Type 1 diabetes in Africa: an immunogenetic study in the Amhara of North-West Ethiopia.

AIMS/HYPOTHESIS: We aimed to characterise the immunogenic background of insulin-dependent diabetes in a resource-poor rural African community. The study was initiated because reports of low autoantibody prevalence and phenotypic differences from European-origin cases with type 1 diabetes have raised doubts as to the role of autoimmunity in this and similar populations. METHODS: A study of consecutive, unselected cases of recently diagnosed, insulin-dependent diabetes (n = 236, ≤35 years) and control participants (n = 200) was carried out in the ethnic Amhara of rural North-West Ethiopia. We assessed their demographic and socioeconomic characteristics, and measured non-fasting C-peptide, diabetes-associated autoantibodies and HLA-DRB1 alleles. Leveraging genome-wide genotyping, we performed both a principal component analysis and, given the relatively modest sample size, a provisional genome-wide association study. Type 1 diabetes genetic risk scores were calculated to compare their genetic background with known European type 1 diabetes determinants. RESULTS: Patients presented with stunted growth and low BMI, and were insulin sensitive; only 15.3% had diabetes onset at ≤15 years. C-peptide levels were low but not absent. With clinical diabetes onset at ≤15, 16-25 and 26-35 years, 86.1%, 59.7% and 50.0% were autoantibody positive, respectively. Most had autoantibodies to GAD (GADA) as a single antibody; the prevalence of positivity for autoantibodies to IA-2 (IA-2A) and ZnT8 (ZnT8A) was low in all age groups. Principal component analysis showed that the Amhara genomes were distinct from modern European and other African genomes. HLA-DRB1*03:01 (p = 0.0014) and HLA-DRB1*04 (p = 0.0001) were positively associated with this form of diabetes, while HLA-DRB1*15 was protective (p < 0.0001). The mean type 1 diabetes genetic risk score (derived from European data) was higher in patients than control participants (p = 1.60 × 10-7). Interestingly, despite the modest sample size, autoantibody-positive patients revealed evidence of association with SNPs in the well-characterised MHC region, already known to explain half of type 1 diabetes heritability in Europeans. CONCLUSIONS/INTERPRETATION: The majority of patients with insulin-dependent diabetes in rural North-West Ethiopia have the immunogenetic characteristics of autoimmune type 1 diabetes. Phenotypic differences between type 1 diabetes in rural North-West Ethiopia and the industrialised world remain unexplained.

Outcomes from a Randomized Controlled Trial of the Relief Nursery Program.

An independent, randomized controlled trial of the community-developed, multiple-component Relief Nursery prevention program was conducted with families with young children considered "at risk" for child abuse and neglect. This established program, currently operating at multiple sites in the state of Oregon, comprises an integrated package of prevention services to children and families, including early childhood education, home visiting, and parent education and support, as well as other interventions tailored to the needs of each particular family. Families who contacted the Relief Nursery for the first time were randomly assigned to one of two conditions, the Full Program condition, whose members had access to all services available from the Relief Nursery, or the Respite Care condition, whose members had access only to respite care and referrals to services provided by other community agencies. A primary caregiver in each family was interviewed prior to intervention and then every 6 months across a period of 2 years. Standardized measures were collected on a variety of risk and protective factors related to child abuse and neglect. Analyses were conducted at the end of the study period. Differences were found between the conditions in terms of perceived helpfulness and satisfaction with services and in terms of social support, in each case favoring the Full Program condition. Implications of the findings for future studies of multicomponent child abuse prevention programs with similar characteristics to the Relief Nursery are discussed.

Functional performance in older adults with hearing loss: Application of the International Classification of Functioning brief core set for hearing loss: A pilot study.

OBJECTIVES: The beta version of the International Classification of Functioning, Disability, and Health (ICF) brief core set for hearing loss in adults was developed and recommended to be validated through the audiologic rehabilitation clinical practice. The aims of this pilot study were to validate the ICF brief core set by examining the dimensions of hearing performance measures used in a standard care university clinic specializing in amplification, and seeing if those dimensions support the structure provided by the core set. DESIGN: ICF linking, classification, and qualifier coding procedures were applied on a data set identified from clinical records and two paper-pencil questionnaires; and completed by consensus of two experienced audiologists. STUDY SAMPLE: Forty-nine participants were recruited from an out-patient population at an audiology clinic. RESULTS: Eighteen of 27 items from the brief core set were able to be linked and validated. Four factors were identified, and confirmed the structure of ICF concept: Auditory function, Other functions, Activities/contextual interaction, and Third-party disability. Further, three predictors significantly discriminated performance in 28 participants: the use of hearing assistive devices, speech-reading, and active social life. CONCLUSIONS: The ICF brief core set is a valuable tool for use in audiologic rehabilitation clinical practice and research design.

Speech based optimization of cochlear implants.

OBJECTIVE: This study describes an innovative method to optimize cochlear implant (CI) devices for individual patients using speech stimuli. DESIGN: Baseline performance of clinically created CI settings was evaluated objectively (CNC and BKB-SIN) and subjectively (listening situation questionnaire). Participants underwent the Clarujust optimization procedure during two sessions, each two weeks apart, allowing for acclimatization and experience with each group of programs. Outcome testing was completed on both optimization settings during the two week follow-up session. CNC and BKB-SIN scores were compared within participants across test sessions. STUDY SAMPLE: Twenty adult experienced CI users were reprogrammed using the Clarujust™ fitting procedure. RESULTS: Significant improvements (p < 0.05) on CNC words and BKB-SIN sentences were observed with optimized maps compared to maps programmed using standard methods. Subjective performance also showed increased satisfaction with the optimized maps. The maps for individual users varied significantly and no single fitting applied for all patients. CONCLUSIONS: The Clarujust optimization method of programming CIs shows promise to improve patient performance and increase patient satisfaction in a shorter clinical test time.

The effect of a hearing conservation program on adolescents' attitudes towards noise.

Crandell et al., reported that education programs such as hearing conservation programs (HCPs) represent the most common and well-recognized procedure in reducing the incidence of noise-induced hearing loss (NIHL). The purpose of this study was to assess the effectiveness of an HCP in changing knowledge and attitudes toward exposures to high intensity sounds or noise among adolescents aged 12-14 years. Local middle school students in physical education classes were recruited for participation. Sixty-four middle school students between the ages of 12 and 14 received pre- and post-test measures and participated in the HCP. The pre-test measure had 24 questions that included 5 demographic questions and 19 Likert-type questions [modified from the Youth Attitude to Noise Scale] that assess adolescents' attitudes towards noise; and a post-test measure included the identical 24 questions of the pre-test measure in addition to three subjective questions. A Wilcoxon signed rank test and a Two-Factor Analysis of Variance were completed to assess changes in knowledge and attitudes toward noise among the study population after receiving the HCP. A statistically significant reduction (P< 0.003) in pro-noise attitudes among the adolescents was present after the intervention. It was established that an HCP facilitated a change in pro-noise attitudes among adolescents. Further, the students thought this program facilitated learning of the auditory system and healthy hearing behaviors.

Integrity in Guardianship Decision Making: Applying the Will and Preferences Paradigm.

Guardianship laws have changed significantly over the 20th and 21st centuries to shift from the "best interests" model to the "supported decision-making" model. Such changes reflect the importance of supporting the dignity of risk of persons who lack decision-making capacity for some decisions. Recent changes to the Victorian Guardianship and Administration Act 2019 (Vic) in Australia require guardians to give effect to the "will and preferences" of the represented person, as far as practicable. The changes reveal a compromise between the competing rights to autonomy and to safety. Here, we explore the meaning of "will and preferences" before considering the personal factors that may contribute to the understanding of an individual's will and preferences. The practical challenge of ascertaining, interpreting, and giving effect to a person's will and preferences are also discussed. Finally, we consider the practical challenge of identifying when a person needs decision-making support.

An Ageing Population Creates New Challenges Around Consent to Medical Treatment.

Obtaining consent for medical treatment in older adults raises a number of complex challenges. Despite being required by ethics and the law, consent for medical treatment is not always validly sought in this population. The dynamic nature of capacity, particularly in individuals who have dementia or other cognitive impairments, adds complexity to obtaining consent. Further challenges arise in ensuring that older people comprehend the medical treatment information provided and that consent is not vitiated by coercion or undue influence. Existing mechanisms to address issues surrounding consent for older adults only address incapacity and raise further challenges. As the ageing population increases, these issues are likely to become more profound, thus action is required to address these challenges. Raising awareness, more education, engaging with people with dementia, and conducting further research would assist in beginning to overcome these challenges.

Use of Alcohol in Long Term Care Settings: A Comparative Analysis of Personal Choice, Public Health Advice and the Law.

Alcohol is one of the most widely available psychoactive substances globally. Many accept the risks associated with alcohol consumption for reasons such as social engagement and feelings of pleasure. Alcohol consumption in a nursing home (NH) setting highlights the moral and logistical challenges of balancing the need for a safe living and working environment with the dignity of risk (DoR) and personal autonomy of residents. This analysis explores public health, human rights, and legal frameworks in their approach to a NH resident's choice to drink alcohol. Key issues under the public health framework include the medical risks associated with alcohol consumption, whether residents with impaired cognitive functioning have the capacity to make a decision about alcohol consumption, and the practical and ethical implications of supplying alcohol to residents. Under a legal framework, NHs must consider the legal imperative to respect residents' rights, the possibility of liability in negligence, duties owed to employees, the existence of substitute decision-makers, and liquor licensing laws. Fundamental considerations under the human rights framework include the damaging psychological effects of risk-avoidance and the importance of inclusive risk assessment processes. Alcohol policies should incorporate elements from all 3 frameworks. There is limited data publicly available about alcohol policies in NHs. Further research is needed to establish current practice and to evaluate the merits and disadvantages of different policies. Establishing inclusive and thorough decision-making processes is key to achieving better consumer-directed care.

Systematic Review of Randomized Controlled Trials in Australian Nursing Homes from 2000 to 2018.

BACKGROUND/OBJECTIVES: High-quality research provides an evidence base for optimal practice care in clinical settings, yet, little is known about the nature and extent of randomized control trials (RCTs) conducted in Australian nursing homes (NHs). Research from other settings and other countries is not necessarily transferable to the Australian NH sector. We sought to identify and describe RCTs conducted in Australia which investigated interventions targeted at improving care for NH residents. DESIGN: The design of this study comprised a systematic literature search with a narrative review. Studies were included if they were RCTs published after 2000, conducted in an Australian NH, and evaluated a health intervention which may have directly or indirectly benefitted the NH resident. SETTING: Australian NHs. PARTICIPANTS: Nursing home residents. MEASUREMENTS: Jurisdiction (state or territory where the study was conducted), number of NHs recruited in each trial, number of residents included in each trial, intervention characteristics, comparator characteristics, and characteristics of outcome. RESULTS: Only 43 articles reporting on 39 RCTs were identified. In contrast, 30 Australian musculoskeletal RCTs were published in just 2 years (2011-2012). Most of the RCTs identified were conducted in New South Wales (n = 14), Queensland (n = 10), and Victoria (n = 9). The mean number of NHs included in each trial was 22.4 (standard deviation (SD) = 27.0), with a median of 14.5 (interquartile range (IQR) = 27.8), while the mean number of residents included was 412.4 (SD = 921) with a median of 187 (IQR = 341.0). The most common interventions targeted: managing dementia (n = 20), prevention of falls (n = 7), and addressing mental health issues (n = 6). CONCLUSION: This review provides evidence of the paucity of high-quality research in the form of RCTs, in the Australian NH setting and demonstrates the need for Australia to improve its research capability in the NH sector.

Role of a Clinical Ethics Committee in Residential Aged Long-Term Care Settings: A Systematic Review.

OBJECTIVES: To conduct a systematic review of literature examining the establishment and operation of clinical ethical committees (CECs) in long-term care (LTC). DESIGN: Systematic review. SETTING AND PARTICIPANTS: LTC recipients/family or staff. METHODS: Five databases (Ovid Medline, Ovid Cochrane Library, Ovid PsycINFO, Ovid EMBASE, and CINAHL via EbscoHost) were systematically searched from their inception to May 8, 2020. The initial search was conducted on August 22, 2017, and updated on May 8, 2020, to identify peer-reviewed studies, commentaries, or editorials. The quality of studies was assessed using the Mixed Methods Appraisal Tool. RESULTS: Thirty-three articles were identified for inclusion, of which 13 were primary studies. Most articles were set in the United States. The purpose of establishing a CEC in LTC was typically to assist in dealing with ethical issues and improve the quality of care. The articles described the roles of CECs to include prospective case consultation, case review, policy development, and ethics education. Articles rarely reported whether the CEC was required by or enshrined in law. Membership of CECs was between 4 and 20 members and most commonly included nursing staff, physicians, and directors/administrators. The rationale behind the membership was rarely described. For case consultation, articles described that CECs were typically convened upon referral. The resident issues which a CEC could address included end-of-life care decisions, autonomy/self-determination, and medical treatment decisions. The staff issues addressed by CECs included medical treatment decisions, end-of-life care decisions, and decision-making issues. The decision-making process followed by CECs varied. The outcome of a CEC meeting was typically a recommendation, whereas the implementation of CEC recommendations and decisions were rarely reported. CONCLUSIONS AND IMPLICATIONS: This systematic review identifies how CECs operate in the LTC setting. CECs have the potential to provide valuable support in addressing complex ethical issues in LTC; however, empirical research is required to determine their efficacy in the LTC setting.

Deaths due to thermal injury from cigarette smoking in a 13-year national cohort of nursing home residents.

OBJECTIVES: To examine the nature and frequency of deaths due to thermal injuries from cigarette smoking reported to Australian coroners and to examine the decisions which surround these deaths. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Residents dwelling in accredited nursing homes whose deaths were reported to coroners between 1 July 2000 and 30 June 2013 and attributed to thermal injuries from cigarette smoking. MEASURES: A descriptive analysis was undertaken to report socio-demographic characteristics of the deceased, medical history, mobility, level of observation, safety equipment provided/used, nursing home location, decision to smoke, timing of incident, time from incident to death, incident findings, mechanism of death, formal reports attached and coroners' recommendations. RESULTS: Ten deaths of nursing home residents due to thermal injury from cigarette smoking were reported in Australia over a 13-year period. The median age of residents was 78 years (IQR = 15.25); nine residents were female and one was male. Seven residents had impaired mobility with three residents being wheelchair bound and one resident bed bound. None of the residents were supervised by staff while they smoked, and none of the residents utilised any safety equipment to minimise harm. Burns/thermal injury was the mechanism of harm in most cases. CONCLUSIONS: This national study confirms that thermal injuries caused by cigarette smoking in nursing homes result in fatalities, particularly in the absence of supervision. It also demonstrates the complex tension arising from balancing autonomy with safety. IMPLICATIONS FOR PRACTICE: Nurses and aged care practitioners should endeavour to give effect to each resident's wishes while mitigating the risk of harm. The supervision requirements for cigarette smoking residents should be tailored to the needs of individual residents and staff should try to ensure that residents who require supervision receive it.

Managing risk for aging patients in long-term care: a narrative review of practices to support communication, documentation, and safe patient care practices.

Resident safety and welfare in long-term care (LTC) is being redefined as the focus shifts to promoting an optimal quality of life especially in LTC. Achieving this requires contemporary practice to improve the organization and staff's ability in identifying, communicating, documenting, and managing the risks that arise from the choices a person makes in pursuit of a better quality of life. This article is a narrative realist style review examining the issues of how to manage risks for older residents living in LTC. The issues are examined in six stages: context, identifying, communicating, documenting, enacting, reviewing and reflecting on how choices are made and risks managed. It is important for individuals to be supported in making an informed choice - this requires identifying, providing, and communicating the available options and the potential consequences. Documenting consent, perhaps with formal risk agreements, provides clarity for all involved and assists in determining how and who is responsible for enacting choices. Reviewing and reflecting upon the decisions and actions to enact choices are familiar to prudent LTC managers who implement and monitor robust governance systems. Learning from these experiences is essential to better meet individual resident, staff, organizational, and community expectations. Improving practice at each of the six steps should reduce adverse professional and legal repercussions and enable the resident, families, and staff to better cope with respecting choices when a known harmful outcome eventuates.

Perceived hearing status and attitudes toward noise in young adults.

PURPOSE: To estimate the prevalence of perceived hearing loss, tinnitus, and temporary threshold shift (TTS) in community college students and to see whether those students' attitudes toward noise affected their perception of their own possible hearing loss, tinnitus, and TTS. METHOD: Young adults (N = 245; age 18-27) completed 3 questionnaires: the Hearing Symptom Description, Youth Attitude to Noise Scale, and Adolescents' Habits and Hearing Protection Use. RESULTS: Perceived TTS and pain associated with loud noise were the most common hearing related factors, followed by perceived tinnitus and hearing loss. The students' attitudes toward noise in their daily environment showed the most negative response, whereas attitudes toward noise and concentration indicated a more positive, or less harmful, response. Chi-square analysis indicated a significant correlation between perceived hearing loss and respondents' overall attitudes toward noise exposure. Hearing protection use was limited for all participants, with the majority reporting never having used hearing protection. CONCLUSION: Approximately 6% of respondents reported perceived hearing loss, and 13.5% reported prolonged tinnitus. In general, participants had neutral attitudes toward noise. Over 20% of participants reported ear pain, tinnitus, and/or TTS after noise exposure at least sometimes. Coincidentally, few participants reported consistent use of hearing protection.

Bimodal Programming: A Survey of Current Clinical Practice.

PURPOSE: The purpose of this study was to determine the current clinical practice in approaches to bimodal programming in the United States. To be specific, if clinicians are recommending bimodal stimulation, who programs the hearing aid in the bimodal condition, and what method is used for programming the hearing aid? METHOD: An 11-question online survey was created and sent via email to a comprehensive list of cochlear implant programming centers in the United States. The survey was sent to 360 recipients. RESULTS: Respondents in this study represented a diverse group of clinical settings (response rate: 26%). Results indicate little agreement about who programs the hearing aids, when they are programmed, and how they are programmed in the bimodal condition. Analysis of small versus large implant centers indicated small centers are less likely to add a device to the contralateral ear. CONCLUSIONS: Although a growing number of cochlear implant recipients choose to wear a hearing aid on the contralateral ear, there is inconsistency in the current clinical approach to bimodal programming. These survey results provide evidence of large variability in the current bimodal programming practices and indicate a need for more structured clinical recommendations and programming approaches.

Evaluation of Speech Perception via the Use of Hearing Loops and Telecoils.

A cross-sectional, experimental, and randomized repeated-measures design study was used to examine the objective and subjective value of telecoil and hearing loop systems. Word recognition and speech perception were tested in 12 older adult hearing aid users using the telecoil and microphone inputs in quiet and noise conditions. Participants were asked to subjectively rate cognitive listening effort and self-confidence for each condition. Significant improvement in speech perception with the telecoil over microphone input in both quiet and noise was found along with significantly less reported cognitive listening effort and high self-confidence. The use of telecoils with hearing aids should be recommended for older adults with hearing loss.

Personal style and hearing aid fitting.

Why do I have to drag information out of some patients? Why is another patient so talkative? Why didn't this patient like the XYZ 2002 digital hearing aid when she had the same degree, type, and configuration of hearing impairment as the patient I successfully fit last month? Could the answer be as basic as a difference in personality?

Analysis of prefitting versus postfitting hearing aid orientation using the Glasgow Hearing Aid Benefit Profile (GHABP).

Results of this study demonstrate the advantages of both pre- and postfitting hearing aid orientation (HAO) sessions. This study demonstrated that HAO counseling is helpful in expediting hearing aid benefit and satisfaction through the education of our clients and that this benefit and satisfaction is age dependent as measured by the Glasgow Hearing Aid Benefit Profile (GHABP) (Gatehouse, 1997). Patients with greater initial disability, as identified by item 1 of the GHABP, receive significant benefit from prefitting and/or postfitting counseling as compared to patients receiving no counseling. Implications of these findings are discussed.

Doctor of Audiology program at the University of Florida.

The University of Florida on-campus AuD program is described. To date, 63 students have been enrolled in this program. Sixteen doctoral-level audiology faculty teach in this program, either in the classroom or clinically. Coursework spans all areas included in the audiology scope of practice. The curriculum also has classes taught by faculty in other related disciplines, such as medicine, neuroscience, pharmacology, and counseling. Clinical practicum experiences throughout the program occur in a major health science center on campus, along with a number of other clinical sites. With the support of a large faculty and the availability of a wide variety of clinical placements, the University of Florida AuD program provides the necessary knowledge and skills for students to become autonomous professionals.