer (NC) and to associate these with clinico‐pathological parameters.

Materials and methods

miRNA microarray profiling was utilized to obtain the expression profile of miRNAs in four OSCC and four NC samples. The expression of miR‐31 and miR‐375 was further validated in 26 OSCC and three NC samples using real‐time‐PCR. The association between miRNA expression and clinico‐pathological parameters was tested by univariate and multivariate analyses.

Results

Microarray profiling demonstrated that 15 and four miRNAs were up‐regulated and down‐regulated, respectively, in OSCC as compared with NC. miR‐31 and miR‐375 were validated as up‐ and down‐regulated miRNAs, respectively. In univariate analyses, expression of miR‐31 was significantly elevated in early stage, tumours with no metastatic nodes and those from the buccal mucosa. By contrast, low miR‐375 expression was significantly associated with late stage disease, larger tumour size and the non‐cohesive type of pattern of invasion in OSCC. The association between miR‐31 expression with tumour staging and site and miR‐375 with tumour staging remained significant in multivariate analyses.

Conclusions

This study has identified 19 miRNAs significantly associated with OSCC, and expressions of miR‐31 and miR‐375 were significantly related with clinico‐pathological parameters suggesting they could be important in driving oral tumourigenesis.
Everyday activities for people with dementia in residential aged care: associations with person‐centredness and quality of life
Authors: Edvardsson David , Petersson Lisa , Sjogren Karin , Lindkvist Marie , Sandman Per‐Olof
Published: April 2013

Background

Providing everyday activities is central to high quality residential aged care, but further research is needed on the association between activity participation, person‐centred care and quality of life.

Aims and objectives

To explore the point‐prevalence of participation in everyday activities for residents with dementia within a national sample of Swedish residential aged care units and to explore if residents participating in everyday activities lived in more person‐centred units and/or had higher quality of life as compared to residents not participating in everyday activities.

Design and methods

A cross‐sectional design was used to collect valid and reliable questionnaire data on activity participation, unit person‐centredness and quality of life in a sample of residents in residential aged care (n = 1266).

Results

Only 18% of residents participated in everyday activities such as making coffee, setting or clearing the table, cleaning or watering plants, 62% participated in outdoor walks, 27% participated in parlour games, and 14% and 13% participated in excursions and church visits, respectively. Those residents who had participated in everyday activities lived in more person‐centred units, had significantly higher quality of life and higher cognitive scores as compared to those residents who had not participated in everyday activities.

Conclusions

Even though the prevalence of resident participation in everyday activities was low, resident participation was significantly associated with unit person‐centredness and resident quality of life. It seems that everyday activities that are routine and commonplace to residential aged care can be potent nursing interventions for promoting resident quality of life.

Implications for practice

The study indicates that residents can benefit from participation in everyday activities that are commonly occurring in aged care practice. It seems that such everyday tasks and procedures can provide fruitful ways to make person‐centred care happen in clinical practice, and ways to increasingly involve residents with cognitive impairment need to be further developed.
Cardiac Resynchronization Therapy in Patients with Atrial Fibrillation: A 2‐Year Follow‐Up Study
Authors: EISEN ALON , NEVZOROV ROMAN , GOLDENBERG GUSTAVO , KUZNITZ HAIM , PORTER AVITAL , GOLOVTZINER GREGORY , STRASBERG BORIS , HAIM MOTI
Published: April 2013

Introduction

Atrial fibrillation (AF) is the most common arrhythmia in patients with heart failure (HF) and represents an important comorbidity in these patients. Cardiac resynchronization therapy (CRT) has been shown to be beneficial in patients with HF. Whether patients with AF benefit similarly from CRT as their counterparts in sinus rhythm is controversial.

Methods and Results

We conducted a cohort analysis of 175 patients (138 men; age range 57–79 years) who underwent CRT implantation during 2004–2008 in our institution. AF was documented in 66 patients (37.7% of patients, 52 men). There were no differences in 1‐ or 2‐year mortality between patients with and without AF (13.6% vs 11.79%, P = 0.7; 25.8% vs 16.9%, P = 0.2, respectively). There were no differences between the groups in the rate of complications after CRT implantation or in the rate of appropriate electrical shocks. In the subgroup of AF patients with cardiac resynchronization therapy defibrillator (CRT‐D) (n = 32, 48.5%), the 1‐year mortality was 3.1% as compared to 23.5% in AF patients with cardiac resynchronization therapy pacemaker (P = 0.03). This difference was no longer evident after 2 years (25.0% vs 26.5%, P = 0.8, respectively). Ten patients (15.2%) with AF underwent atrioventricular (AV) node ablation. The 2‐year mortality of these patients was 10.0% as compared to 28.6% in AF patients who did not undergo AV‐node ablation (P = 0.4).

Conclusions

In this study, no difference in mortality appears to exist between patients with or without AF and who undergo CRT implantation. Our findings of the beneficial effects of AV‐node ablation and CRT‐D in AF patients deserve further investigation.
New validated recipes for double‐blind placebo‐controlled low‐dose food challenges
Authors: Winberg Anna , Nordström Lisbeth , Strinnholm Åsa , Nylander Annica , Jonsäll Anette , Rönmark Eva , West Christina E.
Published: April 2013

Double‐blind placebo‐controlled food challenges are considered the most reliable method to diagnose or rule out food allergy. Despite this, there are few validated challenge recipes available. The present study aimed to validate new recipes for low‐dose double‐blind placebo‐controlled food challenges in school children, by investigating whether there were any sensory differences between the active materials containing cow's milk, hen's egg, soy, wheat or cod, and the placebo materials. The challenge materials contained the same hypoallergenic amino acid–based product, with or without added food allergens. The test panels consisted of 275 school children, aged 8–10 and 14–15 yr, respectively, from five Swedish schools. Each participant tested at least one recipe. Standardized blinded triangle tests were performed to investigate whether any sensory differences could be detected between the active and placebo materials. In our final recipes, no significant differences could be detected between the active and placebo materials for any challenge food (p > 0.05). These results remained after stratification for age and gender. The taste of challenge materials was acceptable, and no unfavourable side effects related to test materials were observed. In summary, these new validated recipes for low‐dose double‐blinded food challenges contain common allergenic foods in childhood; cow's milk, hen's egg, soy, wheat and cod. All test materials contain the same liquid vehicle, which facilitates preparation and dosing. Our validated recipes increase the range of available recipes, and as they are easily prepared and dosed, they may facilitate the use of double‐blind placebo‐controlled food challenges in daily clinical practice.
High‐resolution multiphoton tomography and fluorescence lifetime imaging of UVB‐induced cellular damage on cultured fibroblasts producing fibres
Authors: Stefania Seidenari , Simona Schianchi , Paola Azzoni , Luisa Benassi , Stefania Borsari , Jennifer Cautela , Chiara Ferrari , Paul French , Stefania Giudice , Karsten Koenig , Cristina Magnoni , Clifford Talbot , Christopher Dunsby
Published: April 2013

Background

Multiphoton tomography (MPT) is suitable to perform both ex vivo and in vivo investigations of living skin and cell cultures with submicron resolution. Fluorescence lifetime imaging (FLIM) generates image contrast between different states of tissue characterized by various fluorescence decay rates. Our purpose was to combine MPT and FLIM to evaluate fibroblasts and collagen fibres produced in vitro.

Methods

Fibroblast cultures, 2–4 days old, at a subconfluent stage, were evaluated before and after irradiation with a single UVB dose. One month old cultures stimulated with ascorbic acid were also assessed.

Results

After UVB radiation, fibroblasts appear irregular in size, lose their alignment and show a decrease in fluorescence lifetime. One month‐old fibroblasts, producing collagen fibres after stimulation with ascorbic acid, appear as small roundish structures intermingled by filaments showing a granular arrangement.

Conclusion

The combination of MPT and FLIM may be useful for the in vitro study of cell modifications induced by injurious or protective agents and drugs.
The Human Polygyny Index and its Ecological Correlates: Testing Sexual Selection and Life History Theory at the Cross‐National Level
Authors: Schmitt David P. , Rohde Percy A.
Published: April 2013

Objectives

Sexual selection theory suggests patterns of covariance among polygynous mating behaviors and ecological variables at the cross‐national level. We quantified national levels of polygyny using the human polygyny index (HPI), a ratio of men's to women's variability in the numbers of sex partners over the past year.

Methods

HPI scores were available for 48 nations from the International Sexuality Description Project (Schmitt, 2005), and were used to test three hypotheses: (1) human polygyny should be associated with increased intrasexual competition (e.g., high male‐male aggression and resource competition), (2) human polygyny should be associated with features of natural and intersexual selection (e.g., high pathogen stress and an emphasis on physical attractiveness in mate choice), and (3) human polygyny should be associated with early and more prolific reproduction.

Results

All three hypotheses received at least partial support.

Conclusions

Discussion focuses on the limitations and implications of the current findings.
Temporal trends and regional variability of 2001–2002 multiwave DENV‐3 epidemic in Havana City: did Hurricane Michelle contribute to its severity?
Authors: Hsieh Ying‐Hen , de Arazoza Hector , Lounes Rachid
Published: April 2013

Objectives

To investigate the temporal and regional variability of the 2001–2002 dengue outbreak in Havana City where 12 889 cases, mostly of DENV‐3 type, were reported over a period of 7 months.

Methods

A simple mathematical model, the Richards model, was used to fit the weekly reported dengue case data by municipality, in order to quantify the transmissibility and temporal changes in the epidemic in each municipality via the basic reproduction number R0.

Results

Model fits indicate either a 2‐wave or 3‐wave outbreak in all municipalities. Estimates for R0 varied greatly, from 1.97 (95% CI: 1.94, 2.01), for Arroyo Naranjo, to 61.06 (60.44, 61.68), for Boyeros, most likely due to heterogeneity in community structure, geographical locations and social networking.

Conclusions

Our results illustrate the potential impact of climatological events on disease spread, further highlighting the need to be well prepared for potentially worsening disease spread in the aftermath of natural disasters such as hurricanes/typhoons.
Development of an Oral Curcumin Nanocrystal Formulation
Authors: Ravichandran R.
Published: April 2013

During the last ten years, the formulation of drugs as nanocrystals has rapidly evolved into a mature drug delivery strategy, with currently five products on the market. The major characteristic of these systems is the rapid dissolution velocity, enabling bioavailability enhancement after oral administration. This study describes the preparation of a solid dosage capsule form of spray-dried curcumin nanocrystal and compares its dissolution behavior with market capsule in different media. The aim was to obtain a stable nanocrystal loaded drug capsule with an increased drug saturation solubility and dissolution velocity. The solubility and dissolution experiments were performed to verify the obvious improvement of the dissolution behavior compared with commercial product. Improved dissolution behavior in drug nanocrystal-loaded solid dosage forms should lead to better bioavailability of poorly soluble drugs in the body.
Investigation of shunt path evolution originated from transparent conductive oxides in Si-based thin film solar cells
Authors: Joo Minho , Lee Jungmin , Park Kyuho , Chung Jin-Won , Ahn Seh-Won , Lee Heon-Min
Published: April 2013

The evolution of the shunt path on the performance of Si-based thin film solar cells with an glass/Al-doped ZnO (AZO)/amorphous (a)-Si:H/a-SiGe:H/Al was investigated by conductive atomic force microscopy, electroluminescence measurement, and transmission electron microscopy. AZO films were highly textured for the light management before the deposition of absorption layers. The cell performance was found to be strongly dependent on the existence of nanocracks formed in a-Si:H/a-SiGe:H layers. The defects by nanocracks are expected to attribute to the leakage current in the cells. The authors introduce two types of shunt path evolution modes: pinhole defects (type A) and highly textured groove of AZO film (type B). Both crack defects by types A and B induced high leakage current, leading to a relatively reduced fill factor on the performance.
Adding thermal and granularity effects to the effective density fluid model
Authors: Williams Kevin L.
Published: April 2013

Previously, an effective density fluid model (EDFM) was developed by the author [J. Acoust. Soc. Am. 110, 2276–2281 (2001)] for unconsolidated granular sediments and applied to sand. The model is a simplification of the full Biot porous media model. Here two additional effects are added to the EDFM model: heat transfer between the liquid and solid at low frequencies and the granularity of the medium at high frequencies. The frequency range studied is 100 Hz–1 MHz. The analytical sound speed and attenuation expressions obtained have no free parameters. The resulting model is compared to ocean data.
HIV-1 Concentrations in Human Breast Milk Before and After Weaning
Authors: Kuhn Louise , Kim Hae-Young , Walter Jan , Thea Donald M. , Sinkala Moses , Mwiya Mwiya , Kankasa Chipepo , Decker Don , Aldrovandi Grace M.
Published: April 2013

Reducing the frequency of breast-feeding during weaning and nonexclusive breast-feeding boosts HIV-1 RNA and DNA concentrations in the breast milk of HIV-infected women.
H3 Minority Report
Authors: Schaefer Anne
Published: April 2013

Histone H3 gain-of-function mutation paralyzes the histone methyltransferase Ezh2 in pediatric glioblastoma.
Identification ofSalmonellaPathogenicity Island-2 Type III Secretion System Effectors Involved in Intramacrophage Replication of S. enterica Serovar Typhimurium: Implications for Rational Vaccine Design
Authors: Figueira Rita , Watson Kathryn G. , Holden David W. , Helaine Sophie
Published: April 2013

Salmonella entericaserovars cause severe diseases in humans, such as gastroenteritis and typhoid fever. The development of systemic disease is dependent on a type III secretion system (T3SS) encoded bySalmonellapathogenicity island-2 (SPI-2). Translocation of effector proteins across theSalmonella-containing vacuole, via the SPI-2 T3SS, enables bacterial replication within host cells, including macrophages. Here, we investigated the contribution of these effectors to intramacrophage replication ofSalmonella entericaserovar Typhimurium using Fluorescence Dilution, a dual-fluorescence tool which allows direct measurement of bacterial replication. Of 32 strains, each carrying single mutations in genes encoding effectors, 10 (lackingsifA,sseJ,sopD2,sseG,sseF,srfH,sseL,spvD,cigR, orsteD) were attenuated in replication in mouse bone marrow-derived macrophages. The replication profiles of strains combining deletions in effector genes were also investigated: a strain lacking the genessseG,sopD2, andsrfHshowed an increased replication defect compared to single-mutation strains and was very similar to SPI-2 T3SS-deficient bacteria with respect to its replication defect. This strain was substantially attenuated in virulencein vivoand yet retained intracellular vacuole integrity and a functional SPI-2 T3SS. Moreover, this strain was capable of SPI-2 T3SS-mediated delivery of a model antigen for major histocompatibility complex (MHC) class I-dependent T-cell activation. This work establishes a basis for the use of a poly-effector mutant strain as an attenuated vaccine carrier for delivery of heterologous antigens directly into the cytoplasm of host cells.

IMPORTANCELive attenuated strains ofSalmonella entericaserotype Typhi have generated much interest in the search for improved vaccines against typhoid fever and as vaccine vectors for the delivery of heterologous antigens. A promising vaccine candidate is the ΔaroCΔssaVS. Typhi strain, which owes its attenuation mainly to lack of a type III secretion system (SPI-2 T3SS). The SPI-2 T3SS is important for bacterial proliferation inside macrophages, but not all of the effectors involved in this process have been identified. Here, we show that 10 effectors of the related strainS. Typhimurium contribute to intracellular replication in macrophages. Moreover, we establish that a poly-effector mutant strain ofS. Typhimurium can have a severe replication defect and maintain a functional SPI-2 T3SS, which can be exploited for delivery of heterologous antigens.
In-Depth Analysis of the Interaction of HIV-1 with Cellular microRNA Biogenesis and Effector Mechanisms
Authors: Whisnant Adam W. , Bogerd Hal P. , Flores Omar , Ho Phong , Powers Jason G. , Sharova Natalia , Stevenson Mario , Chen Chin-Ho , Cullen Bryan R.
Published: April 2013

The question of how HIV-1 interfaces with cellular microRNA (miRNA) biogenesis and effector mechanisms has been highly controversial. Here, we first used deep sequencing of small RNAs present in two different infected cell lines (TZM-bl and C8166) and two types of primary human cells (CD4
+
peripheral blood mononuclear cells [PBMCs] and macrophages) to unequivocally demonstrate that HIV-1 does not encode any viral miRNAs. Perhaps surprisingly, we also observed that infection of T cells by HIV-1 has only a modest effect on the expression of cellular miRNAs at early times after infection. Comprehensive analysis of miRNA binding to the HIV-1 genome using the photoactivatable ribonucleoside-induced cross-linking and immunoprecipitation (PAR-CLIP) technique revealed several binding sites for cellular miRNAs, a subset of which were shown to be capable of mediating miRNA-mediated repression of gene expression. However, the main finding from this analysis is that HIV-1 transcripts are largely refractory to miRNA binding, most probably due to extensive viral RNA secondary structure. Together, these data demonstrate that HIV-1 neither encodes viral miRNAs nor strongly influences cellular miRNA expression, at least early after infection, and imply that HIV-1 transcripts have evolved to avoid inhibition by preexisting cellular miRNAs by adopting extensive RNA secondary structures that occlude most potential miRNA binding sites.

IMPORTANCE
MicroRNAs (miRNAs) are a ubiquitous class of small regulatory RNAs that serve as posttranscriptional regulators of gene expression. Previous work has suggested that HIV-1 might subvert the function of the cellular miRNA machinery by expressing viral miRNAs or by dramatically altering the level of cellular miRNA expression. Using very sensitive approaches, we now demonstrate that neither of these ideas is in fact correct. Moreover, HIV-1 transcripts appear to largely avoid regulation by cellular miRNAs by adopting an extensive RNA secondary structure that occludes the ability of cellular miRNAs to interact with viral mRNAs. Together, these data suggest that HIV-1, rather than seeking to control miRNA function in infected cells, has instead evolved a mechanism to become largely invisible to cellular miRNA effector mechanisms.
Acral erosive mycosis fungoides: successful treatment with localised radiotherapy
Authors: Wang Connie Mengyan , Duvic Madeleine , Dabaja Bouthaina Shbib
Published: April 2013

Mycosis fungoides encompasses a wide range of variants with differing clinical and histopathological findings, clinical courses and methods of treatment. Two patients were referred to MD Anderson Cancer Center for the evaluation of treatment-refractory palmoplantar dermatoses suggestive of a rare variant of mycosis fungoides—mycosis fungoides palmaris et plantaris (MFPP). Both patients eventually had progressive and ulcerative cutaneous disease extending beyond acral regions that showed remarkable response to local radiation therapy. Although most documented cases of MFPP show an indolent course, one must be aware of the possibility of development of severe cutaneous disease in patients initially presenting with palmoplantar involvement. Local radiotherapy is a safe and effective palliative treatment option for MFPP and cutaneous disease refractory to systemic treatment.
Limbic encephalitis as the presenting symptom of oesophageal adenocarcinoma: another cancer to search?
Authors: Menezes Renata Barbosa , de Lucena Adson Freitas , Maia Fernanda Martins , Marinho Antônia Rosivalda Teixeira
Published: April 2013

Limbic encephalitis is a syndrome characterised by irritability, depression, sleeping disturbance, convulsion, hallucination and short-period memory loss that is commonly associated with a malignancy even if there is no evidence of it by the time of presentation. Most reported cases of limbic encephalitis as a paraneoplastic syndrome are associated with small-cell lung cancer and lymphoma. This article is a case report of a patient with limbic encephalitis associated with an oesophageal adenocarcinoma. The patient is a middle-aged man who presented apathy and unstable mood. After months, developed diplopia, reduced visual acuity and involuntary movements. Later, gait disability, disorientation, memory loss and aggressive behaviour were detected, associated with seizures. After investigation, limbic encephalitis was diagnosed and, as the patient developed dysphagia, oesophageal adenocarcinoma was detected. Oesophageal carcinoma usually does not have neurological symptoms associated.
Unusual case of a lung abscess
Authors: Musa Duduzile , Godbole Gauri , Chiodini Peter L , Phillips Russell
Published: April 2013

A 56-year-old Caucasian lady presented with a short history of pleuritic chest pain on the background of a 2-month history of fever, chills, 10-kg weight loss and cough with brown sputum after a laparoscopic cholecystectomy. She had persistent eosinophilia and was diagnosed with a lung abscess as seen on chest x-ray. She did not respond to standard intravenous broad spectrum antibacterial medication and her chest CT scan showed a moderate pleural collection in continuity with the abscess. She also underwent bronchoscopy, the microscopy of the bronchial washings revealing eggs of the trematodeFasciola. The bacterial and fungal cultures of the washings were sterile. She had visited Turkey in the previous year but did not remember consuming any watercress or aquatic plants. She was successfully treated with two doses of the antiparasitic agent triclabendazole. EctopicFasciolacan be a rare cause of a lung abscess.
Primary schwannoma of maxillary sinus masquerading as malignant tumour
Authors: Minhas R S , Thakur J S , Sharma D R
Published: April 2013

Polyp and mucocele are the commonest sinonasal tumours and schwannoma is rarely found in the paranasal sinuses. We report a case of a 64-year-old man presenting with progressive nasal obstruction and numbness on left cheek for the past 2 months. High-resolution CT found a soft tissue mass in the maxillary antrum with bony destruction. Clinical features, radiological scan and nasal endoscopic examination were suggestive of a malignant tumour. Tumour was excised through Caldwell-Luc's approach and histopathological examination found a mixed schwannoma.
The science of human factors: separating fact from fiction
Authors: Russ Alissa L , Fairbanks Rollin J , Karsh Ben-Tzion , Militello Laura G , Saleem Jason J , Wears Robert L
Published: April 2013

Background

Interest in human factors has increased across healthcare communities and institutions as the value of human centred design in healthcare becomes increasingly clear. However, as human factors is becoming more prominent, there is growing evidence of confusion about human factors science, both anecdotally and in scientific literature. Some of the misconceptions about human factors may inadvertently create missed opportunities for healthcare improvement.

Methods

The objective of this article is to describe the scientific discipline of human factors and provide common ground for partnerships between healthcare and human factors communities.

Results

The primary goal of human factors science is to promote efficiency, safety and effectiveness by improving the design of technologies, processes and work systems. As described in this article, human factors also provides insight on when training is likely (or unlikely) to be effective for improving patient safety. Finally, we outline human factors specialty areas that may be particularly relevant for improving healthcare delivery and provide examples to demonstrate their value.

Conclusions

The human factors concepts presented in this article may foster interdisciplinary collaborations to yield new, sustainable solutions for healthcare quality and patient safety.
ASSOCIATION OF TREATMENT PREFERENCES, SPIRITUAL BELIEFS AND RELIGION AMONG ADOLESCENTS INFECTED WITH HIV/AIDS PARTICIPATING IN FAMILY CENTERED (FACE) ADVANCE CARE PLANNING (ACP)
Authors: Lyon M E , Briggs L A , Gaines J , Cheng Y I , Wang J
Published: April 2013

Background

Among adults religious beliefs are associated with treatment preferences at the end-of-life (EOL). This is unknown for adolescents with HIV/AIDS.

Aim

To determine if spiritual beliefs, religious practices or religion are correlated with treatment preferences for end-of-life (EOL) care among adolescents with HIV/AIDS.

Methods

Adolescents (N=53) aged 14 to 21 were enrolled in a 3-site, controlled, randomised clinical trial. Data were collected between 7/2011–10/2012. FACE-ACP consists of weekly, 60-min sessions: (1) Lyon Advance Care Planning Survey©; (2) Respecting Choices Interview; (3) Five Wishes©. Measures were Brief Multidimensional Measurement of Religiousness/Spirituality and Statement of Treatment Preferences. Six subjects had missing data.

Results

Mean age was 18 years; 57% male; 94% African-American; 74% perinatally infected. In Situation 1 (long hospitalisation, low chance survival) 53% of adolescents reporting religion and 100% of non-religion group chose to continue treatment (p=0.0317). In Situation 2 (physical impairment) 74% of adolescents who ‘felt God's presence most days’ chose to continue treatments; 45% who did not ‘feel God's presence’ chose to continue (p=0.0426). In Situation 3 (mental impairment), there was no significant associations. Combining the three situations, 28% of religion group choose to continue treatment; 71% of non-religion group chose to continue (p=0.0364). Belief in miracles, HIV is a punishment from God, feeling abandoned by God, religious practices were not associated with treatment preferences.

Conclusion/Discussion

Religious beliefs were associated with decisions to continue treatment, depending on the situation. These data begin to fill the gap in understanding the complexities of the influence of spirituality/religion on treatment preferences.
AUDIT OF RESUSCITATION PLANNING AND DOCUMENTATION AT A TERTIARY CHILDREN'S HOSPITAL OVER A 12 MONTH PERIOD
Authors: Kelly J , Herbert A , Ritchie J
Published: April 2013

Background

Resuscitation planning is a very important aspect of care for children with life limiting conditions.

Aim

This research aims to evaluate the practice of resuscitation planning at a major tertiary children's hospital.

Methods

A list of patients who had died in 2011 was obtained from medical records. We collected information regarding parental demographics, patient diagnosis, the scope and timing of discussions and treatments/limitations to treatment, which were felt to be appropriate. The location of the documentation was also recorded.

Results

Of the 45 patients identified, 35 charts were available. 28 individuals had a condition carrying a poor prognosis or life limiting condition. In seven cases, death was unexpected. In 24 of 28(85.6%) charts a discussion was documented regarding end of life cares. However, only two (8.3%) of these were readily identifiable. In two cases, discussions were held more than 12 months before the child's death. When adjusted to exclude these variables, documentation was dated on average 35.6 days before death.

Discussion

Patients of the Royal Children's Hospital with a life limiting condition had a documented resuscitation plan 85.6% of the time. However, this was not easily identified in 91.7% of cases. The timing of discussion varied considerably in relation to the time from resuscitation planning to death and the scope of discussion.

Conclusions

The sensitive and timely discussion of end of life cares should be undertaken and documented clearly and with a consistent manner in order to facilitate communication between all health care professionals providing care for the child. This study has identified considerable room for improvement at our institution.
PILOTING AN INTEGRATED APPROACH OF ADVANCE CARE PLANNING FOR AN ELDERLY POPULATION WITHIN A PROVINCIAL CITY
Authors: Fowler J
Published: April 2013

Background

Advance Care Planning (ACP) has been introduced into New Zealand in recent years. New Zealand National ACP Cooperative has developed ACP tools and resources. Wanganui is a provincial region (population 62 000 and above average elderly age group), and took the opportunity to take an integrated approach for piloting and implementing the Cooperatives tools.

Aim

To implement ACP within Wanganui region and gain sector-wide engagement and coordination (integration).

Methods

The 6 month pilot trialled the National ACP tools in primary and secondary areas; General Practitioner practice; Maori patients in a medical ward; Assessment Treatment and Rehabilitation Service; Aged Residential Care Facility. Clinical staff in the pilot areas had ACP conversations with elderly participants. Clinical staff raised ACP awareness with the general public.

Results

Of the 82 participants, 75% were interested in continuing ACP conversations (verbal and/or documented) with appropriate people for example, family/whanau; health professionals; lawyers. The pilot evaluation and recommendations identified several key areas, including outcomes and challenges that are being addressed collaboratively across the sectors. These are forming the basis for a Wanganui district wide application of ACP, that are in align with national and regional directions.

Discussion

An integrated approach has been a successful way to introduce ACP to Wanganui region stakeholders, and has enabled significant progress in a short period of time.

Conclusion

Findings to-date, indicate the Wanganui pilot supports an integrated approach for ACP across the specialist; primary and community services, with a common vision, shared processes and systems to improve end of life health care for the elderly.
DIGNITY OF LIFE AND PERSON-CENTRED PROCESSES FOR ADVANCE CARE PLANNING IN THE COMMUNITY
Authors: Smith C , Jaffray L , Ellis I
Published: April 2013

Background

As life expectancy increases, so do the number of elderly people living with advanced life-limiting chronic illness, including prolonging life through artificial or mechanical means. The aim of Advance Care Plans is to ensure that individual's treatment wishes and preferences are known and respected.

Aim

Whilst research continues in regard to the development of electronic Advance Care Plans in the palliative care setting and residential aged care setting, there is a need to understand the relevance and practicality of developing Advance Care Plans for use by elderly people living with life-limiting chronic illnesses in the community.

Methods

Systematic review—models of Advance Care Planning for elderly people living in the community

Meta- analysis and meta-synthesis

Interviews—sample of ACP programme stakeholders and community dwelling elderly (early 2013)

Results

Seventy-one papers resulted from the search strategy with 17 papers selected for review. A meta-analysis and meta-synthesis has informed our proposed model for electronic Advance Care planning in the community—the Dignity of Life Model (a person-centred and dignity of life focussed approach). Interview data will inform the relevance and practicality of this proposed model.

Discussion

This research will assist to understand the relevance and practicality of developing an electronic Advance Care Plan (eAPC) for use by elderly people living with life-limiting chronic illnesses in the community.

Conclusion

Provide guidance on a model for electronic Advance Care Plan (eAPC) for use by elderly people living with life-limiting chronic illnesses in the community.
AUSTRALIAN PSYCHIATRISTS' KNOWLEDGE, ATTITUDES, AND PRACTICE IN RELATION TO ADVANCE CARE PLANNING FOR MENTAL HEALTH TREATMENT
Authors: Mountjoy R , Silvester W , Newton R , Fullam R , Mawren D
Published: April 2013

Background

Proposed revisions to the Victorian Mental Health Act intend to consider Advance Care Planning (ACP) in mental health treatment. No research has explored the feasibility and benefits of Psychiatric Advanced Directives (PADs) in Australia. International studies suggest that implementation of PADs can be limited by mental health clinicians' attitudes and knowledge.

Aim

To establish Australian psychiatrists' knowledge, attitudes and practice regarding PADs.

Methods

A national online survey of Australian psychiatrists.

Results

Of 165 respondents, 56% reported low to very low knowledge of PADs and only 27% reported experience with PADs or a similar instrument. 76% of psychiatrists expressed support for the introduction of PAD legislation and 83% would be more inclined to use PADs if the law acknowledged their role as important. 79% expected that PADs will have a positive impact on mental health care, with the benefits considered to outweigh specific clinical issues such as medication refusal (54%) and limitations on patient care (64%).

Discussion

Australian psychiatrists have low levels of knowledge and experience regarding PADs. A high level of general support for PAD use and legislation was expressed.

Conclusion

Australian psychiatrist expressed encouraging attitudes towards the implementation and use of PADs, and further research is required to develop an effective and sustainable model of ACP for mental health care in Australia.
TALKING WITH FAMILIES ABOUT ORGAN DONATION IN THE ICU
Authors: Truog R D
Published: April 2013

Background

There is a shortage of organs for life-saving transplants, and organ donation is an altruistic act that should be supported and encouraged. Patients may indicate their desire to be an organ donor through donor registries, but in most countries transplant coordinators still seek the assent of the family before proceeding with donation. These conversations with families are ethically challenging.

Aim

To explore the ethically challenging features of these conversations, in the context of talking with families about organ donation after circulatory death, or DCD.

Methods

Review of the literature and of training videos that explore these ethical features.

Results

Four ethical tensions are identified:

The decision to withdraw life sustaining treatment versus the decision to donate organs.

Optimising the quality of the dying process versus optimising the quality and quantity of the donated organs.

Obligations to provide balanced informed consent versus the belief that we should promote organ donation.

Belief that we need to follow the ‘dead donor rule’ versus increasingly contrived protocols for dying and definitions of death.

Discussion

After exploring these four ethical features, we will view segments from a video training tape that illustrate different approaches for resolving these tensions.

Conclusion

The important goal of promoting organ donation needs to be pursued with awareness and sensitivity for the ethical tensions inherent in this process.
PROGNOSIS-BASED GUIDELINES FOR TREATMENT LIMITATION DECISIONS IN NEWBORN INFANTS
Authors: Wilkinson D
Published: April 2013

Decisions to withdraw or withhold life-sustaining treatment from newborn infants are common in neonatal intensive care units (NICUs). The majority of deaths in NICU follow such treatment limitation decisions. There are professional guidelines for end of life decision-making in NICUs, however, these guidelines have been criticised. Many existing guidelines provide only vague guidance. For example, they indicate that treatment may be withheld when it is not in the best interests of an infant, but provide little assistance for clinicians in determining when this is the case. Other guidelines provide very specific criteria, for example specifying gestational age thresholds for resuscitation. However, guidelines of this nature potentially ignore other important prognostic factors.

In this talk I will examine the use of explicit prognosis-based guidelines for decision-making in intensive care. Is it possible and is it desirable to derive such guidelines? I outline and defend one potential practice framework based on the concept of ‘gestational-age equivalence’.
ADVANCE CARE PLANNING AS A DYNAMIC PROCESS: A DESCRIPTIVE 1 YEAR REVIEW OF CHANGES IN ACP PLANS IN TAN TOCK SENG HOSPITAL
Authors: Ng R , Chong R , Chau H , Poi C H , Eng Ramdat J , May Y Z , Loke A , Wu H Y
Published: April 2013

Background

Advance care planning (ACP) is a process and people can change their minds about treatment preferences when goals of care change. The ACP project team in Tan Tock Seng Hospital continually audits ACP outcomes including any change in ACP plans.

Aim

To examine rate of change in ACP plans and factors that may have contributed to changes in ACP plans.

Methods

ACP outcomes for readmissions and death were analysed from retrospective audit of paper and electronic medical records.

Results

Between October 2011 to December 2012, a total of 154 Preferred Plan of Care (PPC), a POLST-type ACP were completed with patients and/or their next-of-kin (NOK). Out of these 154 PPCs, 5 ACP plans were revised. Time lapse between creation of first and second ACP plan ranged from 3 to 91 days. One patient had decision making capacity at first and second ACP documentation, while 4 other patients had no decision making capacity at both ACP documentation. four revisions were initiated by doctors whilst one was initiated by the substitute decision maker. Two ACP plans were changed after further clarifications with NOK whilst three revisions took place when there were changes in the patients' medical condition or after trial of medical intervention. Three of the patients have since passed away.

Discussion

The number of changed ACP plans is a small fraction of the total completed. Doctors were active in continual exploration of ACP plans.

Conclusion

In our cohort, ACP plans remain relatively stable. ACP is a dynamic process that need a culture of review and re-exploration of care preferences in order to be responsive to changes in medical condition and care preferences.
STARTING PILOTS IN ADVANCE CARE PLANNING IN A TERTIARY HOSPITAL IN SINGAPORE: 1 YEAR REVIEW
Authors: Ng R , Chong R , Chau H , Poi C H , Eng Ramdat J , May Y Z , Loke A , Wu H Y
Published: April 2013

Background

Engagement with Respecting Choices since 2009 resulted in pilot initiatives in advance care planning (ACP) starting in hospitals and the community in Singapore since 2009. Since December 2011, a dedicated ACP project team was formed in Tan Tock Seng Hospital to support ACP pilot initiatives. These initiatives namely Preferred Plans of Care (POLST-type ACP) sprouted in the disciplines of Cardiology, Neurology, Neuro-surgery, General Medicine, Palliative Medicine, Post Acute Care at Home, Respiratory Medicine and Home Ventilation and Respiratory Support Services.

Aim

To audit awareness of ACP plans and congruence of patients' ACP plans with care delivery during readmission episodes and upon death.

Methods

ACP outcomes for readmissions and death were analysed from retrospective audit of paper and electronic medical records.

Results

From October 2011 to December 2012, a total of 154 preferred plans of care were completed with patients and/or next-of-kin. Five ACP plans were revised. Medical team was aware of patients' ACP plans in 75% of 67 readmissions. Medical interventions and initial place of care in event of deterioration were congruent with patients' stated preferences in 98% and 94% of readmissions respectively. Preferred place of death was honoured 74% upon death of patients.

Discussion

There was high awareness of advance care plan during readmission, and high congruence between patients' preferences and care delivery.

Conclusion

Advance care planning is an effective process in honouring patients' care preferences. More can be done to examine resource allocation, sustainability and reach of the programme and to address barriers to ACP.
SURVEY OF THE ATTITUDES OF GENERAL PRACTITIONERS AND PATIENTS ABOUT DISCUSSING RESUSCITATION
Authors: Lim I , Silvester W
Published: April 2013

Background

When confronted with acutely unwell, elderly patients, doctors often have limited knowledge about the patient's wishes for resuscitation. Providing inappropriate resuscitation causes patients to suffer, places unnecessary strain on their families and is a poor use of healthcare resources. Is the general practitioner (GP) well placed to discuss these issues with patients?

GP Survey answer N=90Frequently or almost always (%)Occasionally or neverI discuss resuscitation with my patient24 (27%)66 (73%)I don't because: “lack of time”24 (36%)I don't because: “patients don't wish to talk about it”21 (32%)I don't because: “it should only be discussed near death”18 (27%)I don't because: “lack of knowledge/confidence”2 (3%)

Aim

To survey the practice and attitudes of GPs and patients to discussing resuscitation and identify strategies to encourage such discussion.

Methods

From 18 April 2011 to 26 June 2011 Victorian GPs were surveyed anonymously through GP Divisions of Victoria and patients attending Ararat Medical Clinic aged over 65 were surveyed anonymously.

Results

90 GPs responded.

Identified incentives to discuss resuscitation included: ‘knowledge that my patient wanted discussion’ 79%, ‘incorporation into management plan’ 71%, ‘discussion guidelines available’ 42%, ‘medicare item number’ 34%. Very few felt uncomfortable about the discussion or ‘not my duty’.

Of 97 patients, 63% did not know what a resuscitation order was but 70% would like their GP to discuss it with them and 84% would be comfortable talking about it with family.

Discussion

Although the majority of GPs do not discuss resuscitation frequently with their patients, for various reasons, there are opportunities, through perceived ‘incentives’, to improve the discussion rate. The majority of their patients are keen and comfortable to have this discussion.

Conclusion:

The majority of GPs believe that it is their responsibility, and the majority of patients that it is their wish, to discuss resuscitation. There are realistic opportunities to increase the discussion rate.
AN AUDIT OF CURRENT PRACTICE OF DOCUMENTATION AND IDENTIFICATION OF SUBSTITUTE DECISION-MAKERS/PERSONS RESPONSIBLE IN AUSTRALIAN RESIDENTIAL AGED CARE FACILITIES
Authors: Welz M , Gee W , Workman B , Morton J
Published: April 2013

Background

There is little data on the correct identification and documentation of substitute decision-makers (SDM) or ‘persons responsible’ (PR) in residential aged care facilities (RACF). Current practice may not be consistent with the Victorian Guardianship and Administration Act (GAA) 1986.

Aim

To determine the extent of correct identification and documentation of SDMs or PRs as per GAA in two RACFs in Victoria, Australia.

Methods

Retrospective audit of paper and scanned electronic medical records (n=88).

Admission forms, which include the resident personal details form and the medical admission were examined for identification of next-of-kin (NOK), Power of Attorney-Medical Treatment (POA-MT) or guardian. The complete medical file was then examined to confirm correct identification on the admission forms. VCAT was also contacted where confirmatory documents were not found in medical records.

Results

First NOK was more consistently documented than second NOK (75% vs 33%).

POA-MT or guardianship with healthcare powers (GHCP) was noted in ∼15% of admission forms with only 15.4% having valid documents available.

In 26.1%, admission forms were unclear; of these, 34.8% were confirmed to have a POA-MT or GHCP. In 59.1%, no POA-MT or GHCP was noted; of these, 1.9% were found to have a POA-MT.

For residents with no confirmed POA-MT or GHCP, the first NOK was a potential PR (as per GAA) in 71.8%. Of these, 49% were confirmed as the PR.

Discussion/Conclusion

Documentation of POA-MT or GHCP is often incomplete or incorrect. A listed NOK is not necessarily the PR. Procedures and forms that use clear, unambiguous terminology must be developed to aid correct identification and documentation of SDMs.