The timing and development of infections in a fish-cestode host-parasite system.

The cestode Schistocephalus solidus is a common parasite in freshwater threespine stickleback populations, imposing strong fitness costs on their hosts. Given this, it is surprising how little is known about the timing and development of infections in natural stickleback populations. Previous work showed that young-of-year stickleback can get infected shortly after hatching. We extended this observation by comparing infection prevalence of young-of-year stickleback from 3 Alaskan populations (Walby, Cornelius and Wolf lakes) over 2 successive cohorts (2018/19 and 2019/20). We observed strong variation between sampling years (2018 vs 2019 vs 2020), stickleback age groups (young-of-year vs 1-year-old) and sampling populations.

Replicated evolutionary inhibition of a complex ancestral behaviour in an adaptive radiation.

Adaptive radiations often exhibit high levels of phenotypic replication, a phenomenon that can be explained by selection on standing variation in repeatedly divergent environments or by the influence of ancestral plasticity on selection in divergent environments. Here, we offer the first evidence that plastic loss of expression of a complex display in a novel environment, followed by selection against expression, could lead to replicated evolutionary inhibition of the phenotype. In both ancestral (oceanic) and benthic (freshwater) populations of the threespine stickleback fish, cannibalism is common and males defending nests respond to approaching groups with a complex diversionary display. This display is not exhibited by males in allopatric, limnetic (freshwater) populations from which cannibalistic groups are absent. Laboratory-reared males from three limnetic populations exhibit a reduced tendency to respond to cannibalistic foraging groups relative to laboratory-reared ancestral and benthic males, but still are capable of producing a similar array of forms of the display despite many generations of disuse. Thus, replication in adaptive radiations can reflect reduced expression of an ancestral trait followed by evolutionary inhibition while the population retains the capacity to express the trait under extreme ancestral conditions.

End of life care for long-term care residents with dementia, chronic illness and cancer: prospective staff survey.

BACKGROUND: Little is known about the quality of end of life care in long-term care (LTC) for residents with different diagnostic trajectories. The aim of this study was to compare symptoms before death in LTC for those with cancer, dementia or chronic illness. METHODS: After-death prospective staff survey of resident deaths with random cluster sampling in 61 representative LTC facilities across New Zealand (3709 beds). Deaths (n = 286) were studied over 3 months in each facility. Standardised questionnaires - Symptom Management (SM-EOLD) and Comfort Assessment in End of life with Dementia (CAD-EOLD) - were administered to staff after the resident's death. RESULTS: Primary diagnoses at the time of death were dementia (49%), chronic illness (30%), cancer (17%), and dementia and cancer (4%). Residents with cancer had more community hospice involvement (30%) than those with chronic illness (12%) or dementia (5%). There was no difference in mean SM-EOLD in the last month of life by diagnosis (cancer 26.9 (8.6), dementia 26.5(8.2), chronic illness 26.9(8.6). Planned contrast analyses of individual items found people with dementia had more pain and those with cancer had less anxiety. There was no difference in mean CAD-EOLD scores in the week before death by diagnosis (total sample 33.7(SD 5.2), dementia 34.4(SD 5.2), chronic illness 33.0(SD 5.1), cancer 33.3(5.1)). Planned contrast analyses showed significantly more physical symptoms for those with dementia and chronic illness in the last month of life than those with cancer. CONCLUSIONS: Overall, symptoms in the last week and month of life did not vary by diagnosis. However, sub-group planned contrast analyses found those with dementia and chronic illness experienced more physical distress during the last weeks and months of life than those with cancer. These results highlight the complex nature of LTC end of life care that requires an integrated gerontology/palliative care approach.

Evolution of steroid hormones in reproductive females of the threespine stickleback fish.

Hormones play a prominent role in animal development, mediating the expression of traits and coordinating phenotypic responses to the environment. Their role as physiological integrators has implications for how populations respond to natural selection and can impact the speed and direction of evolutionary change. However, many emerging and established fish models with the potential to be ecologically or evolutionarily informative are small-bodied, making hormone sampling through traditional methods (whole-body or plasma) lethal or highly disruptive. Sampling methodology has thus restricted study design, often limiting sample sizes, and has prevented the study of at-risk/endangered populations. We utilize water-borne hormone sampling, a minimally invasive method of measuring the rate of steroid hormone release across the gills and further validate this method in a novel, evolutionary context. First, we compare water-borne hormone measures of cortisol with those quantified from plasma and whole-body samples collected from the same individuals to establish the relationship between concentrations quantified via the three methods. We then compare the release of steroid hormones in three populations of threespine stickleback to establish the sensitivity of this tool in measuring within-individual and between-individual variation in biologically relevant contexts (reproductive stages), and in assessing differences among populations with distinct evolutionary histories. We demonstrate a strong positive relationship between cortisol concentrations measured with water-borne, plasma, and whole-body collection techniques. Tracking estradiol and testosterone throughout clutch production in females produced anticipated patterns associated with growing and maturing eggs, with divergence in estradiol production in one population. Additionally, differences among populations in cortisol levels at ovulation paralleled the relative presence of a social stressor, and thus expected energetic needs within each population. We confirm that water-borne hormone sampling is sufficiently sensitive to capture biologically relevant fluctuations in steroid hormones between environmental contexts and demonstrate that among-population differences are detectable. This technique can be applied broadly to small fish to answer important ecological and evolutionary questions. By linking population variation in hormones and the multivariate phenotype, this technique will help elucidate both proximate mechanisms underlying phenotypic development and variation, and the way hormone networks alter evolutionary responses to selection.

Family experiences of the transition to palliative care in aged residential care (ARC): a qualitative study.

PURPOSE: To address a gap in the literature by exploring bereaved families' perceptions of the transition to palliative care for their relative in long-term care. METHODS: In-depth interviews were conducted with a convenience sample of twenty-six family members who were most involved in the care of residents who had died within the last 12 months. Interviews explored care, perceptions of staff palliative care knowledge, communication with staff, care planning and decision-making. The range of responses fit the Donabedian (1966) health care model of structure/process/outcome. In the case of long-term care, structure includes staff training; process is the manner of care and outcome would be a 'good' (or bad) death. RESULTS: There was little evidence that a well-managed transition to a palliative approach to care was being initiated. Key themes included: 1) unrecognised need for transition; 2) information gaps and 3) feeling 'out of the loop'. Ten subthemes were also identified. IMPLICATIONS: Engaging family and relevant internal and external health providers in care planning not only promotes care in line with resident wishes but also assists family bereavement. Results indicate the need for the development of a new collaborative, multidisciplinary model to enhance the delivery of palliative care in long-term care.

The 'Big Five'. Hypothesis generation: a multidisciplinary intervention package reduces disease-specific hospitalisations from long-term care: a post hoc analysis of the ARCHUS cluster-randomised controlled trial.

INTRODUCTION: long-term care (LTC) residents have higher hospitalisation rates than non-LTC residents. Rapid decline may follow hospitalisations, hence the importance of preventing unnecessary hospitalisations. Literature describes diagnosis-specific interventions (for cardiac failure, ischaemic heart disease, chronic obstructive pulmonary disease, stroke, pneumonia-termed 'big five' diagnoses), impacting on hospitalisations of older community-dwellers, but few RCTs show reductions in acute admissions from LTC. METHODS: LTC facilities with higher than expected hospitalisations were recruited for a cluster-randomised controlled trial (RCT) of facility-based complex, non-disease-specific, 9-month intervention comprising gerontology nurse specialist (GNS)-led staff education, facility benchmarking, GNS resident review and multidisciplinary discussion of residents selected using standard criteria. In this post hoc exploratory analysis, the outcome was acute hospitalisations for 'big five' diagnoses. Re-randomisation analyses were used for end points during months 1-14. For end points during months 4-14, proportional hazards models are adjusted for within-facility clustering. RESULTS: we recruited 36 facilities with 1,998 residents (1,408 female; mean age 82.9 years); 1,924 were alive at 3 months. The intervention did not impact overall rates of acute hospitalisations or mortality (previously published), but resulted in fewer 'big five' admissions (RR = 0.73, 95% CI = 0.54-0.99; P = 0.043) with no significant difference in the rate of other acute admissions. When considering events occurring after 3 months (only), the intervention group were 34.7% (HR = 0.65; 95% CI = 0.49-0.88; P = 0.005) less likely to have a 'big five' acute admission than controls, with no differences in likelihood of acute admissions for other diagnoses (P = 0.96). CONCLUSIONS: this generic intervention may reduce admissions for common conditions which the literature shows are impacted by disease-specific admission reduction strategies.

Underage drinking: prevalence and correlates of risky drinking measures among youth aged 12-20.

BACKGROUND: Underage drinking and its effects have been researched extensively. However, no study to date has examined how the levels of drinking that have been defined as risky for adults might relate to youth who have a heightened physiological vulnerability to alcohol. OBJECTIVES: To examine a range of drinking measures that go beyond common measures of youth alcohol use to gain a more detailed understanding of the nature of underage drinking and its associated correlates and outcomes. METHODS: Analyzing data from a 2013 nationally representative US survey, we examined a variety of measures of alcohol use among 24,445 youth (weighted N = 381,155,562), the demographic groups most likely to have reported drinking in these ways, and associations between these measures of drinking and a number of adverse outcomes. RESULTS: On all measures of potentially risky drinking, including meeting diagnostic criteria for an alcohol use disorder, underage drinkers exceeded the rates found for adults. Independent of sex, race, and age, youth who reported drinking in ways that exceeded guidelines set for adults had increased odds of meeting diagnostic criteria for an alcohol, tobacco, or other drug use disorder, and of reporting a number of health problems. CONCLUSIONS: The high rates at which youth report engaging in a range of risky drinking behaviors suggest a need for a more nuanced approach to substance use and mental health screening and interventions in clinical practice. The findings also underscore the need to address apparent misconceptions about what constitutes unhealthy or unsafe alcohol use among youth.

Insights from a pilot program to integrate medical and social services.

This study examines lessons learned from the design, implementation, and early results of an integrated managed care pilot program linking member benefits of a Medicare-Medicaid health care plan with community services and supports. The health plan's average monthly costs for members receiving an assessment and services declined by an economically meaningful, statistically significant amount in the postintervention period relative to the preintervention period compared with those who did not accept an assessment or services. The results along with the lesson learned from the pilot are viewed by the parties as supportive of further program development.

A healthy ticker... or a good heart?

The amount of paperwork requiring completion by NHS professionals has increased over the years. Some employees feel that is driving them away from client care. In this article, one midwife tots up a week's worth of what she describes as 'box-ticking', and asks: what is the effect of this quantifying trend on the quality of care provided for women and families? Does a mark on a page provide a real representation of the interactions that have taken place? Whilst acknowledging that good documentation is an essential part of care, she questions its domination as a reflection of a job well done.

Lipoprotein profiles in Miniature Schnauzer dogs with idiopathic hypertriglyceridemia and hypercortisolism.

Miniature Schnauzer dogs (MSs) are predisposed to both idiopathic hypertriglyceridemia (iHTG) and hypercortisolism (HCort). To our knowledge, the lipoprotein profiles of MSs with iHTG have not been compared to those with HCort. We analyzed cholesterol and triglyceride concentrations and lipoprotein fractions in 4 groups of MSs: normotriglyceridemia (NTG) without concurrent disease (Healthy-NTG), HCort and NTG (HCort-NTG), HCort and HTG (HCort-HTG), and iHTG. Lipoprotein fractions were assessed by lipoprotein electrophoresis and compared between groups. Fifty-one plasma samples were analyzed. Twenty-five dogs had NTG (16 Healthy-NTG, 9 HCort-NTG) and 26 dogs had HTG (7 iHTG, 19 HCort-HTG). Dogs with iHTG or HCort-HTG had significantly higher cholesterol concentrations than Healthy-NTG dogs. Dogs with HCort-HTG had higher cholesterol than HCort-NTG dogs. There was a significantly higher low-density lipoprotein (LDL) percentage in iHTG and HCort-HTG dogs than HCort-NTG dogs. HCort-HTG dogs also had lower high-density lipoproteins (HDL) than HCort-NTG dogs. It was not possible to readily distinguish MSs with iHTG from MSs with HCort-HTG or Healthy-NTG using lipoprotein electrophoresis fractions. The diagnosis of iHTG remains a diagnosis by exclusion.

The exclusion of nicotine: closing the gap in addiction policy and practice.

Addiction is a complex brain disease with frequently overlapping expressions involving nicotine, alcohol, and other drugs. Yet current health care practices, public policies, and national treatment data too often exclude nicotine or address its use as completely separate from other forms of substance use and addiction, compromising patients' health and incurring unnecessary health care costs. Effective prevention and treatment requires the inclusion of nicotine in a comprehensive approach addressing all manifestations of addiction within health care policy and practice.

Privacy and Security Risk Factors Related to Telehealth Services - A Systematic Review.

The objective of the study is to identify challenges and associated factors for privacy and security related to telehealth visits during the COVID-19 pandemic. The systematic search strategy used the databases of PubMed, ScienceDirect, ProQuest, Embase, CINAHL, and COCHRANE, with the search terms of telehealth/telemedicine, privacy, security, and confidentiality. Reviews included peer-reviewed empirical studies conducted from January 2020 to February 2022. Studies conducted outside of the US, non-empirical, and non-telehealth related were excluded. Eighteen studies were included in the final analysis. Three risk factors associated with privacy and security in telehealth practice included: environmental factors (lack of private space for vulnerable populations, difficulty sharing sensitive health information remotely), technology factors (data security issues, limited access to the internet, and technology), and operational factors (reimbursement, payer denials, technology accessibility, training, and education). Findings from this study can assist governments, policymakers, and healthcare organizations in developing best practices in telehealth privacy and security strategies.

Aged Residential Care Health Utilisation Study (ARCHUS): a randomised controlled trial to reduce acute hospitalisations from residential aged care.

BACKGROUND: For residents of long term care, hospitalisations can cause distress and disruption, and often result in further medical complications. Multi-disciplinary team interventions have been shown to improve the health of Residential Aged Care (RAC) residents, decreasing the need for acute hospitalisation, yet there are few randomised controlled trials of these complex interventions. This paper describes a randomised controlled trial of a structured multi-disciplinary team and gerontology nurse specialist (GNS) intervention aiming to reduce residents' avoidable hospitalisations. METHODS/DESIGN: This Aged Residential Care Healthcare Utilisation Study (ARCHUS) is a cluster- randomised controlled trial (n = 1700 residents) of a complex multi-disciplinary team intervention in long-term care facilities. Eligible facilities certified for residential care were selected from those identified as at moderate or higher risk of resident potentially avoidable hospitalisations by statistical modelling. The facilities were all located in the Auckland region, New Zealand and were stratified by District Health Board (DHB). INTERVENTION: The intervention provided a structured GNS intervention including a baseline facility needs assessment, quality indicator benchmarking, a staff education programme and care coordination. Alongside this, three multi-disciplinary team (MDT) meetings were held involving a geriatrician, facility GP, pharmacist, GNS and senior nursing staff. OUTCOMES: Hospitalisations are recorded from routinely-collected acute admissions during the 9-month intervention period followed by a 5-month follow-up period. ICD diagnosis codes are used in a pre-specified definition of potentially reducible admissions. DISCUSSION: This randomised-controlled trial will evaluate a complex intervention to increase early identification and intervention to improve the health of residents of long term care. The results of this trial are expected in early 2013. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry: ACTRN 12611000187943.

Prescription medication abuse and illegitimate internet-based pharmacies.

Abuse of controlled prescription medications in the United States exceeds that of all illicit drugs combined except marijuana and has grown considerably in the past decade. Although available through traditional channels, controlled prescription medications can also be purchased on the Internet without a prescription. This issue has gained the attention of federal regulators, law enforcement, and the media, but physician awareness of the problem is scarce. This article describes the nature of the problem and its magnitude, discusses the challenges to federal and private efforts to combat illegitimate online pharmacies, and outlines strategies for physicians to recognize and minimize the unwarranted effects of the availability of these medications on the Internet.

Building Best Practices for Telehealth Record Documentation in the COVID-19 Pandemic.

Telehealth services for patient visits have substantially surged during the COVID-19 pandemic. Thus, there is increased importance and demand for high-quality telehealth clinical documentation. However, little is known about how clinical data documentation is collected and the quality of data items included. This study aimed to identify the current state of and gaps in documentation and develop a best practice strategy for telehealth record documentation. Data were collected from January to February 2021 via a self-designed questionnaire for administrators and managers from physicians' offices and mental health facilities, resulting in 76 valid responses. Survey items included health organization demographic information, use of telehealth policies and procedures, and clinical documentation for telehealth patient visits. Findings from this study can be used to assist government, policymakers, and healthcare organizations in developing best practices in telehealth usage and clinical documentation improvement strategies.

Patient clinical documentation in telehealth environment: are we collecting appropriate and sufficient information for best practice?

BACKGROUND: During the COVID-19 pandemic, the use of telehealth for patient visits grew rapidly and served an important role as a valuable and necessary resource. Although clinical documentation is critical for telehealth patient visits, there is limited information about how healthcare facilities manage telehealth patient visit documentation, technology used for telehealth visits, and challenges encountered with telehealth patient visit documentation. This study aimed to assess the use of telehealth during the pandemic, the quality of clinical documentation in telehealth practice and to identify challenges and issues encountered with telehealth patient visits in order to develop a strategy for best practices for telehealth documentation and data management. METHODS: Data were collected for this cross-sectional study in January-February 2021 via a self-designed survey of administrators/managers from physicians' offices and mental health facilities. Survey questions included four categories: health organization demographic information; telehealth visits; clinical documentation for telehealth visit; and challenges and barriers related to telehealth documentation technology use. RESULTS: Of 76 respondents, more than half (62%) of the healthcare facilities started using telehealth for patient visits within one year of the onset of the COVID-19 pandemic, with 94% of respondents indicating an increased use of telehealth for patient visits since the pandemic. The most common types of telehealth patient care provided during the pandemic included pediatrics, primary care, cardiology, and women's health. The most consistent data documentation of telehealth visits included: date of service, patient identification number, communication methods, patient informed consent, diagnosis and impression, evaluation results, and recommendations. The telehealth visit data was most commonly used for patient care and clinical practice, billing and reimbursement, quality improvement and patient satisfaction, and administrative planning. The top barriers to telehealth use by the healthcare professionals included patient challenges with telehealth services, such as inequities in quality of technology, lack of patient understanding, and lack of patient satisfaction; this was followed by frustration with constant updates of telehealth guidelines and procedures, understanding required telehealth documentation for reimbursement purposes, payer denial for telehealth visits, and legal and risk issues. CONCLUSIONS: Findings from this study can assist government entities, policymakers, and healthcare organizations in developing and advocating best practices in telehealth usage and clinical documentation improvement strategies.

The role of developmental plasticity in evolutionary innovation.

Explaining the origins of novel traits is central to evolutionary biology. Longstanding theory suggests that developmental plasticity, the ability of an individual to modify its development in response to environmental conditions, might facilitate the evolution of novel traits. Yet whether and how such developmental flexibility promotes innovations that persist over evolutionary time remains unclear. Here, we examine three distinct ways by which developmental plasticity can promote evolutionary innovation. First, we show how the process of genetic accommodation provides a feasible and possibly common avenue by which environmentally induced phenotypes can become subject to heritable modification. Second, we posit that the developmental underpinnings of plasticity increase the degrees of freedom by which environmental and genetic factors influence ontogeny, thereby diversifying targets for evolutionary processes to act on and increasing opportunities for the construction of novel, functional and potentially adaptive phenotypes. Finally, we examine the developmental genetic architectures of environment-dependent trait expression, and highlight their specific implications for the evolutionary origin of novel traits. We critically review the empirical evidence supporting each of these processes, and propose future experiments and tests that would further illuminate the interplay between environmental factors, condition-dependent development, and the initiation and elaboration of novel phenotypes.

Residential aged care in Auckland, New Zealand 1988-2008: do real trends over time match predictions?

BACKGROUND: in Auckland, New Zealand in 1988, 7.7% of those aged over 65 years lived in licenced residential aged care. Age-specific rates approximately doubled for each 5-year age group after the age of 65 years. Even with changes in policies and market forces since 1988, population increases are forecast to drive large growth in demand. This study shows previously unrecognised 20-year trends in rates of care in a geographically defined population. METHODS: four cross-sectional surveys of all facilities (rest homes and hospitals) licenced for long-term care of older people were conducted in Auckland, New Zealand in 1988, 1993, 1998 and 2008. Facility staff completed survey forms for each resident. Numbers of licenced and occupied beds and trends in age-specific and age-standardised rates in residential aged care are reported. RESULTS: over the 20-year period, Auckland's population aged over 65 years increased by 43% (from 91,000 to 130,000) but actual numbers in care reduced slightly. Among those aged over 65 years, the proportion living in care facilities reduced from 1 in 13 to 1 in 18. Age-standardised rates in rest-home level care reduced from 65 to 33 per thousand, and in hospital level care, from 29 to 23 per thousand. Had rates remained stable, over 13,200 people, 74% more than observed, would have been in care in 2008. CONCLUSION: growth predicted in the residential aged care sector is not yet evident. The introduction of standardised needs assessments before entry, increased availability of home-based services, and growth in retirement villages may have led to reduced utilisation.

Higher Visual Function Deficits in Children With Cerebral Visual Impairment and Good Visual Acuity.

In clinical practice Cerebral Visual Impairment (CVI) is typically diagnosed by observation of abnormal visually guided behaviors which indicate higher visual function deficits (HVFDs) suggesting abnormal brain development or brain damage in a child with a suitable clinical history. HVFDs can occur even in the presence of good visual acuity and may remain undiagnosed because the good visual acuity does not prompt further investigation. This leads to a lack of understanding of the child's visual perceptual difficulties. In a prospective study, we determined the spectrum of HVFDs in a group of children with history suggestive of brain damage or disruption of brain development and an independent diagnosis of CVI in comparison with typically developing children with a structured 51 question inventory, the Higher Visual Function Question Inventory (HVFQI-51) adapted from the Cerebral Vision Impairment Inventory, CVI-I. Here, we show that the HVFQI-51 can detect a range of HVFDs in children with CVI with good visual acuity and clearly distinguishes these children from typically developing children. HVFDs in our study group could mostly be attributed to dorsal stream visual processing dysfunction though the spectrum varied between children. We report on the inclusion of the "not applicable" response option in analysis providing a picture of HVFDs more in tune with the overall disability of each child. We also propose a subset of 11 questions (Top-11) which discriminate between children with CVI vs. behaviors seen in typical children: this provides both a potential screening tool for initial assessment of HVFDs and a measure of CVI-related impairment, and needs further validation in a secondary independent sample.