Death with dignity in Washington patients with amyotrophic lateral sclerosis

OBJECTIVES

To describe the amyotrophic lateral sclerosis (ALS) patients who sought medication under the Washington State Death with Dignity (DWD) Act since its inception in 2009.

METHODS

Chart review at 3 tertiary medical centers in the Seattle/Puget Sound region and comparison to publicly available data of ALS and all-cause DWD cohorts from Washington and Oregon.

RESULTS

In Washington State, 39 patients with ALS requested DWD from the University of Washington, Virginia Mason, and Swedish Medical Centers beginning in 2009. The median age at death was 65 years (range 46-86). Seventy-seven percent of the patients used the prescriptions. All of the patients who used the medications passed away without complications. The major reasons for patients to request DWD as reported by participating physicians were loss of autonomy and dignity and decrease in enjoyable activities. Inadequate pain control, financial cost, and loss of bodily control were less commonly indicated. These findings were similar to those of the 92 patients who sought DWD in Oregon. In Washington and Oregon, the percentage of patients with ALS seeking DWD is higher compared to the cancer DWD cohort. Furthermore, compared to the all-cause DWD cohort, patients with ALS are more likely to be non-Hispanic white, married, educated, enrolled in hospice, and to have died at home.

CONCLUSIONS

Although a small number, ALS represents the disease with the highest proportion of patients seeking to participate in DWD. Patients with ALS who choose DWD are well-educated and have access to palliative or life-prolonging care. The use of the medications appears to be able to achieve the patients' goals without complications.

Is parenteral chemotherapy safe in rural hospitals? A prospective audit of neutropenic fever in Albany Hospital, a regional West Australian cancer centre

BACKGROUND

Neutropenic fever is a life-threatening complication of chemotherapy. The widely dispersed population of Australia creates challenges for rural patients in accessing healthcare services. Cancer treatment is particularly, burdensome with patients being forced to relocate to the city for treatment or to endure long and repeated journeys to the city. This study aimed to assess the safety of chemotherapy in a rural centre with a general physician-led model, by analysing neutropenic fever in Albany Hospital, a regional cancer centre in Western Australia.

METHODS

A prospective audit of patients undergoing parenteral chemotherapy was undertaken from March 2014 to March 2015. Cases of neutropenic fever as a consequence of parenteral chemotherapy were analysed and recorded by the Albany Hospital medical registrar.

RESULTS

There were 1294 cycles of chemotherapy administered to 192 patients during the study period. There were 19 cases of neutropenic fever in 16 patients, meaning 8.33% of patients undergoing parenteral chemotherapy had their treatment complicated by neutropenic fever (n = 16/192). The incidence of neutropenic fever was 1.47% per cycle of chemotherapy (n = 19/1294). There were no deaths in the study period. As per guidelines, antibiotics were given within 60 min of arrival in 73.68% of cases (n = 14/19).

CONCLUSIONS

The rate of neutropenic fever observed was similar to rates in other centres worldwide, and the mortality rate was lower than average, with no deaths in the study population. These results provide reassurance with regards to the safe delivery of parenteral chemotherapy in this rural centre with a general physician-led model.

Communities of Care and Caring: The Case of MSWatch.com®

Can a health-care website stimulate its members to become a `community of care and caring', facilitating both medical `information' and personal `support'? This study of MSWatch.com provides conceptual distinctions about `ties' to a `community' and raises questions about communications designed to serve patients with Multiple Sclerosis. An online survey of members of the website shows that members tend to: (1) make use of both its health-care information (care) and support (caring) functions, especially the former; (2) evaluate the website more highly overall if they make use of both information and support; (3) use the website the most during early stages of the disease; and (4) enhance their ties to the virtual community through using communication information and support.

Immigration medical screening and HIV infection in Canada

HIV infection, particularly associated with AIDS, is often used by migrant screening nations to exclude entry into the country. The unique feature of the Canadian immigration HIV screening programme is that it was not primarily for determining inadmissibility of HIV-positive applicants, but for health promotion and disease prevention purposes. All applicants over 15 years of age for permanent residency or temporary residency from designated countries are HIV antibody tested. This includes persons seeking asylum from within Canada. The highest rates of HIV infection were found in migrant applicants from high prevalence areas of the world and reflected the demographic profile of the source region (predominately women). The majorities of HIV-positive persons are exempt from exclusion from Canada due to class of application (refugee, family) or are already in Canada (refugee claimant). Significant issues in notification, reporting and programme management have been identified as a consequence of this programme.

Pre-packing of cost effective antibiotic cement beads for the treatment of traumatic osteomyelitis in the developing world - an in-vitro study based in Cambodia

The developing world often lacks the resources to effectively treat the most serious injuries including osteomyelitis following open fractures or surgical fracture treatment. Antibiotic cement beads are a widely accepted method of delivering antibiotics locally to the infected area following trauma. This study is based in Cambodia, a low income country struggling to recover from a recent genocide. The study aims to test the effectiveness of locally made antibiotic beads and analyse their effectiveness after being gas sterilised, packaged and kept in storage Different antibiotic beads were manufactured locally using bone cement and tested against MRSA bacteria grown from a case of osteomyelitis. Each antibiotic was tested before and after a process of gas sterilisation as well as later being tested after storage in packaging up to 42 days. The gentamicin, vancomycin, amikacin and ceftriaxone beads all inhibited growth of the MRSA on the TSB and agar plates, both before and after gas sterilisation. All four antibiotics continued to show similar zones of inhibition after 42 days of storage. The results show significant promise to produce beads with locally obtainable ingredients in an austere environment and improve cost effectiveness by storing them in a sterilised condition.

Development of a Consumer Engagement Framework

Objective: The purpose of this project was to develop a Consumer Engagement Model to plan for effective baby boomer engagement to inform policy makers in the healthcare system. This is the first stage of that process. Design: Initial model development for healthcare systems based on literature review and author group experience in evidence-based practice and research, and consumer advocacy and engagement. Setting and population: South Australian health and community service systems, and healthcare professionals that work with baby boomers. Findings: To develop an evidence-based Consumer Engagement Plan, it is recommended that policy makers undertake the four steps outlined in this document to design a question, determine consumer and community segments and scope of engagement, determine the breadth and depth of engagement and address the implications, assess risk and develop strategic partnerships to ensure the Plan is evidencebased,reasonable and achievable. Conclusions: We believe this process provides a framework for planning consumer engagement and for implementation, monitoring, evaluation and review of consumer engagement for policy excellence. We propose to undertake a validation of the model thus populating the model with examples of practice-based strategies and revising the model accordingly. Abbreviations: EBP – Evidence-Based Practice; IAP2 – International Association of Public Participation; PIO – Patient Intervention and Outcome.

Evidence-based Practice Intentions and Long-term Behaviours of Physiotherapy Graduates Following an Intensive Education Programme

BACKGROUND

Assisting physiotherapists to implement research evidence into clinical practice is essential to ensure the quality of practice and encourage lifelong learning and professional progression. However, many physiotherapists report barriers to implementing research, and there is little evidence regarding the sustainability of intended evidence-based practice (EBP) behaviours following EBP education programmes. This paper reports on intended and actual long-term EBP behaviours of physiotherapy students who completed an intensive EBP training programme embedded within a post-graduate coursework programme.

METHODS

An intensive 3-week course in quantitative health research methods and EBP was delivered annually from 2007 to 2014 as part of the programme to national and international students. Following the course, students were asked about their intention of using evidence to inform their future clinical practice. An online survey was used to evaluate EBP behaviours of graduates.

RESULTS

Of a possible total of 202 students, contact details for 193 students were sourced, and 65 students responded to the survey (34% response rate). At course completion, 174 students (86%) indicated that they intended to use research to guide their clinical decisions at least once a week. At follow-up, most graduates reported frequently using research to inform their clinical practice; indicated by a mean score of 6.5 (±1.9) from a possible range of 0 (not at all) to 10 (all the time). On average, students reported spending 2.2 (±2.2) hours accessing and reading research evidence per week. The most common barriers to implementing evidence were lack of time, limited access to evidence sources and a perceived lack of generalizability of research findings to specific patient groups.

CONCLUSION

Graduates of an intensive EBP training programme embedded within an existing post-graduate physiotherapy programme regularly implemented EBP in clinical practice. Barriers to evidence implementation were time, access to research and perceived lack of generalizability of research findings. Copyright © 2016 John Wiley & Sons, Ltd.

Embedding Evidence-based Practice Education into a Post-graduate Physiotherapy Program: Eight Years of pre-Post Course Evaluations

BACKGROUND AND PURPOSE

Little has been published about the effectiveness of training postgraduate physiotherapy coursework students in research methods and evidence-based practice (EBP) theory. Graduate qualities in most universities include lifelong learning. Inclusion of EBP in post-graduate coursework students' training is one way for students to develop the knowledge and skills needed to implement current best evidence in their clinical practice after graduation, thereby facilitating lifelong learning. This paper reports on change in confidence and anxiety in knowledge of statistical terminology and concepts related to research design and EBP in eight consecutive years of post-graduate physiotherapy students at one Australian university.

METHODS

Pre-survey/post-survey instruments were administered to students in an intensive 3-week post-graduate course, which taught health research methods, biostatistics and EBP. This course was embedded into a post-graduate physiotherapy programme from 2007 to 2014. The organization and delivery of the course was based on best pedagogical evidence for effectively teaching adult physiotherapists. The course was first delivered each year in the programme, and no other course was delivered concurrently.

RESULTS

There were significant improvements in confidence, significantly decreased anxiety and improvements in knowledge of statistical terminology and concepts related to research design and EBP, at course completion. Age, gender and country of origin were not confounders on learning outcomes, although there was a (non-significant) trend that years of practice negatively impacted on learning outcomes (p = 0.09). There was a greater improvement in confidence in statistical terminology than in concepts related to research design and EBP.

CONCLUSION

An intensive teaching programme in health research methods and biostatistics and EBP, based on best practice adult physiotherapy learning principles, is effective immediately post-course, in decreasing anxiety and increasing confidence in the terminology used in research methods and EBP. Copyright © 2016 John Wiley & Sons, Ltd.

Growth characteristics underlying the lack of a chin in pigs: a histomorphometric study

OBJECTIVES

Despite similar mandibular growth to that of humans, pigs lack a chin projection as shown in most humans. To understand whether this divergence is contributed to differences in local symphyseal growth, this project characterized bone modeling activities at the symphyseal surfaces of juvenile pigs.

MATERIAL AND METHODS

Symphyseal specimens from two age groups (4- and 6-month-old, n = 10) were processed into histological sections with and without decalcification, which were assessed for surface mineral apposition and bone resorption, respectively. In a blinded fashion, measurements of four parameters (MAR: mineral apposition rate, MAZ: mineral apposition zone, ES/BS: eroded surface and OC.N/BS: osteoclast number) were obtained and tested by a multivariate two-way mixed-model analyses of variance (manova) for the differences between symphyseal regions and ages.

RESULTS

Qualitatively, pig symphyseal labial and lingual surfaces were horizontally oriented and characterized by mineral apposition and bone resorption, respectively. Quantitatively, labial mineral apposition tended to be greater rostrally than caudally at 4 months, which became greater caudally than rostrally at 6 months (region/age interactions: p = 0.127 for MAR, p = 0.012 for MAZ). Lingual bone resorption tended to be greater caudally than rostrally, but only ES/BS measurements were significant (p = 0.039) regardless of age, while OC.N/BS measurements varied with ages and regions (age/region interaction, p = 0.087).

CONCLUSIONS

Insufficient differential in symphyseal surface modeling between the labial-caudal and labial-rostral regions contributes to the lack of chin projection in the pig.

The Australian 75+ Health Assessment: could it detect early functional decline better?

OBJECTIVE

The aim of the present study was to identify opportunities to improve the reach and impact of the Australian Medicare 75+ Health Assessment (75+HA) to detect early functional decline (FD).

METHODS

A comparison of two published review articles produced two outputs: (1) assessments identified in the systematic review that underpinned the 75+HA items were ranked for evidence of effectiveness and compared with the volume of research into assessment areas identified by a recent review on indicators of early FD; and (2) items in the 75+HA were compared with those in the recent review.

RESULTS

The review underpinning the 75+HA found 19 assessment areas, with strongest evidence of effectiveness for vision/hearing, teeth/oral, balance/gait, cognitive and service use. The more recent review reported on six domains (eight subdomains) of FD assessment: physical and cognitive elements of the performance capacity domain were the least well assessed, whereas the most comprehensively assessed domains were health service use, performance capacity (mental subdomain), participation (motivation/volition subdomain) and demographics. The 75+HA addresses only some items related to early FD as identified by the recent literature.

CONCLUSION

Reassessment of the 75+HA with a view to including current evidence-based assessments for early FD is recommended. Updating the 75+HA items with ways to detect FD earlier may increase its relevance to Australia's ageing population.

Early indications that low mental quality of life scores in recently unwell older people predict downstream functional decline

Background

Accurately detecting markers of early functional decline (FD) are essential to support older people to successfully age in place; however, these markers are poorly understood. We tested the hypothesis that compromised mental quality of life after a minor health crisis could be an early predictor of FD.

Methods

This longitudinal observational cohort study was conducted in the emergency department (ED) of a large Australian hospital and in the community. Data were collected from 148 community-dwelling people aged 65+ years, who provided data at recruitment (baseline), and at 1 month and 3 months post discharge from the ED. Short Form-12 mental quality of life component scores (MCS) were regressed with patient descriptors taken at baseline (age, sex, socioeconomic status, education, Mini-Mental State Examination, and primary language), and over-time estimates of FD taken at baseline, and at 1 and 3 months post discharge (instrumental activities of daily living, frequency of falls and hospitalizations, use of gait aids, receipt of community services, living status, and requiring a carer).

Results

MCS at 1 month (MCS1) post ED discharge was significantly associated with instrumental activities of daily living at 1 (r=0.45, P<0.001) and 3 months (r=0.401, P=0.001) post ED discharge, but not at baseline (r=0.010, P>0.05). Subjects with lower than the population median MCS showed a significant linear decline in total instrumental activities of daily living scores over 3 months (P=0.025). There was no linear trend over time in the relationship between MCS1 with frequency of falls (P=0.20) or hospitalizations (P=0.42); however, there was a significant difference at 3 months post ED discharge for falls (P=0.036) and hospitalizations (P=0.039) between low and high MCS1 groups. There were no significant confounders.

Conclusion

Low MCS scores 1 month after a minor health crisis appear to significantly predict downstream FD. This finding needs to be tested in a larger sample.

Phylogeny and taxonomical investigation of Trichoderma spp. from Indian region of Indo-Burma Biodiversity hot spot region with special reference to Manipur

Towards assessing the genetic diversity and occurrence of Trichoderma species from the Indian region of Indo-Burma Biodiversity hotspot, a total of 193 Trichoderma strains were isolated from cultivated soils of nine different districts of Manipur comprising 4 different agroclimatic zones. The isolates were grouped based on the morphological characteristics. ITS-RFLP of the rDNA region using three restriction digestion enzymes: Mob1, Taq1, and Hinf1, showed interspecific variations among 65 isolates of Trichoderma. Based on ITS sequence data, a total of 22 different types of representative Trichoderma species were reported and phylogenetic analysis showed 4 well-separated main clades in which T. harzianum was found to be the most prevalent spp. among all the Trichoderma spp. Combined molecular and phenotypic data leads to the development of a taxonomy of all the 22 different Trichoderma spp., which was reported for the first time from this unique region. All these species were found to produce different extrolites and enzymes responsible for the biocontrol activities against the harmful fungal phytopathogens that hamper in food production. This potential indigenous Trichoderma spp. can be targeted for the development of suitable bioformulation against soil and seedborne pathogens in sustainable agricultural practice.

Effect of microwave pre-treatment of thickened waste activated sludge on biogas production from co-digestion of organic fraction of municipal solid waste, thickened waste activated sludge and municipal sludge

Anaerobic co-digestion of organic fraction of municipal solid waste, with thickened waste activated sludge and primary sludge has the potential to enhance biodegradation of solid waste, increase longevity of existing landfills and lead to more sustainable development by improving waste to energy production. This study reports on mesophilic batch and continuous studies using different concentrations and combinations (ratios) of organic fraction of municipal solid waste, thickened waste activated sludge (microwave pre-treated and untreated) and primary sludge to assess the potential for improved biodegradability and specific biogas production. Improvements in specific biogas production for batch assays, with concomitant improvements in total chemical oxygen demand and volatile solid removal, were obtained with organic fraction of municipal solid waste:thickened waste activated sludge:primary sludge mixtures at a ratio of 50:25:25 (with and without thickened waste activated sludge microwave pre-treatment). This combination was used for continuous digester studies. At 15 d hydraulic retention times, the co-digestion of organic fraction of municipal solid waste:organic fraction of municipal solid waste:primary sludge and organic fraction of municipal solid waste:thickened waste activated sludge microwave:primary sludge resulted in a 1.38- and 1.46-fold increase in biogas production and concomitant waste stabilisation when compared with thickened waste activated sludge:primary sludge (50:50) and thickened waste activated sludge microwave:primary sludge (50:50) digestion at the same hydraulic retention times and volumetric volatile solid loading rate, respectively. The digestion of organic fraction of municipal solid waste with primary sludge and thickened waste activated sludge provides beneficial effects that could be implemented at municipal wastewater treatment plants that are operating at loading rates of less than design capacity.

Characterisation and comparison of the uptake of ionizable and polar pesticides, pharmaceuticals and personal care products by POCIS and Chemcatchers

Growing concern about the environmental impact of ionizable and polar organic chemicals such as pesticides, pharmaceuticals and personal care products has lead to the inclusion of some in legislative and regulatory frameworks. It is expected that future monitoring requirements for these chemicals in aquatic environments will increase, along with the need for low cost monitoring and risk assessment strategies. In this study the uptake of 13 neutral and 6 ionizable pesticides, pharmaceuticals and personal care products by modified POCIS (with Strata™-X sorbent) and Chemcatchers™ (SDB-RPS or SDB-XC) was investigated under controlled conditions at pH = 6.5 for 26 days. The modified POCIS and Chemcatcher™ (SDB-RPS) samplers exhibited similar performance with the uptake of the majority of the 19 chemicals of interest categorised as linear over the 26 day deployment. Only a few ionized herbicides (picloram and dicamba) and triclosan showed negligible accumulation. Chemcatcher™ with SDB-XC sorbent performed relatively poorly with only carbamazepine having a linear accumulation profile, and 8 compounds showing no measurable accumulation. Differences in the uptake behavior of chemicals were not easily explained by their physico-chemical properties, strengthening the requirement for detailed calibration data. PES membranes accumulated significant amount of some compounds (i.e. triclosan and diuron), even after extended deployment (i.e. 26 days). At present there is no way to predict which compounds will demonstrate this behavior. Increasing membrane pore size from 0.2 to 0.45 μm for Chemcatcher™ (SBD-RPS) caused an average increase in Rs of 24%.

Norwegian crusted scabies: an unusual case presentation

Scabies is a contagious condition that is transmitted through direct contact with an infected person and has been frequently associated with institutional and healthcare-facility outbreaks. The subtype Norwegian crusted scabies can masquerade as other dermatologic diseases owing to the heavy plaque formation. Successful treatment has been documented in published reports, including oral ivermectin and topical permethrin. Few case studies documenting the treatment of Norwegian crusted scabies have reported the use of surgical debridement as an aid to topical and/or oral treatment when severe plaque formation has been noted. A nursing home patient was admitted to the hospital for severe plaque formation of both feet. A superficial biopsy was negative for both fungus and scabies because of the severity of the plaque formation on both feet. The patient underwent a surgical, diagnostic biopsy of both feet, leading to the diagnosis of Norwegian crusted scabies. A second surgical debridement was then performed to remove the extensive plaque formation and aid the oral ivermectin and topical permethrin treatment. The patient subsequently made a full recovery and was discharged back to the nursing home. At 2 and 6 months after treatment, the patient remained free of scabies infestation, and the surgical wound had healed uneventfully. The present case presentation has demonstrated that surgical debridement can be complementary to the standard topical and oral medications in the treatment of those with Norwegian crusted scabies infestation.

Food web structure in oil sands reclaimed wetlands

Boreal wetlands play an important role in global carbon balance. However, their ecosystem function is threatened by direct anthropogenic disturbance and climate change. Oil sands surface mining in the boreal regions of Western Canada denudes tracts of land of organic materials, leaves large areas in need of reclamation, and generates considerable quantities of extraction process-affected materials. Knowledge and validation of reclamation techniques that lead to self-sustaining wetlands has lagged behind development of protocols for reclaiming terrestrial systems. It is important to know whether wetlands reclaimed with oil sands process materials can be restored to levels equivalent to their original ecosystem function. We approached this question by assessing carbon flows and food web structure in naturally formed and oil sands-affected wetlands constructed in 1970-2004 in the postmining landscape. We evaluated whether a prescribed reclamation strategy, involving organic matter amendment, accelerated reclaimed wetland development, leading to wetlands that were more similar to their natural marsh counterparts than wetlands that were not supplemented with organic matter. We measured compartment standing stocks for bacterioplankton, microbial biofilm, macrophytes, detritus, and zoobenthos; concentrations of dissolved organic carbon and residual naphthenic acids; and microbial production, gas fluxes, and aquatic-terrestrial exports (i.e., aquatic insect emergence). The total biomass of several biotic compartments differed significantly between oil sands and reference wetlands. Submerged macrophyte biomass, macroinvertebrate trophic diversity, and predator biomass and richness were lower in oil sands-affected wetlands than in reference wetlands. There was insufficient evidence to conclude that wetland age and wetland amendment with peat-mineral mix mitigate effects of oil sands waste materials on the fully aquatic biota. Although high variability was observed within most compartments, our data show that 20-year-old wetlands containing oil sands material have not yet reached the same level of function as their reference counterparts.

Implementation of the INTERGROWTH-21st Project in the UK

There are approximately 10,000 births per year in the county of Oxfordshire in the UK, which is one of the two European sites for the International Fetal and Newborn Growth Consortium for the 21(st) Century (INTERGROWTH-21(st) ) Project. The samples for both components of the project--the Fetal Growth Longitudinal Study (FGLS) and Newborn Cross-Sectional Study (NCSS)--were drawn from the John Radcliffe Hospital, a major university hospital with a large regional role that covers more than 75% of deliveries in the county. Special activities to encourage participation in this population included the formation of a research coalition to streamline recruitment in the Maternity Unit and the distribution of study information leaflets to women using the hospital's antenatal care service. This was a demanding project and several challenges were overcome to reach recruitment targets and to maintain high standards of data quality. Amongst the major challenges for FGLS at this study site was the level of ineligibility because of maternal age, smoking and body mass index (BMI) ≥ 30. The major challenge for the NCSS field teams was to ensure that all anthropometric data were collected before the early discharge of uncomplicated deliveries, often within 6 hours of birth. It is evident from our experience in implementing this project that, when large-scale clinical studies are meticulously planned and avoid major disruption to routine clinical care, they are well received by hospital staff and can contribute to the improvement of the overall standard of clinical care.