bluuebunny/crossref_metadata_2025 huggingface dataset:
Sustained mitogen‐activated protein kinase activation with Aggregatibacter actinomycetemcomitans causes inflammatory bone loss
Authors: Dunmyer J. , Herbert B. , Li Q. , Zinna R. , Martin K. , Yu H. , Kirkwood K.L.
Published: May 2012

Aggregatibacter actinomycetemcomitans is a gram‐negative facultative capnophile involved in pathogenesis of aggressive forms of periodontal disease. In the present study, we interrogated the ability of A. actinomycetemcomitans to stimulate innate immune signaling and cytokine production and established that A. actinomycetemcomitans causes bone loss in a novel rat calvarial model. In vitro studies indicated that A. actinomycetemcomitans stimulated considerable production of soluble cytokines, tumor necrosis factor‐α, interleukin‐6 and interleukin‐10 in both primary bone marrow‐derived macrophages and NR8383 macrophages. Immunoblot analysis indicated that A. actinomycetemcomitans exhibits sustained activation of all major mitogen‐activated protein kinase (MAPK) pathways, as well as the negative regulator of MAPK signaling, MAPK phosphatase‐1 (MKP‐1), for at least 8 h. In a rat calvarial model of inflammatory bone loss, high and low doses of formalin‐fixed A.  actinomycetemcomitans were microinjected into the supraperiosteal calvarial space for 1–2 weeks. Histological staining and micro‐computed tomography of rat calvariae revealed a significant increase of inflammatory and fibroblast infiltrate and increased bone resorption as measured by total lacunar pit formation. From these data, we provide new evidence that fixed whole cell A. actinomycetemcomitans stimulation elicits a pro‐inflammatory host response through sustained MAPK signaling, leading to enhanced bone resorption within the rat calvarial bone.
Investigation of Trailing Edge Cooling Concepts in a High Pressure Turbine Cascade—Aerodynamic Experiments and Loss Analysis
Authors: Rehder Hans-Ju¨rgen
Published: May 2012

As part of a European research project, the aerodynamic and thermodynamic performance of a high pressure turbine cascade with different trailing edge cooling configurations was investigated in the wind tunnel for linear cascades at DLR in Go¨ttingen. A transonic rotor profile with a relative thick trailing edge was chosen for the experiments. Three trailing edge cooling configurations were applied, first central trailing edge ejection, second a trailing edge shape with a pressure side cut-back and slot equipped with a diffuser rib array, and third pressure side film cooling through a row of cylindrical holes. For comparison, aerodynamic investigations on a reference cascade with solid blades (no cooling holes or slots) were performed. The experiments covered the subsonic, transonic and supersonic exit Mach number range of the cascade while varying cooling mass flow ratios up to 2 %. This paper analyzes the effect of coolant ejection on the airfoil losses. Emphasis was given on separating the different loss contributions due to shocks, pressure, and suction side boundary layer, trailing edge, and mixing of the coolant flow. Employed measurement techniques are schlieren visualization, blade surface pressure measurements, and traverses by pneumatic probes in the cascade exit flow field and around the trailing edge. The results show that central trailing edge ejection significantly reduces the mixing losses and therefore decreases the overall loss. Higher loss levels are obtained when applying the configurations with pressure side blowing. In particular, the cut-back geometry reveals strong mixing losses due to the low momentum coolant fluid, which is decelerated by the diffuser rib array inside the slot. The influence of coolant flow rate on the trailing edge loss is tremendous, too. Shock and boundary layer losses are major contributions to the overall loss but are less affected by the coolant. Finally a parameter variation changing the temperature ratio of coolant to main flow was performed, resulting in increasing losses with decreasing coolant temperature.
Identification of Spinning Mode in the Unsteady Flow Field of a Low Pressure Turbine
Authors: Lengani Davide , Paradiso Berardo , Marn Andreas , Göttlich Emil
Published: May 2012

This paper presents an experimental investigation of the vane-blade unsteady interaction in an unshrouded low pressure (LP) turbine research rig with uneven blade/vane count (72 blades and 96 vanes). The rig was designed in cooperation with MTU Aero Engines and considerable efforts were put on the adjustment of all relevant model parameters. In particular blade count ratio, airfoil aspect ratio, reduced mass flow, reduced speed, and Mach and Reynolds numbers were chosen to reproduce the full scale LP turbine at take off condition. Measurements by means of a fast-response pressure probe were performed adopting a phase-locked acquisition technique in order to provide the time resolved flow field downstream of the turbine rotor. The probe has been fully traversed both in circumferential and radial traverses. The rotor exit is characterized by strong perturbations due to the tip leakage vortex and the rotor blade wake. Circumferential nonuniformities due to the upstream vane wake and to the downstream exit guide vane potential effects are also identified. Furthermore, in the present configuration with an uneven blade/vane count the nonuniformities due to the stator and rotor row are misaligned along the whole turbine circumference and create a spinning mode that rotates in direction opposite to the rotor at a high frequency. The aeroacoustic theory is employed to explain such further unsteady pattern. The variations of the exit flow angle within a cycle of such pattern are not negligible and almost comparable to the ones within the blade passing period.
Average Flow Inside and Around Fish Cages With and Without Fouling in a Uniform Flow
Authors: Gansel Lars C. , McClimans Thomas A. , Myrhaug Dag
Published: May 2012

The average flow field inside and around the bottom of porous cylinders in a uniform flow is explored using particle image velocimetry (PIV). Tests were conducted on six cylinders with porosities of 0%, 30%, 60%, 75%, 82%, and 90% in a flume tank where the flow field inside and around the models is time averaged over 180 s. The models had a height-to-diameter ratio of 3 and were made from metal mesh. The Reynolds numbers ranged from 5000 to 20,000 based on the diameter of the models and from 75 to 300 based on the diameter of individual strands of the mesh, which corresponds to the Reynolds numbers occurring at salmon fish cage netting used along the Norwegian coast. The porosities of 82%, 75%, and 60% correspond to those of a fish cage netting in Norwegian salmon farming with no, light, and heavy biofouling, respectively. The results from this study are discussed with respect to the instantaneous flow field in and around the same cylinders at identical Reynolds numbers. The focus is on the effect of porosity on the ventilation inside the cages and the vertical transports within the near wake. It is shown that heavy fouling of aquacultural netting can lead to internal circulation inside fish cages and, therefore, has the potential to dramatically reduce the ventilation of the net pens. The description of the time-averaged flow field inside and around porous cylinders can be used as benchmarks to validate and adjust numerical models of the flow past porous cylinders. The results from this study can also be valuable for the fish farming industry, since bio-fouling and the reduced porosity of fish cages can be monitored and controlled directly by fish farmers.
Designing Cell-Compatible Hydrogels for Biomedical Applications
Authors: Seliktar Dror
Published: May 2012

Designer Hydrogels

Hydrogels, which consist of highly water swollen cross-linked polymer networks, can now be made with a range of chemistries and a combination of physical and chemical cross-links. They can also be designed to degrade gradually when exposed to chemical or biological signals and are thus finding use in a wide range of applications, including tissue engineering and drug delivery.
Seliktar
(p.
1124
) reviews recent advances in tailoring hydrogels with specific properties and their applications to biology and medicine.
Quantum Algorithms for Quantum Field Theories
Authors: Jordan Stephen P. , Lee Keith S. M. , Preskill John
Published: May 2012

Quantum Leap?

Quantum computers are expected to be able to solve some of the most difficult problems in mathematics and physics. It is not known, however, whether quantum field theories (QFTs) can be simulated efficiently with a quantum computer. QFTs are used in particle and condensed matter physics and have an infinite number of degrees of freedom; discretization is necessary to simulate them digitally.

Jordan
et al.

(p.
1130
; see the Perspective by

Hauke
et al.

) present an algorithm for the efficient simulation of a particular kind of QFT (with quartic interactions) and estimate the error caused by discretization. Even for the most difficult case of strong interactions, the run time of the algorithm was polynomial (rather than exponential) in parameters such as the number of particles, their energy, and the prescribed precision, making it much more efficient than the best classical algorithms.
Restoring Voluntary Control of Locomotion after Paralyzing Spinal Cord Injury
Authors: van den Brand Rubia , Heutschi Janine , Barraud Quentin , DiGiovanna Jack , Bartholdi Kay , Huerlimann Michèle , Friedli Lucia , Vollenweider Isabel , Moraud Eduardo Martin , Duis Simone , Dominici Nadia , Micera Silvestro , Musienko Pavel , Courtine Grégoire
Published: May 2012

Regaining Limb Movement

Despite many years of intensive research, there is still an urgent need for novel treatments to help patients restore motor function after spinal cord injuries.

van den Brand
et al.

(p.
1182
) produced left and right hemisections at different levels of the rat thoracic spinal cord to cause complete hind limb paralysis mimicking the situation in humans with spinal cord injury. Systemic application of pharmacological agents, combined with a multisystem rehabilitation program including a robotic postural neuroprosthesis, restored voluntary movements of both hind limbs.
Evolution of a Vertebrate Social Decision-Making Network
Authors: O’Connell Lauren A. , Hofmann Hans A.
Published: May 2012

Variation on a Theme

Given the incredible diversity and complexity in social behavior and ecology that exists across animal taxa, revealing the evolution of neural mechanisms for behavior is a great challenge.
O'Connell and Hofmann
(p.
1154
) examined the expression profiles of several genes involved in the social behavior network and the mesolimbic reward system in 88 species across five vertebrate lineages. A remarkable level of conservation was observed in brain regions linked to social behavior and decision-making, but flexibility seems to have been maintained through variability in neuroendocrine ligand expression across the brain.
Structure of a 16-nm Cage Designed by Using Protein Oligomers
Authors: Lai Yen-Ting , Cascio Duilio , Yeates Todd O.
Published: May 2012

Design and Build

Self-assembling biomolecules are attractive building blocks in the development of functional materials. Sophisticated DNA-based materials have been developed; however, progress in designing protein-based materials has been slower.

King
et al.

(p.
1171
) describe a general computational method in which protein building blocks are first symmetrically docked onto a target architecture, and then binding interfaces that drive self-assembly of the building blocks are designed. As a proof of principle, trimeric building blocks were used to design self-assembling 12-subunit complexes with tetrahedral symmetry and 24-subunit complexes with octahedral symmetry.

Lai
et al.

(p.
1129
) were able to build a 12-subunit tetrahedral protein cage from fused oligomeric protein domains.
Tracking the Fukushima Radionuclides
Authors: Yoshida Naohiro , Kanda Jota
Published: May 2012

Ongoing radionuclide monitoring and tracking efforts are required following the nuclear accident at the Fukushima Daiichi Nuclear Power Plant.
Creative Deal Gives NASA Telescope New Lease on Life
Authors: Bhattacharjee Yudhijit
Published: May 2012

A satellite that had been scheduled to be shut down now has a fresh lease on life, thanks to a first-of-a-kind arrangement between the federal government and a research university.
Criticism Continues to Dog Psychiatric Manual as Deadline Approaches
Authors: Miller Greg
Published: May 2012

Less than a year before a new edition of the diagnostic reference for psychiatric illnesses is to be released, the controversy it has generated continues.
What Is Dark Energy?
Authors: Cho Adrian
Published: May 2012

The nature of the "dark energy" that is causing the expansion of the universe to accelerate is now perhaps the most profound mystery in cosmology and astrophysics. And it may remain forever so.
How Hot Is Dark Matter?
Authors: Cho Adrian
Published: May 2012

Astronomers still don't know what the unseen "dark matter" is that provides the gravity that holds the galaxies together, but they may soon be able to narrow in on its most basic properties.
What Reionized the Universe?
Authors: Cartlidge Edwin
Published: May 2012

A few hundred million years after the big bang, most of the universe's matter turned into the light-transmitting ionized plasma that it remains today. What caused this cosmic reionization? No one is sure.
What's the Source of the Most Energetic Cosmic Rays?
Authors: Clery Daniel
Published: May 2012

Data taken from detectors in the past few years have provided some clues to the origin of the highest energy cosmic rays but, as yet, no smoking gun.
Why Is the Sun's Corona So Hot?
Authors: Kerr Richard A.
Published: May 2012

How does heat dissipating from the sun's core out beyond the surface to its corona abruptly punch temperatures up by a factor of 200 and more?
Listen, Understand, Engage
Authors: Thomson Angus , Watson Michael
Published: May 2012

For more effective vaccine advocacy, scientists and policy-makers must translate and apply insights from the cognitive and social sciences to the way they communicate and engage with the public.
Assessment of Accuracy of Identification of Pathogenic Yeasts in Microbiology Laboratories in the United Kingdom
Authors: Borman Andrew M. , Szekely Adrien , Palmer Michael D. , Johnson Elizabeth M.
Published: May 2012

Rapid, accurate identification of yeast isolates from clinical samples has always been important given their innately variable antifungal susceptibility profiles. Recently, this has become paramount with the proposed introduction of species-specific interpretive breakpoints for MICs obtained in yeast antifungal susceptibility tests (M. A. Pfaller, D. Andes, D. J. Diekema, A. Espinel–Ingroff, D. Sheehan, and CLSI Subcommittee for Antifungal Susceptibility Testing, Drug Resist. Updat. 13:180–195, 2010). Here, we present the results of a 12-month evaluation of the accuracy of identifications that accompany yeast isolates submitted to the Mycology Reference Laboratory (United Kingdom) for either confirmation of identity or susceptibility testing. In total, 1,781 yeast isolates were analyzed, and the robustness of prior identifications obtained in microbiology laboratories throughout the United Kingdom was assessed using a combination of culture on chromogenic agar, morphology on cornmeal agar, and molecular identification by pyrosequencing. Over 40% of isolates (755) were submitted without any suggested identification. Of those isolates with a prior identification, 100 (9.7%) were incorrectly identified. Error rates ranged from 5.2% (for organisms submitted for antifungal susceptibility testing) to 18.2% (for organisms requiring confirmation of identity) and varied in a strictly species-specific manner. At least 50% of identification errors would be likely to affect interpretation of MIC data, with a possible impact on patient management. In addition, 2.3% of submitted cultures were found to contain mixtures of at least two yeast species. The vast majority of mixtures had gone undetected in the referring laboratory and would have impacted the interpretation of antifungal susceptibility profiles and patient management. Some of the more common misidentifications are discussed according to the identification method employed, with suggestions for avoiding such misinterpretations.
Differential Patterns of Large Tumor Antigen-Specific Immune Responsiveness in Patients with BK Polyomavirus-Positive Prostate Cancer or Benign Prostatic Hyperplasia
Authors: Sais Giovanni , Wyler Stephen , Hudolin Tvrtko , Banzola Irina , Mengus Chantal , Bubendorf Lukas , Wild Peter J. , Hirsch Hans H. , Sulser Tullio , Spagnoli Giulio C. , Provenzano Maurizio
Published: May 2012

The role of the polyomavirus BK (BKV) large tumor antigen (L-Tag) as a target of immune response in patients with prostate cancer (PCa) has not been investigated thus far. In this study, we comparatively analyzed humoral and cellular L-Tag-specific responsiveness in age-matched patients bearing PCa or benign prostatic hyperplasia, expressing or not expressing BKV L-Tag-specific sequences in their tissue specimens, and in non-age-matched healthy individuals. Furthermore, results from patients with PCa were correlated to 5-year follow-up clinical data focusing on evidence of biochemical recurrence (BR) after surgery (prostate specific antigen level of ≥0.2 ng/ml). In peripheral blood mononuclear cells (PBMC) from patients with PCa with evidence of BR and BKV L-Tag-positive tumors, stimulation with peptides derived from the BKV L-Tag but not those derived from Epstein-Barr virus, influenza virus, or cytomegalovirus induced a peculiar cytokine gene expression profile, characterized by high expression of interleukin-10 (IL-10) and transforming growth factor β1 and low expression of gamma interferon genes. This pattern was confirmed by protein secretion data and correlated with high levels of anti-BKV L-Tag IgG. Furthermore, in PBMC from these PCa-bearing patients, L-Tag-derived peptides significantly expanded an IL-10-secreting CD4
+
CD25
+(high)
CD127
−
FoxP3
+
T cell population with an effector memory phenotype (CD103
+
) capable of inhibiting proliferation of autologous anti-CD3/CD28-triggered CD4
+
CD25
−
T cells. Collectively, our findings indicate that potentially tolerogenic features of L-Tag-specific immune response are significantly associated with tumor progression in patients with BKV
+
PCa.
A Specific Domain of the Chikungunya Virus E2 Protein Regulates Particle Formation in Human Cells: Implications for Alphavirus Vaccine Design
Authors: Akahata Wataru , Nabel Gary J.
Published: May 2012

Virus-like particles (VLPs) can be generated from Chikungunya virus (CHIKV), but different strains yield variable quantities of particles. Here, we define the genetic basis for these differences and show that amino acid 234 in E2 substantially affects VLP production. This site is located within the acid-sensitive region (ASR) known to initiate a major conformational change in E1/E2. Selected other mutations in the ASR, or changes in pH, also increased VLP yield. These results demonstrate that the ASR of E2 plays an important role in regulating particle generation.
Regulation of Virus Neutralization and the Persistent Fraction by TRIM21
Authors: McEwan W. A. , Hauler F. , Williams C. R. , Bidgood S. R. , Mallery D. L. , Crowther R. A. , James L. C.
Published: May 2012

Despite a central role in immunity, antibody neutralization of virus infection is poorly understood. Here we show how the neutralization and persistence of adenovirus type 5, a prevalent nonenveloped human virus, are dependent upon the intracellular antibody receptor TRIM21. Cells with insufficient amounts of TRIM21 are readily infected, even at saturating concentrations of neutralizing antibody. Conversely, high TRIM21 expression levels decrease the persistent fraction of the infecting virus and allows neutralization by as few as 1.6 antibody molecules per virus. The direct interaction between TRIM21 and neutralizing antibody is essential, as single-point mutations within the TRIM21-binding site in the Fc region of a potently neutralizing antibody impair neutralization. However, infection at high multiplicity can saturate TRIM21 and overcome neutralization. These results provide insight into the mechanism and importance of a newly discovered, effector-driven process of antibody neutralization of nonenveloped viruses.
Membrane Fusion-Mediated Autophagy Induction Enhances Morbillivirus Cell-to-Cell Spread
Authors: Delpeut Sébastien , Rudd Penny A. , Labonté Patrick , von Messling Veronika
Published: May 2012

In the context of viral infections, autophagy induction can be beneficial or inhibitory. Within the
Paramyxoviridae
family, only morbilliviruses have been investigated and are reported to induce autophagy. Here we show that morbilliviruses rapidly induce autophagy and require this induction for efficient cell-to-cell spread. Coexpression of both glycoproteins in cells expressing one of the cellular receptors was required for autophagy induction, and LC3 punctum formation, indicative of autophagy, was mainly observed in syncytia. A similar correlation between syncytium formation and autophagy induction was also observed for other paramyxovirus glycoproteins, suggesting that membrane fusion-mediated autophagy may be common among paramyxoviruses and possibly other enveloped viruses.
Prostatic hyperplasia is highly associated with nocturia and excessive sleepiness: a cross-sectional study
Authors: Chartier-Kastler Emmanuel , Leger Damien , Comet Denis , Haab François , Ohayon Maurice M
Published: May 2012

Objectives

The objective of this study is to assess the impact of nocturia on sleep in patients with lower urinary tract symptoms (LUTS)/benign prostatic enlargement (BPE) (nocturia≥2).

Design

Cross-sectional survey.

Setting

798 urologists and general practitioners randomly selected from the overall population of urologists and general practitioners of every French region.

Participants

A total of 2179 LUTS/BPE men (aged 67.5±7.5 years old) were recruited.

Primary and secondary outcome measures

Validated patients' self-administered questionnaires were used to assess the severity of LUTS/BPE (the International Prostate Symptom Score), sleep characteristics (sleep log) and sleep disorders (the International Classification of Sleep Disorders (ICSD-2) and the DSM-IV). Sleepiness was assessed with the Epworth Sleepiness Scale (ESS). The volume of 24 h diuresis (1500 ml) was measured.

Results

Participants had on average 2.9±0.9 nocturia episodes (three or more episodes in 67%) and the International Prostate Symptom Score of 15.8±5.7; 60.9% complained of insomnia according to the ICSD-2, 7.9% of restless leg syndrome and 6.4% of obstructive sleep apnoea. 32.3% had excessive sleepiness (ESS >10) and 3.1% severe excessive sleepiness (ESS >16). Insomnia was mainly nocturnal awakenings with an average wake after sleep onset of 89±47 min. The number of episodes of nocturia per night correlated significantly with wake after sleep onset and ESS but not with total sleep time and sleep latency.

Conclusion

Nocturia is significantly associated with sleep maintenance insomnia and sleepiness in men with BPE.
What is the optimal level of population alcohol consumption for chronic disease prevention in England? Modelling the impact of changes in average consumption levels
Authors: Nichols Melanie , Scarborough Peter , Allender Steven , Rayner Mike
Published: May 2012

Objective

To estimate the impact of achieving alternative average population alcohol consumption levels on chronic disease mortality in England.

Design

A macro-simulation model was built to simultaneously estimate the number of deaths from coronary heart disease, stroke, hypertensive disease, diabetes, liver cirrhosis, epilepsy and five cancers that would be averted or delayed annually as a result of changes in alcohol consumption among English adults. Counterfactual scenarios assessed the impact on alcohol-related mortalities of changing (1) the median alcohol consumption of drinkers and (2) the percentage of non-drinkers.

Data sources

Risk relationships were drawn from published meta-analyses. Age- and sex-specific distributions of alcohol consumption (grams per day) for the English population in 2006 were drawn from the General Household Survey 2006, and age-, sex- and cause-specific mortality data for 2006 were provided by the Office for National Statistics.

Results

The optimum median consumption level for drinkers in the model was 5 g/day (about half a unit), which would avert or delay 4579 (2544 to 6590) deaths per year. Approximately equal numbers of deaths from cancers and liver disease would be delayed or averted (∼2800 for each), while there was a small increase in cardiovascular mortality. The model showed no benefit in terms of reduced mortality when the proportion of non-drinkers in the population was increased.

Conclusions

Current government recommendations for alcohol consumption are well above the level likely to minimise chronic disease. Public health targets should aim for a reduction in population alcohol consumption in order to reduce chronic disease mortality.
End of life care in Wales: evaluation of a care pathway-based implementation strategy
Authors: Johnstone Rosalynde Patricia , Jones Angela , Fowell Andrew , Burton Christopher Richard , Rycroft-Malone Jo
Published: May 2012

Objectives

The All Wales Care Pathway for the End of Life Pathway aims to ensure evidence-based end-of-life care is available across Wales. Implementation of end-of-life care processes was evaluated in a national audit of deaths between July 2007 and June 2009.

Methods

Up to 60 records of deceased patients were reviewed by two researchers from hospital (24), community localities (20), hospice and specialist inpatient (9) settings. Data extraction using a standard template was carried out at all sites to indicate whether end-of-life care processes had been implemented. A total of 1184 records were retrieved. 202 records were excluded due to sudden death (eg, cardiac arrest) or incomplete data. Sampling included 580 decedents (59%) who had received end-of-life care through the pathway.

Results

Pathway use was associated with improved implementation of all evidence-based clinical standards other than for daily review, where implementation was consistently high with (84.5%) or without the pathway (81%). Differences in achievement were most evident for the implementation of bereavement and spiritual support where the pathway was used. Implementation within hospice and specialist inpatient care settings was consistently high.

Conclusion

Integrated care pathway use is associated with the implementation of best practice in end-of-life care. However, variation in implementation across sites and the influence of setting type highlights the mediating effect of organisational context which, together with different methods of feedback, may provide a useful agenda for implementation research within end-of-life care.
ICDs in end-stage heart failure
Authors: Pettit Stephen J , Browne Susan , Hogg Karen J , Connelly Derek T , Gardner Roy S , May Carl R , Macleod Una , Mair Frances S
Published: May 2012

Implantable cardioverter defibrillators (ICDs) reduce mortality in selected patients with chronic heart failure but prognostic benefit is likely to attenuate with progression to end-stage heart failure. The incidence of multiple futile ICD shocks before death is uncertain. Only individual patients, supported by their healthcare professionals, can decide when ICD therapy becomes futile in end-stage heart failure. Despite consensus that ICD deactivation should be routinely discussed, this rarely occurs in clinical practice for many reasons including uncertainty about when to initiate these discussions and reluctance to confront death and dying. Patient and carer opinions about end-stage heart failure and ICD deactivation may not meet professional expectations. Future research should focus on these opinions and examine interventions that bridge the gap between best practice and the reality of current clinical practice.
Shared decision making and advance care planning-underpinnings, similarities and differences
Authors: Krones T , Biller Andorno N , in der Schmitten J , Mitchell C , Spirig R , Zaugg K
Published: May 2012

There are two movements, each rooted in bioethics and evidence-based medicine, that focus on quite similar aims yet are not fully aligned and integrated in the clinical care of dying patients: The first, “advance care planning” focusses on future decisions when one becomes incapable of decision making, and the second, “shared decision making” has led to decision aids designed on the basis of empirical evidence to solicit and support patients' choices and decisions. The aim of our study, beginning in 2012, is to develop, implement and test a complex intervention (continuous multi-professional development – CPD program) for improving patients' preparation for and participation in end of life decisions including both strategies ACP and SDM/DA on end of life issues in an acute care hospital setting. In order to prepare for our randomised controlled trial, we systematically screened existing ACP and SDM programs for end of life issues and analysed their content, scope, aims, similarities and differences. The SDM philosophy relies more on giving tailored statistical information on distinct measures whereas ACP relies more on defining broader goals of care, which might indicate not only different contents but also differing concepts of autonomy. Outcomes are both similar and different. For example, both investigate impact on satisfaction with care and economy. SDM focuses more on knowledge and decisional conflict whereas ACP focuses on numbers of advance directives (ADs), and decisions made according to wishes. We will discuss philosophical and practical underpinnings of bringing the two movements together.
Advance care planning for subjects with early dementia – a pilot study
Authors: Binte Ali N , Chan M , Anthony P , Lim WS , Chong MS
Published: May 2012

Lack of research in our multi-racial society, where different cultures have disparate beliefs with regards to death and dying, prompted us to conduct a pre-implementation feasibility study for the role of ACP on 9 patient-caregiver dyads from a memory clinic in Singapore.

Subjects were recruited if they had mild dementia (global Clinical Dementia Rating of 0.5-1), no significant mood disorders or behavioural problems, and had an identified caregiver. Patients and their caregivers were surveyed individually for their understanding of ACP, and experience of communicating their end-of-life treatment preferences to their loved ones, before and after ACP counselling conducted by a trained ACP facilitator.

Prior to ACP counselling, only 22% patients and 55% caregivers had heard of ACP. While 77% of patients rated their health status as good and 77% had thought of their healthcare proxy, only 22% made future care plans. After ACP counselling, 75% patients are keen for further ACP discussions and none admitted to barriers to communication compared to 62.5% caregivers who acknowledge barriers to communication. The percentage of patients who wished to receive therapy decreased as the likelihood of an adverse outcome (especially cognitive) increased.

There is a disparity in the attitudes of patients and caregivers towards ACP where patients are more willing to discuss it compared to caregivers.

Our study highlights the need for further education and dissemination of information on ACP among subjects with early dementia and their caregivers. We are intending to incorporate ACP and disseminate information on ACP in future dementia workshops.
Cultural concordance in advance care planning discussions: a blessing or a curse
Authors: Deamant C , Liu E , Mackie O , Shariff R
Published: May 2012

Culture narrowly defined is the learned or shared beliefs, values and behaviours of a group. However, concepts of culture are complex and influenced by many factors, such as ethnicity, socioeconomic status, gender, education, sexual orientation, or immigration status.

Health care professionals are expected to demonstrate cultural competency, and possess some knowledge of cultural values, beliefs and practices and practice proficient communication skills. Cultural sensitivity reflects a health care professional's awareness and respect for the patient's cultural viewpoint. Cultural concordance between health care professionals and patients and families has the potential to provide a framework of expectations about communication and complex decision-making in the setting of end of life care.

The literature reflects the disparities in end of life care for minority and vulnerable populations, with underutilisation of hospice care, higher likelihood of using life-sustaining treatment at the end of life and dying in the hospital. Most of the literature focuses on the different cultural perspectives about communication, death and end-of-life care decision-making. There is a paucity of literature about the impact of cultural concordance between health care professionals and patients/families in palliative care and end of life care.

Through several case studies, we will identify potential benefits and challenges for health care professionals who have ethnic, language or racial concordance with patients and families. Using components of effective communication strategies for advance care planning with seriously ill patients, we will add new insight for providing patient-centred, culturally effective care within a culturally diverse health care setting.
Perspectives of community dwelling octogenarians about the use of life-sustaining technologies for their future care
Authors: Kryworuchko J. , Strachan P. , Heyland R.D. , Heyland D.K.
Published: May 2012

To better inform advance care planning initiatives, we conducted a qualitative study of community dwelling people aged 80 or more to enrich our understanding of their perspectives about the use of life-sustaining technologies in relation to their future care. In a semi-structured interview, 14 participants were asked what kind of health care they would want if they became seriously ill, so ill that they might die. We specifically probed their preferences for life-sustaining technologies and circumstances in which they had shared these preferences. Transcripts and field notes were analysed to categorise data in themes and subthemes. Participants represented octogenarians with variable levels of decision preparedness and included people who preferred a range of involvement in decision-making from passive to active consumers. Three overarching themes included: (1) their faith in others to do the right thing, (2) their focus on managing certainties, and (3) the role that perception of prolonging agony or alleviating suffering played in their preference for life-sustaining technologies. Few participants had considered that decisions would need to be made about life-sustaining technologies during the dying process and therefore had never considered the need to discuss their preferences to facilitate decisions in future. A key barrier to engaging some octogenarians may be their perception that there was no decision to be made since “they'll take care of me”. Insights gained from this study highlight the sort of “active engagement” strategies needed to improve advance care planning and end of life decision making.
A public health initiative around advance care conversations and end of life Care
Authors: Matthiesen M , Ashton J , Froggatt K
Published: May 2012

The critical need for family, carer, and community conversations about end of life issues ahs never been more significant. Although most adults would prefer to live their last days at home with support, only 22% of people in Cumbria currently do. Caring for patients outside their preferred place incurs significant costs to the NHS and recently published national statistics cite 54% of NHS complaints are around end of life care. Yet as is pointed out in the national End of Life Care Strategy, “In the absence of open discussions, it is difficult or impossible to elicit peoples needs and preferences and to plan accordingly.'

The aim of this collaborative and integrated public health campaign was to support the public to break the taboo of talking about death and dying while healthy in order to consider options, access resources, and have a say in their future care (advance care planning). Increasing awareness of available options and resources was a key focus.

Project outcomes, evaluations and national endorsements will be shared. As a first step in achieving longer-term goals, the pilot showed that a community-based public awareness campaign on end of life issues can reach the public and achieve greater awareness/educational outcomes.
Does physician remuneration improve advance care planning and end of life discussions in primary care?
Authors: Gill Andrew , Waugh Jan , Simon Jessica
Published: May 2012

It is not known how remuneration for advance care planning and end of life issues (ACPEL) discussions influences physician practice. In Calgary, AB family physicians get remunerated for completing a comprehensive annual care plan proforma (CACP) with patients who have complex care needs. The CACP prompts the physician to ACPEL discussions, with a tickbox answer of yes, no or not applicable.. The local “goals of care designation” (GCD) policy communicates treatment intent, based on medically appropriate care and the patient's own goals. Although not part of the CACP, if discussing ACPEL, determining a GCD is often appropriate.

From a practice of 4000, 59 patients were identified by searching all CACP billing codes submitted from April 1st, 2011 through September 30th. A retrospective notes analysis revealed the percentage of charts with the ACPEL question completed was 49%. Of those that were completed 17% had discussed ACPEL, 17% had not and 66% selected not applicable. Only 1 out of 59 patients had a GCD and that was not determined during their CACP.

Despite being part of a defined, remunerated plan, ACPEL and GCD discussions are not occurring. This baseline data will inform interventions in an audit feedback cycle, including practice-based physician education and mentoring on facilitating ACP conversations and improved clinic processes to ensure patient access to ACP material and to attach GCD documentation to the CACP. In addition it suggests the need for more effective links between remuneration to ACPEL discussions.
Integration of advanced care planning into an undergraduate nursing programme
Authors: Smith G
Published: May 2012

Advanced care planning should be something all health professionals consider when interacting with their patients/clients. It should be a consideration when people are well; something that is encouraged to be discussed in the home amongst family members; and amongst the health care team in the event of chronic or terminal illness diagnosis. Accordingly, this poster will support the premise of the undergraduate educators at Edith Cowan University, that Advanced Care Planning must be integrated into the undergraduate pre-registration nursing education programme.

The findings to date are anecdotal and relate purely to student and graduate nurse feedback to lecturers. Integrating Advanced Care Planning into the undergraduate programme:

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assists in encouraging student and beginner-level nurses to consider the appropriateness of care for patients/clients

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assists in enabling nurses to encourage discussion about advanced care planning amongst the health care team, patients (and their families), and student families

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assists in encouraging student and beginner-level nurses in advocating for their patient/client wishes toward the end of life.
Sowing seeds and building collaborations: challenges faced and learning points in starting systematic advance care planning in a tertiary hospital in Singapore
Authors: Chong RKP , Oh JSY , Ng RHL , Poi CH , Chau HYC
Published: May 2012

This poster aims to describe challenges and learning points in endeavours at starting systematic advance care planning (ACP) in Tan Tock Seng Hospital, a 1200-bed tertiary hospital in Singapore

Based on the model of ACP espoused by Respecting Choices of Wisconsin, USA, a disease-specific pilot project was initiated in the department of cardiology in 2010 and a POLST-like pilot project in the departments of respiratory medicine, neurology and neurosurgery.

28 staff comprising nurse clinicians, case managers and medical social workers were trained in the Respecting Choices model of ACP facilitation. Less experienced facilitators were mentored by senior staff with experience in ACP facilitation. The facilitators also met regularly to share experiences. 5 patients with advanced heart disease, 5 with advanced chronic obstructive pulmonary disease and 2 patients with advanced neurological diseases underwent facilitated ACP discussions by trained facilitators. Outcomes were documented and scanned into the hospital medical records system.

Significant challenges faced were relatively low awareness of ACP among the general public and healthcare professionals as well as the need for clear workflows and co-ordination across multiple disciplines. There are ongoing endeavours at continual quality improvement through forums aimed at engaging the staff and the public, workshops to enhance the skills of facilitators, audits and improvement in resource allocation.

A systematic approach to ACP faces significant challenges in the initial stages of the endeavour in a complex hospital environment. ACP is resource intensive and a clear vision, high level support as well as a multi-pronged approach are paramount for successful implementation.
Values and the advance care planning framework in New Zealand
Authors: Chan H.Y.
Published: May 2012

New Zealand (NZ) is in the early stages of introducing and implementing ACP to the public. There is growing awareness of the values of ACP and the NZ Ministry of Health recently published two guides – one for the healthcare workforce (modelled after the UK ACP: Guide for health and social care staff) and another for the public/consumers.

This presentation explores whether the new policy framework supports or hinders ACP measures within a pluralistic society. It adds to the policy debate on key components essential in ACP policy framework for countries that are at the early stages of rolling out ACP programmes.

The content and scope of the NZ sample care plans and the Guide is analysed and compared against the UK model. The early observation emerging from this review highlights supportive elements crucial to a positive ACP measure. A supportive framework places a premium on personal values in the ACP process. This distinctive recognition is crucial within a multicultural setting, as recognising what matters to people and seeking to incorporate them in care plans means keeping the person at the centre of care. Requiring doctors' involvement in discussing care planning options encourages informed choices and in the long run, cements the trust between doctors and patients.

This presentation draws on preliminary findings from work in progress exploring how elements in an ACP framework contribute to a supportive end-of-life care measures. It informs policy knowledge on distinctive framework which can be replicated in other countries intending to establish ACP programmes.
The role of dignity in advance care planning among homeless individuals
Authors: Ratner E
Published: May 2012

Dignity is an important issue in end of life care, but has not been considered as a possible predictor of advance care planning (ACP). This presentation will describe a study to determine predictors of willingness to participate in ACP among homeless persons, determinants of loss of dignity, and contributors to dignity at the end of life. A prospective, single-blind, randomised trial comparing self-guided completion of an advance directive (AD) with professionally assisted ACP at 8 sites serving homeless persons recruited 262 homeless persons in 2007-08. Subjects were offered a brief presentation and written materials related to ACP versus one-on-one ACP counselling by a social worker. Measures included pre-intervention written surveys and subsequent AD content analysis. The overall completion rate for ADs was 26.7%. Older age, problems finding a place to sleep (OR = 0.29), and feeling a loss of dignity (OR = 0.37) were independently predictive of completion of an AD, with either a self-guided process or individual counselling. Loss of dignity almost every day was reported by 35% of subjects. Being treated with dignity was described as 1) being respected 2) having preferences honoured, 3) receiving adequate care, and 4) having comfort maintained. In summary, lacking a place to sleep and loss of dignity negatively predict willingness to complete an AD among the homeless. Loss of dignity is a frequent problem in this population. There are practical ways providers can maintain dignity in care of homeless at the end of life.
Patients with CHF find decision aid for ACP helpful and computer-generated advance directive accurate
Authors: Green MJ , Hensel J , Farace E , Whitehead  , Lehmann  , Levi BH
Published: May 2012

The fluctuating clinical course of congestive heart failure involves recurrent medical crises and readmission rates of ∼50% within 6 months following hospital discharge. The consequent focus on acute care measures often results in insufficient emphasis on advance care planning (ACP). This pilot study examined whether an interactive computer-based decision aid can effectively address this need by helping individuals with advanced CHF engage in ACP. Adults with advanced congestive heart failure (i.e., Stage 3 or 4) were recruited from a single cardiovascular clinic; screened for cognitive ability, moderate/severe depression, and ≥8thgrade reading level; and asked to complete a computer program, pre-/post-questionnaires, and a follow-up telephone interview. The 24 study participants (mean age = 65 years, 83% male) reported minimal decisional conflict in making ACP decisions (mean=30, 16=least conflict, 80=greatest conflict) and high satisfaction with the computer program (mean=9.3, 1=least satisfied, 10=most satisfied), decisions they made (mean=27, 6=least satisfied, 30=most satisfied), and the accuracy of the computer-generated advance directive (6.6, 1=not at all accurate, 7=extremely accurate). Additionally, participants' knowledge regarding ACP increased significantly (43% → 62%, p<0.001) with no decrease in hopefulness (p=0.49), and the majority (87%) went on to discuss their ACP wishes with family and friends. These preliminary findings show that a computer decision aid program is well-accepted by patients with advanced congestive heart failure, and can help such individuals engage in ACP, increase their knowledge about ACP, create accurate advance directive documents, and discuss their wishes with family and friends.