Estimating phenological sensitivity in contemporary vs. historical data sets: Effects of climate resolution and spatial scale.

PREMISE: Phenological sensitivity, or the degree to which a species' phenology shifts in response to warming, is an important parameter for comparing and predicting species' responses to climate change. Phenological sensitivity is often measured using herbarium specimens or local studies in natural populations. These approaches differ widely in spatiotemporal scales, yet few studies explicitly consider effects of the geographic extent and resolution of climate data when comparing phenological sensitivities quantified from different data sets for a given species. METHODS: We compared sensitivity of flowering phenology to growing degree days of the alpine plant Silene acaulis using two data sets: herbarium specimens and a 6 yr observational study in four populations at Niwot Ridge, Colorado, USA. We investigated differences in phenological sensitivity obtained using variable spatial scales and climate data sources. RESULTS: Herbarium specimens underestimated phenological sensitivity compared to observational data, even when herbarium samples were limited geographically or to nearby weather station data. However, when observational data were paired with broader-scale climate data, as is typically used in herbarium data sets, estimates of phenological sensitivity were more similar. CONCLUSIONS: This study highlights the potential for variation in data source, geographic scale, and accuracy of macroclimate data to produce very different estimates of phenological responses to climate change. Accurately predicting phenological shifts would benefit from comparisons between methods that estimate climate variables and phenological sensitivity over a variety of spatial scales.

Operationalizing legal rights in end-of- life decision-making: A qualitative study.

BACKGROUND: For a patient's legal right to make end-of-life treatment decisions to be respected, health care practitioners, patients and their substitute decision-makers must know what rights exist and how to assert them (or support others to assert them). Yet very little is known about what enhances or obstructs the operationalization of legal rights from the perspective of patients, family members and substitute decision-makers. AIM: To explore barriers and facilitators to the operationalization of rights in end-of-life decision-making from the perspectives of terminally-ill patients and family members and substitute decision-makers of terminally ill patients in Australia. DESIGN: Semi-structured interviews (face to face and telephone) with patients, family or substitute decision-makers experienced in end-of-life decision-making completed between November 2016 and October 2017. A thematic content analysis of interview transcripts. SETTING/PARTICIPANTS: Purposive sampling across three Australian states provided 16 terminally-ill patients and 33 family and/or substitute decision-makers. RESULTS: Barriers and facilitators emerged across three overlapping domains: systemic factors; individual factors, influenced by personal characteristics and decision-making approach; and communication and information. Health care practitioners play a key role in either supporting or excluding patients, family and substitute decision-makers in decision-making. CONCLUSION: In addition to enhancing legal literacy of community members and health practitioners about end-of-life decision-making, support such as open communication, advocacy and help with engaging with advanced care planning is needed to facilitate people operationalizing their legal rights, powers and duties. Palliative care and other support services should be more widely available to people both within and outside health systems.

Role of Law in End-of-Life Decision-Making: Perspectives of Patients, Substitute Decision-Makers and Families.

The law regulating medical end-of-life decisions aims to support patients to receive high-quality health care. It does so through ensuring treatment received reflects the person's wishes and values and protecting health professionals who provide adequate pain and symptom relief even if that treatment may coincidentally hasten death. However, good decision-making is predicated by those involved, including patients themselves and those supporting patients, being familiar with the law and the role it plays in the decision-making process. This article reports on a study exploring the role that law plays in end-of-life decision-making from the perspective of terminally-ill patients, their substitute decision-makers and family members. While participants' decision-making practices were often underpinned by a legal framework, the role of the law was largely invisible. Community education is needed for the public to know their legal rights and responsibilities, and to understand that the law plays a role in supporting end-of-life decision-making.

Embarking to Caregiving Role: A Thematic Analysis of Malay Caregivers of Older Adults with Mental Health Problems Perspectives.

Religion and culture affect the meaning and practicalities of caring for families with mental illness in Malaysia. Such care also differs according to social background, family values and support, commitment, availability, practicality and the needs of the care recipient. This qualitative study explores 14 Malay caregivers of the older adults with mental health problems in Kelantan, Malaysia. A semi-structured interview was translated and transcribed and subjected to thematic analysis using NVivo software. The findings show that cultural values and religion shaped the meaning of care as provided by the caregivers. The nature of the relationship is also important in determining the best person in the family to take over the caregiving role.

Prevalence of advance care directives in the community: a telephone survey of three Australian States.

BACKGROUND: The community prevalence of advance care directives (ACD) is low despite known benefits of advance care planning for patients, families and health professionals. AIM: To determine the community prevalence of instructional and appointing ACD in New South Wales, Victoria and Queensland and factors associated with completion of these documents. METHODS: A telephone survey of adults living in New South Wales, Victoria and Queensland (n = 1175) about completion of instructional ACD (making their own decisions about future healthcare) and appointing ACD (appointing another to decide). Quota sampling occurred based on population size by state, gender and age, with oversampling in smaller jurisdictions (Victoria and Queensland). RESULTS: Overall response rate was 33%. Six per cent of respondents reported completing an instructional ACD while 12% reported completing an appointing ACD. Female gender, higher educational level, personal experience of a major health scare and being widowed were significant predictors of completing an instructional ACD. Older age, higher educational level and being widowed were significant predictors of completing an appointing ACD. CONCLUSIONS: Despite long-standing efforts to increase advance care planning, community prevalence of ACD remains low, particularly for instructional ACD. This study found some different predictors for instructional ACD compared with appointing ACD, and also a potential role for experiential factors in triggering uptake. These findings suggest supplementing general community awareness campaigns with more nuanced and targeted efforts to improve ACD completion.

Community Knowledge of Law on End-of-life Decision-making: An Australian Telephone Survey.

The law has a clear role to play in supporting patients and their substitute decision-makers (SDMs) to be involved in end-of-life (EOL) decision-making. Although existing literature suggests that knowledge of EOL law is variable among health professionals, there is little information about the extent and sources of such knowledge within the general community. A telephone survey of a representative sample of adults in three Australian States used six case scenarios to examine the extent to which adults know their legal duties, rights and powers as patients or SDMs; the sources from which people derive relevant legal knowledge; experiences of EOL decision-making; and individual characteristics associated with levels of knowledge. The results show considerable variation in levels of legal knowledge dependent primarily of the area of decision-making presented, some sizeable gaps in people's knowledge of EOL law, and varied awareness of how to access appropriate information on this subject. This study points to the need to increase community legal literacy around EOL decision-making, enhance awareness of the role of law in these circumstances and promote the availability of reliable and accessible information on the law at the time when it is needed.

Community knowledge of law at the end of life: availability and accessibility of web-based resources.

Objective The aim of the present study was to identify online resources community members may access to inform themselves about their legal duties and rights in end-of-life decision making. Methods Resource mapping identified online resources that members of the public in New South Wales, Victoria and Queensland are likely to identify, and assessed the ease or difficulty in locating them. Resources were then critically analysed for accessibility of language and format using the Patient Education Materials Assessment Tool (PEMAT). Results Identified resources differed considerably based on whether search terms identified by community members or experts were used. Most resources focused on advance directives, enduring powers of attorney and substitute decision making. Relatively few provided information about legal duties (e.g. powers and responsibilities of substitute decision makers) or resolving conflict with health practitioners. Accessibility (understandability and actionability) of resource content varied. Conclusions Although numerous resources on end-of-life law are available online, community members may not be able to identify relevant resources or find resource content accessible. What is known about the topic? Research on participation by patients in decision making about their treatment has focused primarily on medical rather than legal knowledge. What does this paper add? The present study investigated which online resources community members may access to inform themselves about the law on end-of-life decision making. The resources identified were analysed for ease of location and content accessibility. What are the implications for practitioners? Authors of online resources on end-of-life decision making should consider whether their resources can be: (1) identified by search terms used by the public; (2) understood by a general audience; and (3) readily used to promote reader action.

Can clinical supervision sustain our workforce in the current healthcare landscape? Findings from a Queensland study of allied health professionals.

OBJECTIVE: Clinical supervision is widely recognised as a mechanism for providing professional support, professional development and clinical governance for healthcare workers. There have been limited studies about the effectiveness of clinical supervision for allied health and minimal studies conducted within the Australian health context. The aim of the present study was to identify whether clinical supervision was perceived to be effective by allied health professionals and to identify components that contributed to effectiveness. Participants completed an anonymous online questionnaire, administered through the health service's intranet. METHODS: A cross-sectional study was conducted with community allied health workers (n = 82) 8 months after implementation of structured clinical supervision. Demographic data (age, gender), work-related history (profession employment level, years of experience), and supervision practice (number and length of supervision sessions) were collected through an online survey. The outcome measure, clinical supervision effectiveness, was operationalised using the Manchester Clinical Supervision Scale-26 (MCSS-26). Data were analysed with Pearson correlation (r) and independent sample t-tests (t) with significance set at 0.05 (ie the probability of significant difference set at P < 0.05). RESULTS: The length of the supervision sessions (r(s) ≥ 0.44), the number of sessions (r(s) ≥ 0.35) and the total period supervision had been received (r(s) ≥ 0.42) were all significantly positively correlated with the MCSS-26 domains of clinical supervision effectiveness. Three individual variables, namely 'receiving clinical supervision', 'having some choice in the allocation of clinical supervisor' and 'having a completed clinical supervision agreement', were also significantly associated with higher total MCSS-26 scores (P(s) < 0.014). CONCLUSION: The results of the study demonstrate that when clinical supervision uses best practice principles, it can provide professional support for allied health workers, even during times of rapid organisational change.

Predictors of financial capacity performance in older adults using the Financial Competence Assessment Inventory.

BACKGROUND: Declines in financial capacity in later life may arise from both neurocognitive and/or psychiatric disorders. The influence of socio-demographic, cognitive, health, and psychiatric variables on financial capacity performance was explored. METHODS: Seventy-six healthy community-dwelling adults and 25 older patients referred for assessment of financial capacity were assessed on pertinent cognitive, psychiatric, and financial capacity measures, including Addenbrooke's Cognitive Examination - Revised (ACE-R), Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE), Geriatric Depression Scale (GDS), Geriatric Anxiety Inventory (GAI), selected Neuropsychiatric Inventory (NPI) items, Financial Competence Assessment Inventory (FCAI), and Social Vulnerability Scale (SVS). RESULTS: The internal consistency of the debt management subscale of the FCAI was relatively poor in our sample. Financial capacity performance differed between controls and patients. In our sample, performance on the FCAI was predicted by Mini-Mental State Examination, IQCODE, and GAI, but not by ACE-R, GDS, NPI items, or SVS (adjusted R(2) = 0.7059). CONCLUSIONS: Anxiety but not depression predicted financial capacity performance, possibly reflecting relatively low variance of depressive symptoms in this sample. Current cognitive decline as measured by the informant-rated IQCODE was more highly correlated to financial capacity than either educational attainment or ACE-R scores. Lack of significance of ACE-R data may reflect the instrument's decreased sensitivity to domains relevant to financial capacity, compared with more detailed neuropsychological assessment tools. The FCAI displayed fairly robust psychometric properties apart from the debt management subscale.

Legal issues in end-of-life care for speech-language pathologists and social workers: A scoping review.

PURPOSE: End-of-life law governs end-of-life decision-making in clinical practice. There has been little analysis of the specific legal issues relevant to allied health professionals working in end-of-life care. METHOD: A scoping review was undertaken to identify and examine the extent, range, and nature of literature on the legal issues relevant to end-of-life practice for Australian speech-language pathologists and social workers, including current gaps. Literature was identified by searching six electronic databases, Google Scholar, the websites of relevant professional organisations and State/Territory health departments, scanning reference lists, and drawing on existing knowledge. Data charting and thematic analysis of findings was performed. RESULT: Twenty documents were included, spanning various document types. Most focused on adult clinical practice. Documents demonstrated that the two professions encounter similar legal issues. CONCLUSION: Key gaps exist in the literature. Findings will inform these professionals of the legal issues relevant to their clinical practice and inform the development of further resources.

The Morphology Index: predictive value of malignancy among clinicians at various levels of training.

OBJECTIVE: To determine whether clinicians at various levels of training can reproduce and apply the Morphology Index when compared to Ueland's Morphology Index data, and to determine intra-observer variability when applied by observers at various levels of training. METHODS: One hundred four transvaginal ultrasound images of adnexal masses obtained at Indiana University between 1991 and 2003 were identified which had correlating surgical pathology. The images were scored by four investigators at four different levels of training. Scoring was based upon the revised University of Kentucky Morphology Index by Ueland. Each mass received 0-5 points for its structure, and 0-5 points for tumor volume. Each total score was then correlated with the surgical pathology. Sensitivity, specificity, positive predictive value and negative predictive value for each investigator were determined. All images were reviewed independently by each investigator; each was blinded to scores given by the other investigators and to final pathology. RESULTS: Nine malignant and 95 benign masses were noted on final pathology. Ranges for statistical values were: positive predictive value (PPV) 15-18%, negative predictive value (NPV) 93-98%, sensitivity 44-89%, and specificity 52-76%. CONCLUSION: The Morphology Index is a consistent and reliable tool for predicting benign disease demonstrating a high negative predictive value with little intra-observer variability. However, when predicting malignancy, the results showed more intra-observer variability and a positive predictive value half of that previously reported. This study confirms the clinical utility of the Morphology Index when utilized for its NPV and demonstrates its widespread application even among clinicians with minimal ultrasound training.

Managing social support needs in older age for childless Malaysians living in poverty.

OBJECTIVE: To explore how older people manage social support needs when they are childless and living in poverty in the Malaysian context where social policy emphasises family as the primary provider of social support. METHODS: Semi-structured interviews were completed with a purposive sample of 34 childless and older Malaysians living in poverty in Kuala Lumpur, Malaysia. A thematic content analysis focused on their reports of managing social support needs. RESULTS: Key strategies were using existing resources, developing new networks and adjusting expectations. Agency played a vital role in avoiding institutional care. CONCLUSIONS: This paper adds to research on childlessness in older age in varied policy and cultural contexts. It challenges assumptions about families providing social support and argues for policies to recognise older people as an individual unit rather than as part of a family to prolong independent living in the community.

Disrupted prevention: condom and contraception access and use among young adults during the initial months of the COVID-19 pandemic. An online survey.

BACKGROUND: The initial response to COVID-19 in the UK involved a rapid contraction of face-to-face sexual and reproductive health (SRH) services and widespread use of remote workarounds. This study sought to illuminate young people's experiences of accessing and using condoms and contraception in the early months of the pandemic. METHODS: We analysed data, including open-text responses, from an online survey conducted in June-July 2020 with a convenience sample of 2005 16-24-year-olds living in Scotland. RESULTS: Among those who used condoms and contraception, one quarter reported that COVID-19 mitigation measures had made a difference to their access or use. Open-text responses revealed a landscape of disrupted prevention, including changes to sexual risk-taking and preventive practices, unwanted contraceptive pathways, unmet need for sexually transmitted infection (STI) testing, and switches from freely provided to commercially sold condoms and contraception. Pandemic-related barriers to accessing free condoms and contraception included: (1) uncertainty about the legitimacy of accessing SRH care and self-censorship of need; (2) confusion about differences between SRH care and advice received from healthcare professionals during the pandemic compared with routine practice; and (3) exacerbation of existing access barriers, alongside reduced social support and resources to navigate SRH care. CONCLUSIONS: Emerging barriers to STI and pregnancy prevention within the context of COVID-19 have the potential to undermine positive SRH practices, and widen inequalities, among young people. As SRH services are restored amid evolving pandemic restrictions, messaging to support navigation of condom and contraception services should be co-created with young people.

The impact of COVID-19 on the management of heart failure: a United Kingdom patient questionnaire study.

AIMS: The coronavirus disease 2019 (COVID-19) pandemic has created significant challenges to healthcare globally, necessitating rapid restructuring of service provision. This questionnaire survey was conducted amongst adult heart failure (HF) patients in the United Kingdom (UK), to understand the impact of COVID-19 upon HF services. METHODS AND RESULTS: The survey was conducted by the Pumping Marvellous Foundation, a UK HF patient charity. 'Survey Monkey' was used to disseminate the questionnaire in the Pumping Marvellous Foundation 's online patient group and in 10 UK hospitals (outpatient hospital and community HF clinics). There were 1050 responses collected (693/1050-66% women); 55% (579/1050) were aged over 60 years. Anxiety level was significantly higher regarding COVID-19 (mean 7 ± 2.5 on anxiety scale of 0 to 10) compared with anxiety regarding HF (6.1 ± 2.4; P < 0.001). Anxiety was higher amongst patients aged ≤60 years about HF (6.3 ± 2.2 vs. 5.9 ± 2.5 in those aged >60 years; P = 0.005) and COVID-19 (7.3 ± 2.3 vs. 6.7 ± 2.6 those aged >60 years; P < 0.001). Sixty-five per cent of respondents (686/1050) reported disruption to HF appointments (cancellation or postponement) during the lockdown period. Thirty-seven per cent reported disruption to medication prescription services, and Thirty-four per cent reported inability to access their HF teams promptly. Thirty-two per cent expressed reluctance to attend hospital (25% stated they would only attend hospital if there was no alternative, and 7% stated that they would not attend hospital at all). CONCLUSIONS: The COVID-19 pandemic has caused significant anxiety amongst HF patients regarding COVID-19 and HF. Cancellation or postponement of scheduled clinic appointments, investigations, procedures, prescription, and monitoring services were implicated as sources of anxiety.

A Prospective Outcomes Pilot Evaluation of Inspire Now: A Program for People with Lung Cancer.

BACKGROUND: Lung cancer is the leading cause of cancer mortality in Canada, yet patients are often under-supported. A six-week program called Inspire Now, created to address unmet supportive care needs, was evaluated in this study. Feasibility and preliminary outcomes were assessed in order to inform future changes to the program. OBJECTIVES: (1) Assess the feasibility of the program and its evaluation; (2) pilot the collection of patient-reported outcomes; (3) identify outcomes that may be positively influenced; and (4) inform program modifications. METHODS: Participants were recruited from the first session of Inspire Now for an observational pilot study. The primary outcome was feasibility. Secondary outcomes included within-person changes in Functional Assessment of Cancer Therapy - Lung (FACT-L) and Measure Yourself Concerns and Wellbeing (MYCaW), and program satisfaction and qualitative experiences of participants and facilitators through internally-developed questionnaires and semi-structured interviews. Analysis was primarily descriptive, within person changes in FACT-L and MYCaW were analyzed using the Wilcoxon signed-rank test and qualitative data was assessed for common themes. RESULTS: The program and its evaluation were feasible; 8 of 9 (89%) participants consented to the study, median attendance was 6 of 6 sessions (IQR 4.5-6), and questionnaire completion was 100% at baseline and 75% at follow-up. There were clinically meaningful improvements in MYCaW concern 1 (-1.2, 95% CI -2.0 to -0.4) and overall wellbeing (-0.9, 95% CI -2.1 to 0.4). Seven of eight FACT-L sub-sections trended toward improvement, with absolute changes ranging from -1.7 to 10.8%. Participant feedback was overwhelmingly positive; group support and social interactions were highly valued. CONCLUSIONS: The group intervention for people with lung cancer was feasible to both run and evaluate. Participants responded positively to the program. Findings will inform changes to future sessions and an analysis of multiple sessions is planned.

The new caring: financial asset management and older people.

Increasing longevity and the growing proportion of the aged in the population in most countries have served to focus on the question of how governments and older people can finance living, health, and care options in retirement. Prudent management of income and assets is an increasingly complex and important aspect of aging as assets and expectations of self-financing increase. Although many informal caregivers act as asset managers and/or substitute decision-makers for older people, little attention has been paid to this increasingly important aspect of care. This paper summaries key findings of a broad research program exploring family involvement in the management of older people's assets and the practices that constitute good practice as well as financial mismanagement and abuse. It identifies multi-level and multi-strategy responses needed to address the issues raised by the research and outlines an innovative community demonstration project aimed at improving financial management practices in relation to older people's assets.

Effects of gender on physiological responses during submaximal exercise and recovery.

PURPOSE: This investigation was conducted to compare the physiological responses of men and women, both during and following an exercise bout at the same relative submaximal intensity. METHODS: Ten untrained men (20.7+/-0.5 yr, 178.4+/-2.3 cm, 79.6+/-4.8 kg; mean+/-SE) and 10 untrained women (20.3+/-0.3 yr, 163.8+/-2.2 cm, 59.5+/-2.1 kg) cycled for 30 min at 60-65% of their predetermined peak oxygen uptake. Physiological variables were measured before exercise, at 15 and 30 min of exercise, and at 5 and 15 min postexercise. For each variable of interest, a two-way repeated-measures of analysis was used to assess the main effects of gender and time, along with potential interactive effects. RESULTS: Our data revealed that for many variables including HR, relative HR (% peak value), mean arterial pressure, and rectal temperature, men and women responded similarly both during exercise and throughout the recovery period. In contrast, significant (P

Perceptions and employment intentions among aged care nurses and nursing assistants from diverse cultural backgrounds: A qualitative interview study.

The residential aged care industry faces shortages and high turnover rates of direct care workers. This situation is further complicated by the increasing cultural diversity of residents and staff. To retain direct care workers, it is crucial to explore their perceptions of the rewards and difficulties of care work, and their employment intentions in multicultural environments. A qualitative descriptive study was used to understand perceptions of the rewards and difficulties of residential aged care work for core direct care workers (i.e. nurses and nursing assistants), how these were related to their intentions to stay or leave, and how these varied between nurses and nursing assistants, and between locally and overseas born workers. Individual interviews were conducted between June and September 2013 with 16 direct care workers in an Australian residential aged care facility with a specific focus on people from culturally and linguistically diverse backgrounds. It was found that direct care workers' employment intentions were related to their perceptions and management of the rewards and difficulties of care work. Their experiences of care work, the employment characteristics, and the organizational resources that fitted their personality, ability, expectations, and essential needs were viewed as rewards. Evaluating their jobs as meaningful was a shared perception for direct care workers who intended to stay. Individual workers' perceptions of the rewarding aspects of care work served to counterbalance the challenges of care work, and promoted their intentions to stay. Perceptions and employment intentions varied by occupational groups and by cultural backgrounds. Overseas born direct care workers are valuable resources in residential aged care facility rather than a limitation, but they do require organizational support, such as cultural awareness of the management, English language support, a sense of family, and appropriate job responsibility. The findings indicated that aged care policy makers and service providers should understand the range of individual direct care workers' positive and negative perceptions, and their employment intentions within the context of their roles and their cultural backgrounds.

Achieving effective supervision.

Supervision probably does have benefits both for the maintenance and improvement of clinical skills and for job satisfaction, but the data are very thin and almost non-existent in the area of alcohol and other drugs services. Because of the potential complexity of objectives and roles in supervision, a structured agreement appears to be an important part of the effective supervision relationship. Because sessions can degenerate easily into unstructured socialization, agendas and session objectives may also be important. While a working alliance based on mutual respect and trust is an essential base for the supervision relationship, procedures for direct observation of clinical skills, demonstration of new procedures and skills practice with detailed feedback appear critical to supervision's impact on practice. To ensure effective supervision, there needs not only to be a minimum of personnel and resources, but also a compatibility with the values and procedures of management and staff, access to supervision training and consultation and sufficient incentives to ensure it continues.

Pediatricians who prescribe clotrimazole-betamethasone diproprionate (Lotrisone) often utilize it in inappropriate settings regardless of their knowledge of the drug's potency.

Clotrimazole-betamethasone diproprionate (C-BMV) is a fluorinated, high potency topical steroid that has been formulated with clotrimazole in the brand-named product, Lotrisone. The product is frequently used inappropriately in intertriginous areas, particularly in children. The following evaluates the use of this combination based upon a survey of 106 US-based pediatricians with at least two years post-residency, who attended the 1999 American Academy of Pediatrics. Of pediatricians who prescribe C-BMV, 23% prescribe it for diaper dermatitis. 11% of C-BMV prescriptions exceed the recommended duration of therapy. Only 18% of prescribing pediatricians correctly identify "Lotrisone" as a high potency steroid. There is no significant association between knowledge of C-BMV potency and frequency of use (p>.1). These self-reported data confirm and complement the findings of previous studies that used representative national data to assess the use of C-BMV. Pediatricians continue to utilize C-BMV in inappropriate settings, such as diaper dermatitis, regardless of their knowledge of the agent's potency. Our advice is to refrain from using high-potency steroids, such as C-BMV, in pediatric cases as there are more appropriate, safer alternatives with many fewer side effects.