Associations Between Eating, Mobility, and Toileting Functional Dependence and COVID-19 Symptoms

OBJECTIVES

The first goal of this study was to explore associations between functional dependence levels during activities of daily living (eg, functional mobility, eating, and toileting) before COVID-19 and presence of COVID-19 symptoms (eg, fever, dehydration, lethargy, and shortness of breath) during illness. The second goal of this study was to explore associations between presence of specific COVID-19 symptoms and level of functional decline from before to after illness.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

A total of 375 residents at a single skilled nursing facility in New York City.

METHODS

Data were extracted from the Minimum Data Set 3.0 and chart reviews. Multiple linear regressions analyzed relationships between baseline functional dependence in eating, functional mobility, and toileting and presence of dehydration, lethargy, shortness of breath, and fever. Ordinal linear regressions analyzed associations between COVID-19 symptom presence and changes in functional dependence from before to after illness.

RESULTS

Pre-COVID-19 eating dependence was significantly associated with dehydration during COVID-19. Dehydration during COVID-19 was significantly associated with greater functional declines in functional mobility from before to after illness. Shortness of breath was significantly associated with increased functional declines in eating and functional mobility.

CONCLUSIONS AND IMPLICATIONS

Patients with COVID-19 should be monitored for shortness of breath and dehydration, as these symptoms are associated with functional decline. Individuals experiencing functional decline before COVID-19 onset are especially vulnerable to these symptoms. Future research should further explore the relationship between functional status and COVID-19 symptoms.

A NURSING HOME–BASED COVID-19-ONLY REHAB PROGRAM: VARIABLES RELATED TO SUCCESSFUL COMMUNITY DISCHARGE

Many COVID-19 patients continue to test positive for COVID-19 beyond the typical quarantine period. Persistent positive testing complicated hospital discharges to nursing home (NH) based rehabilitation facilities when (in May 2020) New York State (NYS) required a negative COVID result prior to NH admissions. To meet the needs of medically stable persistent positive patients, NYS approved 19 NHs as COVID-only facilities (COF). These facilities provided rehabilitation services and allowed hospitals to regain critical space for incoming acute care patients. In the present study we describe the (1) establishment of a 100 bed COF, (2) patients admitted to the COF and care provided, and (3) predictors of successful discharge to the community.Information on the establishment of the COF was obtained from interviews with NH leadership and clinical staff. Patient, treatment, and outcome data were obtained from the NH’s electronic health record. Of 319 COF admissions over four months, 54% were female and the mean age was 80 years (SD=10.56). 51% had cognitive impairment and the mean number of comorbidities was 6.75 (SD=2.47). All patients received physical and occupational therapy while 37% received speech therapy. Medical treatment included: anticoagulants (52%), oxygen (37%), antibiotics (35%), inhaler/nebulizers (31%), and oral steroids (15%). 59% of COF stays resulted in successful community discharges. This outcome was more likely for patients who had fewer comorbidities, less speech therapy, and did not require antibiotics. Implications for COVID care as well as leveraging NH potential during crisis will be discussed.

BASELINE PURPOSE IN LIFE PREDICTS FUNCTIONAL HEALTH ACROSS 16 WEEKS IN OLDER ADULTS WITH PROGRESSIVE VISION LOSS

Greater purpose in life is associated with various positive outcomes in later life, such as, lower mortality risk, protection against cognitive decline, and lower spending on medical care and emergency room visits. Recent research from the Health and Retirement Study has shown that older adults with greater purpose in life have fewer physical limitations after four years. There has been no research to investigate purpose in life in older adults with progressive vision loss. The aim of this study is to examine whether purpose in life predicts functional health (i.e., activities of daily living) across a 16-week period of time in a sample of older adults (aged 60–96) with vision loss due to macular degeneration who were enrolled in a resilience building program (Nf 122). A repeated measures GLM showed that functional health did not change across 16 weeks (ns). Age (F(1, 112)=8.91, p=.003, ηp2=.07) and purpose in life (F(1,112)=13.21, p < .001, ηp2= .11) were significant overall predictors of functional health across time. Gender, education, cognition, marital status, depression, and loneliness at baseline were not associated with overall functional health. People who were younger were more likely to have better functional health over 16 weeks; purpose in life added 11% of explained variance. Because purpose in life is malleable and also significantly associated with better functional health in older adults with progressive vision loss, future interventions that enhance purpose in life should be studied with this population.

Occupational, Physical, and Speech Therapy Intensities in COVID-19 Patients in a Skilled Nursing Facility

Date Presented 04/01/2022

Two hundred forty-eight patients in a large urban skilled nursing facility (SNF) were studied, examining intensity of rehabilitation services among individuals with coronavirus disease 2019 (COVID-19). Of the population, 58.1% participated in OT and physical therapy services and 13.3% participated in speech therapy services. Significantly higher intensities of rehabilitation services were noted in the 71 patients who were postacute care. More research is needed to determine the most efficacious intensities for geriatric patients with COVID-19, which may vary on the basis of rehabilitation type and patient characteristics.

Primary Author and Speaker: Benjamin E. Canter

Contributing Authors: Himali Weerahandi, Orah Burack, Joann Reinhardt, Kenneth Boockvar, Lauren Siconolfi

Using Clinical Indicators to Optimize Therapeutic Outcomes in Geriatric Patients With COVID-19

Date Presented 04/02/2022

This study examined the relationship between clinical indicators of illness severity in coronavirus disease 2019 (COVID-19) such as blood urea nitrogen-creatinine ratios and symptom count and how these labs relate to functional dependence and therapeutic rehabilitation outcomes in geriatric patients. Their relationship demonstrates the potential role that OTs and OT assistants can play in identifying and preventing risk for dehydration, hospitalization, and other adverse patient outcomes, in addition to the risk of functional decline.

Primary Author and Speaker: Benjamin E. Canter

Contributing Authors: Himali Weerahandi, Orah Burack, Joann Reinhardt, Kenneth Boockvar, Lauren Siconolfi

In Their Own Words: The Challenges Experienced by Certified Nursing Assistants and Administrators During the COVID-19 Pandemic

This qualitative study aimed to provide an in-depth understanding of the challenges experienced by certified nursing assistants and administrators during the unprecedented COVID-19 crisis. We conducted 6 administrator interviews and 10 remote focus groups with day and evening CNAs at 5 nursing homes (N = 56) in downstate New York. Content analysis was conducted, and emerging themes were identified across sites and roles. Results showed numerous challenges for both CNAs and administrators including many that were personal. These personal challenges included feeling helpless, anxious, or fearful; experience of COVID illness; and balancing high concurrent demands of work and family. There were also many operational challenges such as a lack of COVID testing capacity, information, and consistent guidance and support, staffing and equipment. Understanding these challenges can facilitate goals to promote future safety, skill refinement, and enhanced resilience in the workforce.

Perspectives of certified nursing assistants and administrators on staffing the nursing home frontline during the COVID-19 pandemic

Objective

To identify best practices to support and grow the frontline nursing home workforce based on the lived experience of certified nursing assistants (CNAs) and administrators during COVID‐19.

Study setting

Primary data collection with CNAs and administrators in six New York metro area nursing homes during fall 2020.

Study design

Semi‐structured interviews and focus groups exploring staffing challenges during COVID‐19, strategies used to address them, and recommendations moving forward.

Data collection

We conducted interviews with 6 administrators and held 10 focus groups with day and evening shift CNAs (n = 56) at 6 nursing homes. Data were recorded and transcribed verbatim and analyzed through directed content analysis using a combined inductive and deductive approach to compare perceptions across sites and roles.

Principal findings

CNAs and administrators identified chronic staffing shortages that affected resident care and staff burnout as a primary concern moving forward. CNAs who felt most supported and confident in their continued ability to manage their work and the pandemic described leadership efforts to support workers' emotional health and work–life balance, teamwork across staff and management, and accessible and responsive leadership. However, not all CNAs felt these strategies were in place.

Conclusions

Based on priorities identified by CNAs and administrators, we recommend several organizational/industry and policy‐level practices to support retention for this workforce. Practices to stabilize the workforce should include 1) teamwork and person‐centered operational practices including transparent communication; 2) increasing permanent staff to avoid shortages; and 3) evaluating and building on successful COVID‐related innovations (self‐managed teams and flexible benefits). Policy and regulatory changes to promote these efforts are necessary to developing industry‐wide structural practices that target CNA recruitment and retention.

Challenges Reported by Certified Nursing Assistants During COVID-19: A Qualitative Study

Certified nursing assistants (CNAs) who care for vulnerable nursing home residents faced unprecedented circumstances due to the COVID-19 pandemic. While staff and PPE shortages were ubiquitous and widely known, the focus of this qualitative work was to gain a broader understanding of the numerous challenges they faced. We conducted 10 remote focus groups with CNAs at 5 nursing homes (N=56) in downstate New York. Content analysis was conducted, and emerging themes identified. Results showed a myriad of emotional challenges including helplessness, fear and anxiety. Operational challenges focused on lack of COVID testing capacity, information, and consistent guidance and support, in addition to staff and equipment. Individual challenges included personal experience of COVID illness and that of colleagues, and balancing high concurrent demands of work and family. These results are discussed in the context of developing recommendations to promote future safety, skill refinement and enhanced resilience in the workforce moving forward.

DNR Linked to Reduced Depressive Symptoms in Nursing Home Residents During COVID-19 Illness

Prior work shows that older adults who establish future care plans have a lower risk of depression. Residents in long-term care may benefit from establishing a do-not-resuscitate (DNR) order when cardiopulmonary resuscitation is unlikely to provide medical benefit. The current study examines whether having a DNR order in place prior to COVID-19 diagnosis was associated with fewer depressive symptoms during the illness course. Residents at a NYC skilled nursing facility with a positive COVID-19 PCR test between 3/1/2020 – 6/1/2020 were included (N=338). The Minimum Data Set (3.0) was used to examine residents’ Patient Health Questionnaire-9 (PHQ-9) scores 1-30 days after diagnosis, functional status, cognition, age, and sex. A retrospective chart review was conducted to determine whether participants had an established DNR, DNI, and/or DNH order before developing COVID-19. Forty-eight percent, 46%, and 12% of participants had a DNR, DNI, or DNH order prior to COVID-19 illness, respectively. Average PHQ-9 score was 1.65 (SD=2.37). A hierarchical regression showed that after controlling for age (β=-.13, p=.06), sex (β=-.08, p=.28), cognition (β=.14, p=.04), and functional status (β=.23, p=.001; R2=.10, p=.001), having a DNR (β=-.22, p=.006) order in place prior to COVID illness was associated with lower endorsement of depressive symptoms during illness (ΔR2=.04, p=.01). Results suggest that establishing a DNR in long-term care residents when appropriate may potentially buffer depressive symptoms during illness in nursing home residents regardless of their age, sex, cognitive abilities, and functional status. Future examination of the underlying mechanism is warranted.

Variables Impacting Nursing Home Goals of Care Discussions and Order Implementation During COVID-19

Nursing home (NH) residents are especially vulnerable to COVID-19, disproportionately suffering from severe illness and death. As such, resident Goals of Care (GOC) often had to be quickly established to ensure treatment preferences were known and respected. This study examined variables related to the occurrence of GOC discussions and added orders (Do Not Resuscitate, Do Not Intubate, and Do Not Hospitalize), including demographic, physical functioning, cognitive impairment, depression, number of diagnoses, and Optum participation (Optum provided added specialized care by nurse practitioners who routinely address GOC preferences). Subjects were 286 COVID positive residents from a large NYC NH. All data were obtained from the NH’s electronic medical records. Patient median age was 81 n (interquartile range 71-88), 59% were female, 61% were long stay (stay >100 days) and 39% were short stay. Using bivariate correlations we found that older short stay residents were more likely to have GOC conversations. Additionally, older, cognitively impaired, Optum participants were more likely to have orders added. When all independent variables were entered into binary logistic regressions, only older age and being a primary English speaker were significantly related to the occurrence of GOC conversations (□2= 21.76**; N=278; Nagelkerke R2 = .10), while older age and being an Optum participant were related to added orders (□2=32.18**; N=164; Nagelkerke R2 = .24). Results have implications for (1) ensuring the GOC wishes of diverse populations are known and abided by and (2) improving the quality of clinician – resident GOC discussions.

It Was Trial by Fire: Recommendations for Building a Stronger Nursing Home Workforce After COVID-19

The COVID-19 crisis showed the urgent need for a unified, well-supported nursing home workforce. The objective of this qualitative study was to examine the lived experience of certified nursing assistants (CNAs) and administrators during COVID-19 to identify best practices moving forward. Six administrator interviews and 10 remote focus groups with CNAs at 5 nursing homes (N=56) were examined through directed content analysis. Based on priorities identified by CNAs and administrators, the following practices may be most impactful: 1) ongoing and responsive staff training; 2) transparent, direct, and two-way communication channels; 3) prioritizing hiring permanent staff to avoid shortages and reliance on agency staff; 4) building collaborative staff-management relationships; 5) providing flexible job benefits; 6) providing staff-centered emotional support resources; and 7) appraising COVID-19 innovations. Our results suggest that rather than returning to “business as usual,” nursing homes can draw on these lessons to build a more sustainable workforce and industry.

Direct-to-consumer marketing (DTC) of internet-based cognitive behavioral therapy (iCBT) using brief promotional video: Mapping modifiable mechanisms in pre-treatment acceptance

Introduction

Given the suboptimal acceptance of iCBT for depression, finding ways to increase the acceptance and uptake is crucial for its dissemination. Moreover, it remains unknown to what extend the Unified Theory of Acceptance and Use of Technology (UTAUT) could aid the design of DTC in psychological service.

Objectives

To explore whether the regulatory processes theorized in the UTAUT (Performance Expectancy, Effort Expectancy, Social Influence, and Facilitating Condition) could be modified and mediate the change of acceptance of iCBT.

Methods

This randomized controlled trial recruited 219 individuals with at least mild level of depression. Upon completion of pre-assessment, participants were randomly allocated to an intervention (IG) and a control group (CG). The IG received a 7-minute UTAUT-driven promotion video, while the CG received a video of same length on general psychoeducation. Both groups completed a post-assessment.

Results

Repeated measures ANOVA revealed a significant time by group effect on treatment acceptance. The video in IG was perceived to be clearer and more persuasive. Mediation analysis showed that the intervention effect was mediated by increase in perceived performance expectancy of iCBT, and the indirect effect was conditional on dispositional help seeking stigma.

Conclusions

Pre-treatment acceptance of iCBT can be improved by brief DTC promotion video. The finding casts light that performance expectancy was the most modifiable and mediatable regulatory process on iCBT acceptance, although such relation could be attenuated by high help-seeking stigma. In sum, DTC marketing could aid implementation of Internet-based interventions, effort in stigma reduction should continue to encourage uptake of effective treatment.

Disclosure

No significant relationships.

Loneliness and Purpose in Life Are Important Predictors for Future Care Planning

Experiencing purpose and social connection in later life is associated with better quality of life, better cognition, less morbidity, and lower risk of mortality. People who experience less purpose in life are more likely to report loneliness (Neville et al., 2018), and those with vision impairment are at greater risk for loneliness than the general population (Brunes et al., 2019). Planning for future care may be one way to enhance late life outcomes, but it is unclear how loneliness and purpose in life are related to planning behaviors in older people with vision loss. Using a sample of 200 older adults who were diagnosed with macular degeneration, this study explored the association of loneliness and purpose in life on future care planning variables after controlling for basic health and demographic variables. Hierarchical regressions showed that 1) people who are lonelier (β=.26, p&lt;.05) but report greater purpose in life (β=.19, p&lt;.05) are more aware of future care needs (ΔR2= .14, p&lt;.001); 2) people who are lonelier (β=-.16, p&lt;.05) but report greater purpose in life (β=-.46, p&lt;.001) are less avoidant of planning (ΔR2= .14, p&lt;.001); and 3) people who report greater purpose in life are more likely to gather information (β=.24, p&lt;.05; ΔR2= .04, p&lt;.05) and establish concrete plans related to planning for future care (β=.25, p&lt;.05; ΔR2= .06, p&lt;.001). These results suggest that having purpose in later life may boost planning behaviors, while those who are lonely may need help translating their awareness of future care needs into planning behaviors.

More Exercise Is Linked to Less Loneliness in Adult Day Health Attendees

There is a growing evidence that more physical activity is linked to less loneliness (Cigna, 2018; Pels & Kleinert; 2016). It is less clear whether this relationship persists in older adults who are attending adult day health services and often have multiple comorbidities. In this study, we examined whether spending more time exercising would significantly predict whether adult day health attendees reported loneliness. We used UAS-NY data from a sample of 221 adult day health attendees from 2019 to early 2020 who scored five or greater on the Nursing Facility Level of Care Index, which is a score derived from assessments of cognition, communication and vision, mood and behavior, functional status, continence, and nutritional status. A logistic regression showed that after controlling for demographic variables, cognition, health, and quality of family relationships, participants were less likely to report loneliness if they had been attending adult day health services for at least six months or more (B=.86, p<.05), spent less time alone (B=-.45, p<.05), and exercised more (B=.47, p<.05; χ2(3)=15.6, p=.001). These results suggest that in addition to participating in adult day services and spending more time with others, exercising may have an impact on the experience of loneliness.

ADULT DAY HEALTH SERVICES ATTENDANCE IS LINKED TO A REDUCTION IN LONELINESS

Loneliness is the subjective experience of inadequate social contact, and it is linked to numerous detrimental psychological and medical outcomes like depression, cognitive decline, sleep fragmentation, metabolic syndrome, diminished immune functioning, and morbidity. Older adults with cognitive impairment and/or other comorbidities are at greater risk for loneliness due to diminishing social roles, functional status, and death of peers. They are often encouraged to attend adult day services to engage in an environment of socialization and supported activities, and in the case of adult day health services, additional medical services such as physical therapy, skilled nursing care, medical management, and nutritional counseling. In this study we examined whether attending adult day health services (ADHS) at least once a week would be associated with decreased levels of loneliness across time. Our data came from a sample of older adults attending ADHS in New York City from 2018-2019 who scored five or greater on the Nursing Facility Level of Care Index, which is a score derived from assessments of cognition, communication and vision, mood and behavior, functional status, continence, and nutritional status from the Uniform Assessment System in New York (UAS-NY). We found that attendance was linked with fewer reports of loneliness across time, ∑2(1, N=563) = 21.33, p<.001. These results highlight the importance of attending adult day health services for people with a complex health status and the potential role ADHS may play in reducing loneliness in a vulnerable population.

Outcomes of upper extremity versus lower extremity placed peripherally inserted central catheters in a medical-surgical neonatal intensive care unit1

OBJECTIVE

To compare outcomes of peripherally inserted central catheters (PICCs) placed in the upper extremity (UE) versus the lower extremity (LE) in a quaternary medical-surgical neonatal intensive care unit (NICU).

RESULTS

We analyzed a total of 365 PICCs of which 250 (68%) were removed for end of therapy and 115 (32%) were removed due to complications. Patients who had UE insertions compared to LE insertions were of lower gestational age (median (IQR)), 30 (26, 35) vs. 32 (27, 37) weeks respectively (p = 0.014). UE PICCs were more likely to be removed due to complications compared to LE PICCs (39.9% vs. 26.4%, RR 1.51, 95% CI 1.12 -2.03, p = 0.007). UE PICCs were more likely than LE PICCs to be removed for the complications of malposition, dislodgement, and pleural or pericardial effusions; while LE PICCs were more likely to be removed for phlebitis. There were no differences in the rates of sepsis at 13.0% vs. 12.8% for UE vs. LE respectively, or causal organisms for sepsis. Survival analysis demonstrated that LE PICCs had a longer time to removal for a complication (p = 0.031).

CONCLUSIONS

LE compared with UE PICCs were not associated with worse outcomes in a medical-surgical neonatal population that included a significant proportion of full-term neonates, and provide a valuable alternate site for central venous access. Increased awareness of the types of complications for UE compared with LE PICCs may help focus preventive and surveillance efforts based on PICC location, to improve safety and minimize the complications of NICU PICCs.

Sinonasal inverted papilloma recurrence rates and evaluation of current staging systems

BACKGROUND

Sinonasal inverted papillomas (SNIPs) are benign epithelial growths with high recurrence rates after surgical management. This study aims to evaluate SNIP recurrence rates after endoscopic surgery and to provide a comparison of published staging systems.

METHODS

This chart review evaluated primary and revision SNIP cases from January 2008 to December 2016 at a tertiary sinus centre. Data was collected on patient demographics, origin site, surgical approaches, follow-up duration, recurrence, and smoking history. Each case was staged using Krouse, Oikawa, Cannady, Han, and Kamel systems.

RESULTS

52 primary and 22 revision SNIP patients had a mean follow-up of 42.3 (range:3-55) months. 11 primary cases (21.1%) and 5 revision cases (22.7%) had recurrences. Primary and revision cases had a mean time to recurrence of 24.0 (range:3-55) and 14.6 (range:10-20) months respectively. Smoking history had an OR of 0.63 (CI 95%: 0.18-2.22) for recurrence. The age group of 20-39 years featured the highest rates of recurrence. Patient groups defined by each staging system were compared by Kaplan-Meier survival analyses and logrank tests. Chi-squared values for Krouse, Oikawa, Cannady, Han, and Kamel systems were 6.73, 7.02, 6.19, 8.23 and 3.29, respectively.

CONCLUSION

Recurrence rates found in this study are comparable to published literature. No statistical significance was found to associate smoking with recurrence. Han and Cannady staging systems were found to define patient groups that correlated well with recurrence. Staging systems should play a role in the management of SNIPs, especially to identify patients requiring additional post-surgical monitoring.

Are Humor Styles of People With Dementia Linked to Greater Purpose in Life?

Objectives

Little is known about humor and purpose in life in people with dementia. Although having a sense of humor is typically associated with positive psychological outcomes, recent evidence suggests that outcomes may vary depending on whether the humor being used is adaptive versus maladaptive. The goal of this study was to determine whether humor styles are predictive of purpose in life in people with dementia.

Methods

Questionnaires were verbally administered to people with mild-to-moderate dementia to measure humor styles and purpose in life.

Results

Adaptive humor styles were associated with purpose in life whereas maladaptive humor styles were not.

Discussion

Having a sense of humor in dementia may be associated with a stronger sense of purpose in life, but it depends on the type of humor used. Results are discussed in the context of understanding the role of humor in the daily lives of people with dementia and implications for care.

Use of ICSI in IVF cycles in women with tubal ligation does not improve pregnancy or live birth rates

STUDY QUESTION

Does ICSI improve outcomes in ART cycles without male factor, specifically in couples with a history of tubal ligation as their infertility diagnosis?

SUMMARY ANSWER

The use of ICSI showed no significant improvement in fertilization rate and resulted in lower pregnancy and live birth (LB) rates for women with the diagnosis of tubal ligation and no male factor.

WHAT IS KNOWN ALREADY

Prior studies have suggested that ICSI use does not improve fertilization, pregnancy or LB rates in couples with non-male factor infertility. However, it is unknown whether couples with tubal ligation only diagnosis and therefore iatrogenic infertility could benefit from the use of ICSI during their ART cycles.

STUDY DESIGN, SIZE, DURATION

Longitudinal cohort of nationally reported cycles in the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System (SART CORS) of ART cycles performed in the USA between 2004 and 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

There was a total of 8102 first autologous fresh ART cycles from women with the diagnosis of tubal ligation only and no reported male factor in the SART database. Of these, 957 were canceled cycles and were excluded from the final analysis. The remaining cycles were categorized by the use of conventional IVF (IVF, n = 3956 cycles) or ICSI (n = 3189 cycles). The odds of fertilization, clinical intrauterine gestation (CIG) and LB were calculated by logistic regression modeling, and the adjusted odds ratios (AORs) with 95% confidence intervals were calculated by adjusting for the confounders of year of treatment, maternal age, race and ethnicity, gravidity, number of oocytes retrieved, day of embryo transfer and number of embryos transferred.

MAIN RESULTS AND THE ROLE OF CHANCE

The main outcome measures of the study were odds of fertilization (2PN/total oocytes), clinical intrauterine gestation (CIG/cycle) and live birth (LB/cycle). The fertilization rate was higher in the ICSI versus IVF group (57.5% vs 49.1%); however, after adjustment this trend was no longer significant (AOR 1.14, 0.97-1.35). Interestingly, both odds of CIG (AOR 0.78, 0.70-0.86), and odds of LB were lower (AOR 0.77, 0.69-0.85) in the ICSI group. Plurality at birth, mean length of gestation and birth weight did not differ between the two groups.

LIMITATIONS, REASONS FOR CAUTION

This was a retrospective study, therefore only the available parameters could be included, with parameters of interest such as smoking status not available for inclusion. Smoking status may have led practitioners to use ICSI to improve pregnancy and LB outcomes.

WIDER IMPLICATIONS OF THE FINDINGS

Studies have shown that in the USA there is an increasing usage of ICSI for non-male factor infertility despite a lack of evidence-based benefit. Our study corroborates this increasing use over the last 8 years, specifically in the tubal ligation only patient population. Even after adjusting for multiple confounders, the patients who underwent ICSI had no statistically significant improvement in fertilization rate and actually had a lower likelihood of achieving a clinical pregnancy and LB. Therefore, our data suggest that the use of ICSI in tubal ligation patients has no overall benefit. This study contributes to the body of evidence that the use of ICSI for non-male factor diagnosis does not improve ART outcomes over conventional IVF.

STUDY FUNDING/COMPETING INTERESTS

None.

The macular degeneration and aging study: Design and research protocol of a randomized trial for a psychosocial intervention with macular degeneration patients

BACKGROUND

Age-related Macular Degeneration (AMD) is the leading cause of irreversible and predictable blindness among older adults with serious physical and mental health consequences. Visual impairment is associated with negative future outlook and depression and has serious consequences for older adults' quality of life and, by way of depression, on long-term survival. Psychosocial interventions have the potential to alleviate and prevent depression symptoms among older AMD patients.

METHODS

We describe the protocol of the Macular Degeneration and Aging Study, a randomized clinical trial of a psychosocial Preventive Problem-Solving Intervention. The intervention is aimed at enhancing well-being and future planning among older adults with macular degeneration by increasing preparation for future care.

RESULTS

Adequate randomization and therapeutic fidelity were achieved. Current retention rates were acceptable, given the vulnerability of the population. Acceptability (adherence and satisfaction) was high.

CONCLUSION

Given the high public health significance and impact on quality of life among older adults with vision loss, this protocol contributes a valid test of a promising intervention for maintaining mental and physical health in this population.

Fucoidan from New Zealand Undaria pinnatifida: monthly variations and determination of antioxidant activities

The content and composition of fucoidans extracted from Undaria pinnatifida from mussel farms at the Marlborough Sounds, New Zealand were investigated using CaCl2 extraction. Crude fucoidan (F0) was subsequently extracted on a monthly basis from U. pinnatifida harvested from July to October 2011 from mussel farms in the Marlborough Sounds, New Zealand. Fucoidan yield varied between the frond and sporophyll parts of the algae, with the sporophyll consistently the highest content. The yield from the sporophyll increased significantly from July (25.4-26.3%) to September (57.3-69.9%). Sulphate content in the extracted fucoidan increased more than twice within the same period, while fucose content remained constant. F0 was further purified by ion-exchange chromatography to yield three fractions, F1, F2 and F3. All three fucoidan fractions contained fucose as the primary sugar component followed by galactose, with xylose, glucose and mannose as minor constituents. All fractions exhibited strong antioxidant activities using the DPPH scavenging and CUPRAC assays. This study showed that sporophyll maturation of U. pinnatifida in New Zealand influenced fucoidan content and composition. Sporophyll fucoidan could potentially be a good resource for natural antioxidants.

The relationship of preparation for future care to depression and anxiety in older primary care patients at 2-year follow-up

BACKGROUND

: Preparation for future care needs has been hypothesized to help older adults adjust to inevitable life and health transitions and thereby decrease the likelihood of developing depression or anxiety.

METHODS

: A total of 190 primary care patients aged 65 years or more completed semistructured research interviews and mail-back surveys at study intake and 2 years later. Interviews included the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the Hamilton Depression Rating Scale, Clinical Anxiety Scale and a measure of preparation for future care. Multiple regression analyses were used to determine the independent association of preparation for future care at intake with depression and anxiety severity at 2-year follow-up.

RESULTS

: Patients who had made more concrete plans at intake were less likely to meet criteria for depression diagnosis at follow-up. They also had lower anxiety severity scores. Patients who had avoided thinking about future care needs had greater depression symptom severity at follow-up. Findings were independent of potential confounds, including illness burden.

CONCLUSIONS

: Failure to prepare for future care is a novel putative risk marker for depression and anxiety in older adulthood. Clinicians should be aware that the lack of care planning and frank avoidance may pose a risk for depression and anxiety older their patients. Future research should explore the mechanisms of care planning's effects on subsequent mood.

Trajectories of preparation for future care among first-degree relatives of Alzheimer's disease patients: an ancillary study of ADAPT

PURPOSE

 This study examines the longitudinal patterns of Preparation for Future Care (PFC), defined as Awareness, Avoidance, Gathering Information, Decision Making, and Concrete Plans, in first-degree relatives of people with Alzheimer's disease (AD). 

DESIGN AND METHODS

 Eight time points across 6.5 years from a subsample of adults aged 70 years and older who were participating in the Alzheimer's Disease Anti-inflammatory Prevention Trial (ADAPT) were analyzed using latent growth modeling. Baseline attitudes toward planning for future care and demographic variables functioned as predictors in the conditional analyses. 

RESULTS

 Awareness, Gathering Information, Decision Making, and Concrete Planning increased across time, but Avoidance did not. Covariates were more often associated with the initial levels of planning behavior than with change across time. Women engaged in more initial Decision Making than men. Education was associated with more initial Gathering Information, Decision Making, and less Avoidance. Favorable attitudes toward planning were more predictive of baseline Awareness, Gathering Information, Avoidance, and less so for Decision Making or Concrete Planning. 

IMPLICATIONS

 Older adults with an elevated risk for AD increase in positive PFC behaviors gradually across time. Demographic characteristics and attitudes predict initial levels of planning, making it possible to identify individuals who might need help progressing to more advanced levels of planning. Future studies are needed to understand rates of change in planning behaviors.

Planning and Decision Making for Care Transitions

The need to plan for future health care and residential adjustments increases with age, growing frailty, and restrictions in coverage of long-term care and will continue to grow with population aging. Older adults' lack of financial preparation for health care costs, insufficient knowledge about available options, and inadequate communication about care-related values has become an increasing public health challenge. This chapter describes a model of Preparation for Future Care (PFC), which encompasses different levels and domains of planning. Research about the extent to which planning is helpful in navigating care transitions is reviewed, and barriers and facilitators of planning including individual, familial, cultural, and national long-term care policy factors are discussed. Planning in the context of dementia and practical approaches that can be taken to enhance PFC is addressed, as well as recommendations for future research in the area of planning and decision making in the context of care transitions.

Increased gene coverage and Alu frequency in large linkage disequilibrium blocks of the human genome

The human genome has linkage disequilibrium (LD) blocks, within which single-nucleotide polymorphisms show strong association with each other. We examined data from the International HapMap Project to define LD blocks and to detect DNA sequence features inside of them. We used permutation tests to determine the empirical significance of the association of LD blocks with genes and Alu repeats. Very large LD blocks (>200 kb) have significantly higher gene coverage and Alu frequency than the outcome obtained from permutation-based simulation, whereas there was no significant positive correlation between gene density and block size. We also observed a reduced frequency of Alu repeats at the gaps between large LD blocks, indicating that their enrichment in large LD blocks does not introduce recombination hotspots that would cause these gaps.

Nonthymoma early-onset- and late-onset-generalized myasthenia gravis—A retrospective hospital-based study

OBJECTIVE

Acquired myasthenia gravis (MG) is predominantly due to nicotinic acetylcholine receptor (AChR) autoantibodies (Ab). Differences between nonthymoma early-onset and late-onset MG were reported. We studied the clinical and serological characteristics of nonthymoma AChR Ab-positive-generalized MG patients.

PATIENTS AND METHODS

Chinese AChR Ab-positive-generalized MG patients who had generalized disease for 3 years or longer were studied.

RESULTS

Among 41 such patients, 25 (61%) were female. The mean onset age was 43.5 years (range 9-78 years) and the mean follow-up duration was 7.8 years (range 3-20 years). Sixteen (39%) patients had late-onset disease (onset age >or=50 years). Compared to early-onset patients (onset age <50 years), late-onset patients were characterized by male predominance (p=0.002), absence of thymic lymphofollicular hyperplasia (p=0.036), and a higher striated muscle Ab seropositivity rate (94% versus 4%, p<0.001). Although there was no statistically significant difference in clinical severity and outcome or response to treatment between late-onset and early-onset patients, 50% and 75% of late-onset patients had moderate or severe disease at onset and worst status, respectively, compared to 28% and 52% for early-onset patients at onset and worst status, respectively. Also 63% of late-onset patients had disease progressed within first 3 years compared to only 40% of early-onset patients did.

CONCLUSION

Nonthymoma late-onset-generalized MG patients were common among Hong Kong Chinese, with a statistically non-significant trend that it was clinically more severe than early-onset MG but with similar clinical outcome or response to treatment; >90% of these patients were seropositive for striated muscle Ab.

Humor comprehension in older adults

The goal of this study was to understand factors related to humor comprehension in old age. This study proposes that, in contrast to younger adults, older adults have greater difficulty with humor comprehension due to age-related cognitive decline. Tests of verbal and nonverbal humor comprehension and tests of cognitive flexibility, abstract reasoning, and short-term memory were administered to 40 younger and 41 older adults. In general, older adults scored lower than younger adults on tests of humor and cognitive abilities. Regression analyses support the idea that cognition affects humor comprehension, but the relative contribution of each specific mechanism remains unclear. The results of this study suggest that there may be age-related deficits in humor comprehension, but more importantly, that a more sophisticated model is needed to clarify the role of cognition in humor comprehension. Humor comprehension warrants further study because of the potential physical and psychological benefits of humor.