Vision characteristics of Special Olympics athletes seen at the United States National Games 2010-2018.

BACKGROUND: Special Olympics International (SOI) has provided eye assessments at no cost to athletes participating in competitions through the Special Olympics Lions Clubs International Foundation Opening Eyes (OE) programme. Access to vision services is crucial given the high rates of eye abnormalities found in studies collected at OE programmes in other countries. As of 2022, no studies covering vision data have been published on SOI athletes specifically from the USA. Therefore, this multiple cross-sectional study hopes to investigate the vision profile of US athletes over three national games, detecting any changes in vision and ocular health outcomes over an 8-year period. METHODS: Vision assessments were conducted in the US national games of 2010, 2014 and 2018. Demographic and clinical data from 1427 vision assessments were used in this study. Prevalence of vision and ocular health abnormalities were compared across national games. RESULTS: In our cohort of 1427 assessments with athletes' mean age ± SD of 29.8 ± 11.5 years, 85.3% (n = 1170) had an abnormal vision result with at least one of the following findings: decreased visual acuity of 20/40 or worse (31.0%, n = 442), refractive error including myopia (52.8%, n = 754), hypermetropia (15.7%, n = 224), and astigmatism (35.0%, n = 499), ocular misalignment distant (16.2%, n = 224) or near (17.2%, n = 239), or ocular abnormality (19.1%, n = 273). CONCLUSIONS: This study demonstrates the burden of vision defects and ocular disease in US SOI athletes over the past decade. While continued effort must be made to train eye providers in caring for patients with ID to increase eyecare accessibility outside of SOI, vision assessments at national games can continue providing opportunities for improved ocular health in children and adults with ID.

Local policy proposals can bridge Latino and (most) white Americans' response to immigration.

In the past 15 years, the adoption of subnational immigration policies in the United States, such as those established by individual states, has gone from nearly zero to over 300 per year. These include welcoming policies aimed at attracting and incorporating immigrants, as well as unwelcoming policies directed at denying immigrants access to public resources and services. Using data from a 2016 random digit-dialing telephone survey with an embedded experiment, we examine whether institutional support for policies that are either welcoming or hostile toward immigrants differentially shape Latinos' and whites' feelings of belonging in their state (Arizona/New Mexico, adjacent states with contrasting immigration policies). We randomly assigned individuals from the representative sample (n = 1,903) of Latinos (US and foreign born) and whites (all US born) to consider policies that were either welcoming of or hostile toward immigrants. Across both states of residence, Latinos, especially those foreign born, regardless of citizenship, expressed more positive affect and greater belonging when primed with a welcoming (vs. hostile) policy. Demonstrating the importance of local norms, these patterns held among US-born whites, except among self-identified politically conservative whites, who showed more negative affect and lower levels of belonging in response to welcoming policies. Thus, welcoming immigration policies, supported by institutional authorities, can create a sense of belonging not only among newcomers that is vital to successful integration but also among a large segment of the population that is not a direct beneficiary of such policies-US-born whites.

Sexual function, self-esteem, and general well-being in Chinese adult survivors of childhood cancers: a cross-sectional survey.

INTRODUCTION: This study was conducted to evaluate sexual function in adult survivors of childhood cancers and investigate possible relationships between sexual function and quality of life, as measured by general well-being, self-esteem, body image, and depressive symptoms. METHODS: This cross-sectional survey was performed in our centre from 14 August 2015 to 8 September 2017. Adult patients who had a history of childhood cancers, and who were disease-free for >3 years, were approached for the study during clinical follow-up. Clinical information was collected from medical records. Self-administered questionnaires regarding quality of life and sexual functioning were given to the patients and resulting data were analysed. RESULTS: Two hundred patients agreed to participate in the study. The overall response rate was 64.8%. Ninety-one (45.5%) patients were women, and the mean age was 25.4 ± 5.57 years. The overall sexual functioning score was 28.3 ± 20.09. Forty-eight (24.0%) patients reported at least one sexual problem. Among patients who reported no sexual problems, more had haematological cancers (P=0.009), fewer underwent surgery (P=0.004), fewer underwent surgery with external effects (P=0.032), and fewer were regular social drinkers (P=0.013); additionally, they had a higher mean Rosenberg self-esteem scale score (P=0.010), lower mean body image scale score (P=0.008), and lower mean Patient Health Questionnaire score (P=0.001). CONCLUSION: Aspects of life beyond disease condition and physical function should be considered in adult survivors of childhood cancers. Appropriate referral and intervention should be initiated for these patients when necessary.

Cell-bound complement activation products (CB-CAPs) have high sensitivity and specificity in pediatric-onset systemic lupus erythematosus and correlate with disease activity.

OBJECTIVE: Elevated levels of cell-bound complement activation products (CB-CAPs) (C4d deposition on B lymphocytes (BC4d) and/or erythrocytes (EC4d)) are sensitive and specific in diagnosis and monitoring of adult systemic lupus erythematosus (SLE). Our objective was to evaluate the role of CB-CAPs for diagnosis and monitoring of pediatric-onset SLE (pSLE). METHODS: A prospective cohort study of 28 pSLE and 22 juvenile arthritis patients was conducted. SLE disease activity was determined using a clinical Systemic Lupus Erythematosus Disease Activity Index (SLEDAI) that excluded serologies. Autoantibodies were measured using solid-phase immunoassays, C3 and C4 using immunoturbidimetry, and CB-CAPs using quantitative flow cytometry. Abnormal CB-CAPs were defined as EC4d or BC4d above the 99th percentile for healthy adults (>14 and > 60 net mean fluorescence intensity (MFI), respectively). Performance characteristics of CB-CAPs were assessed using area under the curve (AUC) for receiver operating characteristics. Linear mixed effect models evaluated the correlation between CB-CAPs and clinical SLEDAI over 6 months. RESULTS: BC4d yielded higher AUC (0.91 ± 0.04) than C3 (0.63 ± 0.08) and C4 (0.67 ± 0.08) ( p < 0.05). Abnormal CB-CAPs were 78% sensitive and 86% specific for diagnosis of pSLE (Youden's index = 0.64 ± 0.11). In contrast to BC4d, EC4d levels correlated with clinical SLEDAI ( p < 0.01). CONCLUSION: CB-CAPs (EC4d and BC4d) have higher sensitivity and specificity than low complement in pSLE, and may help with diagnosis of pSLE. EC4d could provide a useful biomarker for disease activity monitoring.

Randomized clinical trial of hepatic resection versus radiofrequency ablation for early-stage hepatocellular carcinoma.

BACKGROUND: Hepatic resection and radiofrequency ablation (RFA) are treatment options for early-stage hepatocellular carcinoma (HCC). Whether tumour recurrence and long-term survival favour either treatment has not been established. This randomized trial aimed to test the hypothesis that RFA is superior to hepatic resection in terms of lower tumour recurrence rate and better long-term survival. METHODS: Patients with early-stage HCC (solitary tumour no larger than 5 cm; or no more than 3 tumours, each 3 cm or smaller) were randomized into hepatic resection and RFA groups. Demographic and clinical characteristics, and short- and long-term outcome measures were compared between groups. Primary and secondary outcome measures were overall tumour recurrence and survival respectively. RESULTS: Clinicopathological data were similar in the two groups, which each contained 109 patients. The RFA group had a shorter treatment duration, less blood loss and shorter hospital stay than the resection group. Mortality and morbidity rates were similar in the two groups. The overall tumour recurrence rate was similar in the resection and RFA groups (71·3 versus 81·7 per cent respectively). The 1-, 3-, 5- and 10-year overall survival rates were 94·5, 80·6, 66·5 and 47·6 per cent respectively in the resection group, compared with 95·4, 82·3, 66·4 and 41·8 per cent in the RFA group (P = 0·531). Corresponding disease-free survival rates were 74·1, 50·9, 41·5 and 31·9 per cent in the resection group, and 70·6, 46·6, 33·6 and 18·6 per cent in the RFA group (P = 0·072). CONCLUSION: RFA for early-stage HCC is not superior to hepatic resection, in terms of tumour recurrence, overall survival and disease-free survival. Registration number: HKUCTR-10 (http://www.hkuctr.com).

Epidemiology: Past, Present, and Future Impacts on Understanding Disease Dynamics and Improving Plant Disease Management-A Summary of Focus Issue Articles.

Epidemiology has made significant contributions to plant pathology by elucidating the general principles underlying the development of disease epidemics. This has resulted in a greatly improved theoretical and empirical understanding of the dynamics of disease epidemics in time and space, predictions of disease outbreaks or the need for disease control in real-time basis, and tactical and strategic solutions to disease problems. Availability of high-resolution experimental data at multiple temporal and spatial scales has now provided a platform to test and validate theories on the spread of diseases at a wide range of spatial scales ranging from the local to the landscape level. Relatively new approaches in plant disease epidemiology, ranging from network to information theory, coupled with the availability of large-scale datasets and the rapid development of computer technology, are leading to revolutionary thinking about epidemics that can result in considerable improvement of strategic and tactical decision making in the control and management of plant diseases. Methods that were previously restricted to topics such as population biology or evolution are now being employed in epidemiology to enable a better understanding of the forces that drive the development of plant disease epidemics in space and time. This Focus Issue of Phytopathology features research articles that address broad themes in epidemiology including social and political consequences of disease epidemics, decision theory and support, pathogen dispersal and disease spread, disease assessment and pathogen biology and disease resistance. It is important to emphasize that these articles are just a sample of the types of research projects that are relevant to epidemiology. Below, we provide a succinct summary of the articles that are published in this Focus Issue .

A Risk Assessment Framework for Seed Degeneration: Informing an Integrated Seed Health Strategy for Vegetatively Propagated Crops.

Pathogen buildup in vegetative planting material, termed seed degeneration, is a major problem in many low-income countries. When smallholder farmers use seed produced on-farm or acquired outside certified programs, it is often infected. We introduce a risk assessment framework for seed degeneration, evaluating the relative performance of individual and combined components of an integrated seed health strategy. The frequency distribution of management performance outcomes was evaluated for models incorporating biological and environmental heterogeneity, with the following results. (1) On-farm seed selection can perform as well as certified seed, if the rate of success in selecting healthy plants for seed production is high; (2) when choosing among within-season management strategies, external inoculum can determine the relative usefulness of 'incidence-altering management' (affecting the proportion of diseased plants/seeds) and 'rate-altering management' (affecting the rate of disease transmission in the field); (3) under severe disease scenarios, where it is difficult to implement management components at high levels of effectiveness, combining management components can be synergistic and keep seed degeneration below a threshold; (4) combining management components can also close the yield gap between average and worst-case scenarios. We also illustrate the potential for expert elicitation to provide parameter estimates when empirical data are unavailable. [Formula: see text] Copyright © 2017 The Author(s). This is an open access article distributed under the CC BY-NC-ND 4.0 International license .

A White Paper on Global Wheat Health Based on Scenario Development and Analysis.

Scenario analysis constitutes a useful approach to synthesize knowledge and derive hypotheses in the case of complex systems that are documented with mainly qualitative or very diverse information. In this article, a framework for scenario analysis is designed and then, applied to global wheat health within a timeframe from today to 2050. Scenario analysis entails the choice of settings, the definition of scenarios of change, and the analysis of outcomes of these scenarios in the chosen settings. Three idealized agrosystems, representing a large fraction of the global diversity of wheat-based agrosystems, are considered, which represent the settings of the analysis. Several components of global changes are considered in their consequences on global wheat health: climate change and climate variability, nitrogen fertilizer use, tillage, crop rotation, pesticide use, and the deployment of host plant resistances. Each idealized agrosystem is associated with a scenario of change that considers first, a production situation and its dynamics, and second, the impacts of the evolving production situation on the evolution of crop health. Crop health is represented by six functional groups of wheat pathogens: the pathogens associated with Fusarium head blight; biotrophic fungi, Septoria-like fungi, necrotrophic fungi, soilborne pathogens, and insect-transmitted viruses. The analysis of scenario outcomes is conducted along a risk-analytical pattern, which involves risk probabilities represented by categorized probability levels of disease epidemics, and risk magnitudes represented by categorized levels of crop losses resulting from these levels of epidemics within each production situation. The results from this scenario analysis suggest an overall increase of risk probabilities and magnitudes in the three idealized agrosystems. Changes in risk probability or magnitude however vary with the agrosystem and the functional groups of pathogens. We discuss the effects of global changes on the six functional groups, in terms of their epidemiology and of the crop losses they cause. Scenario analysis enables qualitative analysis of complex systems, such as plant pathosystems that are evolving in response to global changes, including climate change and technology shifts. It also provides a useful framework for quantitative simulation modeling analysis for plant disease epidemiology.

Do men and women with intellectual disabilities understand death?

BACKGROUND: Individuals with ID are often withheld information about the death of their loved ones as it has often been thought that they do not understand death or cannot grieve. This grief exacerbates the stress of individuals with ID as they often encounter secondary losses such as transitioning to a care facility. The aim of this study is to investigate men and women with ID understanding death concepts and to what extent. METHOD: Adopting a stratified random sampling method, 156 Chinese people with ID were invited to join the study. One hundred and ten participants were interviewed using simple death related vignettes expanding upon and replicating a published study carried out in Ireland. The understanding of the five death concepts: causality, irreversibility, nonfunctionality, universality and inevitability was examined. The correlates of demographics, bereavement experiences and comprehension were explored. RESULTS: The majority of the participants did understand concepts such as death is irreversible and that the deceased no longer function. One third of the participants understood causality and the universality of death. One fifth understood the inevitability of death. Previous bereavement experiences were correlated with higher understanding. Communication and community skills were correlated with all concepts of death except universality. CONCLUSION: The results indicate that individuals with ID do have a partial to full understanding of the concepts of death. The culture of Hong Kong is one that considers death to be a taboo or unlucky subject. Therefore, the results mirror the the lack of understanding of universality and inevitability concepts as it is forbidden to speak of these concepts. An open and honest environment is encouraged to educate individuals with ID about death and bereavement.

Targeted B cell therapies in the treatment of adult and pediatric systemic lupus erythematosus.

Belimumab (Benlysta) is a fully-humanized monoclonal antibody that inhibits B-lymphocyte stimulator (also known as B cell activating factor) and was approved by the U.S. Federal Drug Administration and European Medicines Evaluation Agency for treatment in adults with autoantibody-positive systemic lupus erythematosus (SLE). Rituximab (Rituxan) is a chimeric anti-CD20 monoclonal antibody targeting B lymphocytes. This review discusses the key findings of the phase III trials in adults with SLE and of real-world use of belimumab and rituximab in the care of both adult and pediatric SLE patients. It highlights the safety profile of belimumab and rituximab and gives insight into the consideration of these therapies for specific SLE disease states. It concludes with a discussion of the current clinical trials investigating B cell therapies in specific SLE disease states and a look to the future, with ongoing clinical trials.

Sex differences in genomics in lupus: girls with systemic lupus have high interferon gene expression while boys have high levels of tumour necrosis factor-related gene expression.

OBJECTIVES: Systemic lupus erythematosus (SLE) is a chronic disease occurring up to 15 times more frequently in females than males. This bias extends to possible differences in disease flares and response to therapy. This study was initiated to investigate the differences between girls and boys with childhood-onset SLE (cSLE) at the molecular level. METHOD: We analysed the Gene Expression Omnibus National Center for Biotechnology Information (GEO NCBI) microarray data available for 88 girls and 16 boys with treatment-naïve cSLE and compared the results to those from healthy controls. Transcriptional profiles were generated using the platforms of Affymetrix U133A and U133B gene chips and Bioconductor/R programming packages were used to process and compare the data. RESULTS: Girls with cSLE overexpressed an interferon (IFN)-α signature that was absent in boys. Boys with cSLE were observed to overexpress tumour necrosis factor-related genes that were absent in girls. Both boys and girls were observed to overexpress several genes related to granulopoeisis. CONCLUSIONS: Our results suggest a potential application of genomics to differentially predict response to therapy between females and males with SLE.

Patient experience survey in telemedicine for spinal cord injury patients.

STUDY DESIGN: Patient feedback study. OBJECTIVES: To measure how patients value the telemedicine consultation service at the National Spinal Injuries Centre over a period of 8 months. SETTING: United Kingdom (south of England). METHODS: Telephone survey conducted by an external surveyor who does not work in the department. RESULTS: Our study showed that most patients (n=29) found the service of high quality and useful to their care. CONCLUSION: This provides evidence, from the spinal cord injury patients' perspective, that telemedicine service has an important role in their management.

Sleep duration, C-reactive protein and risk of incident coronary heart disease--results from the Framingham Offspring Study.

BACKGROUND: Both sleep-duration and C-reactive protein (CRP) are useful predictors of coronary heart disease (CHD). The increased CRP level is associated with the unusual sleep-duration. However, it is unclear whether CRP impacts the CHD risk prediction of sleep-duration. METHODS AND RESULTS: A total of 3381 individuals from the Framingham Offspring Study, aged 30+, CHD-free, and without missing measurement of CRP and sleep-duration and being followed to the end of 2007 were included in this analysis. Hazards ratio (HR) from the Cox regression models was used to evaluate the strength of association between the sleep-duration, CRP levels, and risk of incident CHD. Compared to sleep-duration 7-8 h (n = 2512) after adjusting for age and gender, the HR (95% CL) of incident CHD were 1.42 (1.15, 1.76, p < 0.005) for sleep-duration ≤6 h (n = 588) and 1.23 (0.90, 1.70, p < 0.2) for sleep-duration ≥9 h (n = 281), respectively. A further adjustment for other covariates including CRP did not change the CHD risk association. When subjects were categorized into 9 groups by sleep-duration (≤6, 7-8, and ≥9 h) and CRP levels (<1, 1-3, and ≥3 mg/L), and compared to those whose sleep-duration was 7-8 h and CRP levels were <1 mg/L, the HRs of CHD were similar for sleep-duration in ≤6 h or ≥9 h categories regardless of their CRP levels. The increased CRP levels, however, did show an increased risk for CHD when sleep-duration was 7-8 h CONCLUSION: The levels of CRP do not significantly attenuate the association between sleep duration and incident CHD.

Integration policies shape ethnic-racial majorities' threat reactions to increasing diversity.

Increasing ethnic and racial diversity often fuels feelings of threat among ethnic-racial majorities (e.g., self-identified white Americans and European nationals). We contend that these threat perceptions depend on the policy context. Across four studies, we test whether more inclusive immigrant integration policies attenuate ethnic-racial majorities' threat reactions. Studies 1 to 3 (n = 469, 733, and 1745, respectively) used experimental methods with white American participants in the United States. Study 4 (n = 499,075) used secondary analysis of survey data comparing attitudes of nationals in 30 European countries and measured the impact of actual changes in diversity and policies over 10 years. Our results show that integration policies shape threat reactions even in those situations when increasing diversity could be seen as the most threatening: when narratives highlight the majority's impending minority position or when diversity suddenly increases. When policies are more inclusive toward immigrants, ethnic-racial majority participants report less threat (or no threat) in response to increasing diversity.

Dendritic cells: cellular mediators for immunological tolerance.

In general, immunological tolerance is acquired upon treatment with non-specific immunosuppressive drugs. This indiscriminate immunosuppression of the patient often causes serious side-effects, such as opportunistic infectious diseases. Therefore, the need for antigen-specific modulation of pathogenic immune responses is of crucial importance in the treatment of inflammatory diseases. In this perspective, dendritic cells (DCs) can have an important immune-regulatory function, besides their notorious antigen-presenting capacity. DCs appear to be essential for both central and peripheral tolerance. In the thymus, DCs are involved in clonal deletion of autoreactive immature T cells by presenting self-antigens. Additionally, tolerance is achieved by their interactions with T cells in the periphery and subsequent induction of T cell anergy, T cell deletion, and induction of regulatory T cells (Treg). Various studies have described, modulation of DC characteristics with the purpose to induce antigen-specific tolerance in autoimmune diseases, graft-versus-host-disease (GVHD), and transplantations. Promising results in animal models have prompted researchers to initiate first-in-men clinical trials. The purpose of current review is to provide an overview of the role of DCs in the immunopathogenesis of autoimmunity, as well as recent concepts of dendritic cell-based therapeutic opportunities in autoimmune diseases.

Rust Fungi Forming Aecia on Berberis spp. in Sweden.

Barberry (Berberis spp.) hosts the aecial stage of several rust species, including Puccinia graminis, which causes stem rust on grasses and cereals. The aecial stage of this pathogen has received less attention because it is not as economically important compared with the uredinial and telial stages. The main objective of this study was to identify and describe the rust species that were found on Berberis spp. collected in different parts of Sweden. A morphological study, including spore measurements and aecia descriptions, was conducted, as well as DNA sequence analyses (using the internal transcribed spacer region and the EF1-α gene). Based on spore and aecia morphology as well as the genetic analyses, three different taxa could be distinguished on barberry: P. graminis f. sp. avenae, P. graminis f. sp. tritci/secalis, and P. arrhenatheri. The genetic analysis revealed little or no differentiation between P. graminis f. sp. tritici and P. graminis f. sp. secalis and, thus, this group of samples was denominated P. graminis f. sp. tritici/secalis. Aecial morphology may be used to differentiate between different taxa. In particular, examination of aecial cross-sections may be used to distinguish between P. graminis f. sp. avenae and P. graminis f. sp. tritici/secalis. A clear differentiation in the mode of growth on barberry was also found; P. arrhenatheri always appeared systemic whereas P. graminis always appeared localized.

First Report of a Leaf Spot Disease of Golden Dewdrop (Duranta erecta) Caused by Pseudomonas cichorii and a Xanthomonas Species in Florida.

Duranta erecta (Verbenaceae) is used extensively in southern states as an ornamental shrub and has replaced boxwood as the most common short hedge accenting flower beds. Over the past 2 years, during warm wet periods, dark necrotic leaf spots have been observed on golden dewdrop plants in Florida. Isolations from these spots on Difco nutrient agar (NA) consistently yielded two types of bacterial colonies that were not always simultaneously present: 1) round butyrous, bright yellow and 2) flat cream-colored. Both were 2 mm in size after 48 h, gram-negative, and produced a hypersensitivity reaction (HR) on tobacco cv Hicks. Yellow colony bacteria were oxidase negative and non-fluorescent on King's medium B (KMB) (1). Cream-colored colony bacteria were oxidase positive and fluorescent on KMB. Three isolates of both types were selected for further study. Partial 16S rDNA sequencing and fatty acid analysis (FAME) MIDI Microbial Identification System (Microbial ID, Inc., Newark, DE) were used for identification of strains. The 16S rDNA primers used were; forward primer AMB14 5'-TCCAGCAATGCCGCGTGTGT-3' and reverse primer AMB13 5'-CATCCACCGCTTGTGCGGGT-3'. The PCR program consisted of an initial denaturing cycle of 95°C for 2 min followed by 30 cycles of denaturing at 95°C for 30 s, annealing at 60°C for 40 s and extension at 72°C for 1 min and one final extension at 72°C for 10 min. Using FAME analysis, the three strains of the cream-colored colony type were identified as Pseudomonas cichorii with high similarity values (0.907, 0.961, 0.819) and this corresponded well with the 16S rDNA sequences where 99% sequence identity was observed with P. cichorii strain JBC1 16S ribosomal RNA gene, partial sequence GenBank Accession No. JF951725. Two of the three yellow colony strains were identified by MIDI FAME profiles as Xanthomonas axonopodis pv. manihotis with similarity coefficients of 0.767 and 0.826. The third strain had a low similarity match to X. a. pv. carotae (0.541). The 16S rDNA sequencing of these strains showed 98% sequence identity to X. citri subsp. citri strain SA1 16S ribosomal RNA gene only, partial sequence identity JQ890091.1, thus indicating a possible undescribed X. axonopodis pathovar. To satisfy Koch's postulates, three golden dewdrop 'Golden Mound' plants were sprayed with a suspension of 108 CFU/ml of a 2-day NA culture of each strain, bagged for 24 h to raise humidity, and placed in a greenhouse. A strain of P. cichorii (P409) isolated from chrysanthemum was used as a positive control when comparing cream-colored strains. A saline buffered control was used as a negative control. Within 3 weeks, leaf spots developed on plants sprayed with each of the six strains, including positive control strain of P. cichorii. Reisolations yielded the same type of colony as the originally inoculated strain. Inoculation experiments were repeated three times with a minimum of three plants per isolate with similar results. To our knowledge, this is the first report in the United States of bacterial leaf spot caused by P. cichorii and X. axonopodis on golden dewdrop. An earlier morphological and physiological description of a Xanthomonas sp. was done on Duranta in India in 1962 (2). Due to the difficulty in controlling bacterial diseases and the popularity of Duranta spp. in the landscape, these diseases may present a problem in ornamental trade. References: (1) E. O. King et al. J. Lab. Clin. Med. 44:301, 1954. (2) M. C. Srinivasan et al. Proc. Indian Acad. Sci. 56:88, 1962.

Hospital Careful Hand Feeding Program Reduced Feeding Tube Use in Patients with Advanced Dementia.

OBJECTIVES: Tube feeding is prevalent among patients with advanced dementia despite empirical data that suggest its lack of benefit. To provide an alternative to tube feeding for end-of-life patients, a careful hand feeding program was launched in a Hong Kong geriatric convalescent hospital in February 2017. We aim to compare the rates of feeding tube insertion before and after program implementation and determine risk factors for feeding tube insertion. For patients on careful hand feeding, we evaluated their sustainability on oral feeding and the rates of hospital readmissions compared with tube feeding patients over the next 12 months. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Advanced dementia patients ≥60 years with indication for tube feeding due to feeding problems admitted from January 2015-June 2019. METHODS: Data was collected on demographic and clinical variables, initial feeding mode (careful hand feeding vs. tube feeding), subsequent feeding mode changes, and hospital admissions over the next 12 months. Rates of feeding tube insertion, sustainability on oral feeding, and hospital readmissions were compared using Chi-square test. Risk factors for feeding tube insertion were assessed using logistic regression models. RESULTS: Among 616 advanced dementia patients admitted with feeding problems, feeding tube insertion rate declined significantly after careful hand feeding program implementation (72% vs 51% p<.001). Independent risk factors for feeding tube insertion were admission prior to program implementation, presence of dysphagia alone, dysphagia combined with poor intake, and lack of advance care planning. Among patients on careful hand feeding, 91% were sustained on oral feeding over the next twelve months and did not differ significantly before or after careful hand feeding program implementation (p=.67). There was no significant difference in hospital readmission rates between careful hand feeding patients and tube feeding patients before (83% vs 86%, p=.55) and after careful hand feeding program implementation (87% vs 85%, p=.63). CONCLUSIONS AND IMPLICATIONS: A hospital careful hand feeding program significantly reduced the feeding tube insertion rate among advanced dementia patients with feeding problems. The vast majority of patients on careful hand feeding were sustained on oral feeding over the next 12 months but their rate of hospital readmissions remained similarly high after program implementation.