Recommendations for Medical and Mental Health Care in Assisted Living Based on an Expert Delphi Consensus Panel: A Consensus Statement.

Importance: Assisted living (AL) is the largest provider of residential long-term care in the US, and the morbidity of AL residents has been rising. However, AL is not a health care setting, and concern has been growing about residents' medical and mental health needs. No guidance exists to inform this care. Objective: To identify consensus recommendations for medical and mental health care in AL and determine whether they are pragmatic. Evidence Review: A Delphi consensus statement study was conducted in 2021; as a separate effort, the extent to which the recommendations are reflected in practice was examined in data obtained from 2016 to 2021 (prepandemic). In the separate effort, data were from a 7-state study (Arkansas, Louisiana, New Jersey, New York, Oklahoma, Pennsylvania, Texas). The 19 Delphi panelists constituted nationally recognized experts in medical, nursing, and mental health needs of and care for older adults; dementia care; and AL and long-term care management, advocacy, regulation, and education. One invitee was unavailable and nominated an alternate. The primary outcome was identification of recommended practices based on consensus ratings of importance. Panelists rated 183 items regarding importance to care quality and feasibility. Findings: Consensus identified 43 recommendations in the areas of staff and staff training, nursing and related services, resident assessment and care planning, policies and practices, and medical and mental health clinicians and care. To determine the pragmatism of the recommendations, their prevalence was examined in the 7-state study and found that most were in practice. The items reflected the tenets of AL, the role of AL in providing dementia care, the need for pragmatism due to the diversity of AL, and workforce needs. Conclusions and Relevance: In this consensus statement, 43 recommendations important to medical and mental health care in AL were delineated that are highly pragmatic as a guide for practice and policy.

Feline thelaziosis (Thelazia callipaeda) in Spain: state-of-the-art and first prophylactic trial in cats.

OBJECTIVES: Thelaziosis caused by the nematode Thelazia callipaeda (Spirurida, Thelaziidae) affects the eyes of domestic and wild carnivores, lagomorphs and even humans. The role of cats in spreading thelaziosis remains unclear. The present study assesses the current status of feline T callipaeda infection in Spain and presents the results of the first prophylactic trial conducted in this species. METHODS: We retrospectively analysed the occurrence of feline thelaziosis (study 1), examined its prevalence based on cross-sectional sampling of endemic areas (study 2), and assessed the therapeutic/prophylactic benefits of a spot-on (moxidectin) and therapeutic efficacy of an eye drop (ivermectin) formulation (study 3). RESULTS: In study 1, 69 Thelazia-infected cats were examined. Autochthonous cases were detected in 18/26 municipalities surveyed in Spain, which corresponds to 88.4% (n = 61/69) of the total number of cases. In study 2, 74 cats (20 from La Vera region and 54 from Orense province) were examined from 2011 to 2013. Ten of these cats (13.5%) were infected with T callipaeda. The infection prevalence was 40% (n = 8/20) in La Vera and 3.7% (n = 2/54) in Orense. The therapeutic efficacy of ivermectin was assessed over a summer (2011) in 12 cats, while that of moxidectin was examined over a 17-month period in seven cats. Four of these seven cats were subsequently included in an all-year-round prophylaxis trial. Treatment efficacy ranged from 91.7% (ivermectin) on day 28 after treatment to 100% (moxidectin) on day 14. Moxidectin prevented reinfections in cats. CONCLUSIONS AND RELEVANCE: Our data confirm the endemic status of T callipaeda infection in Spain, revealing its high prevalence in cats living in known endemic areas. Moxidectin was effective in treating and preventing infection. We strongly recommend the inclusion of thelaziosis in the differential diagnosis of pets and humans presenting with ocular manifestations, along with adequate preventive measures.

Update on the treatment and prevention of ocular thelaziosis (Thelazia callipaeda) in naturally infected dogs from Spain.

This study examines the therapeutic and year-round prophylactic efficacy of different formulations used in dogs in three Spanish areas where canine thelaziosis is endemic. The study was conducted as a Good Clinical Practice, multicentre, randomised field study in privately owned outdoor dogs naturally infected with Thelazia callipaeda. The active pharmaceutical ingredients tested were: an oral formulation of milbemycin oxime 12.5 mg combined with praziquantel 125 mg (A), a subcutaneous sustained-release formulation of moxidectin 10 g (B), a moxidectin 2.5% weight/volume (w/v) spot-on formulation combined with imidacloprid 10% w/v (C), and an eye drop formulation (6 µg) of ivermectin 10 mg/ml diluted 10% in propylene glycol (D). Infected dogs were randomly allocated to treatment Groups A, B, C and D. Dogs testing negative for T. callipaeda inspection in two visits (Day 7/Day 14 and D30) were enrolled in the prophylaxis trial and reallocated to the corresponding study group (A, B, C or D). Treatment efficacy ranged from 70.4% recorded in Group A 1 week after treatment, to 100% recorded in Group C on Day 30 and in Group B on Day 60. Treatment was more efficacious in Group D (85.7% 1 week after treatment) than A, but was never 100% efficacious as in Groups B and C. Year-round prophylactic efficacy was 83.3% in Group A, 100% in Group B, 93.5% in Group C and 87.5% in Group D. In conclusion, products containing moxidectin were highly efficacious both in treating and preventing canine thelaziosis. Milbemycin also emerged as a good option. However, the off-label use of topical or subcutaneous ivermectin should be avoided due to possible adverse reactions such as pruritus, irritation or redness. In endemic areas, monthly prophylaxis to limit the spread of T. callipaeda to new areas across Europe and reduce zoonotic risks is essential.

Spain as a dispersion model for Thelazia callipaeda eyeworm in dogs in Europe.

Thelazia callipaeda (Spirurida, Thelaziidae) causes ocular infection in carnivorous animals and humans. While growing numbers of companion dogs and sometimes cats are being diagnosed with thelaziosis, little is known about its real spread. As it has been also diagnosed in wild animals and human beings, it is considered a potential emerging zoonotic disease. This study provides information about the spread of the parasite in dogs in Spain since its initial description in 2010 until 2018. The first detection of T. callipaeda in the Principality of Andorra in 2017 is also reported. Two different studies were conducted: a) a survey in which clinical cases from veterinary practices were collected and b) a prevalence study in two endemic areas in western and central Spain (Site 1 La Vera region, Cáceres, and Site 2 El Escorial municipality, Madrid). In total, 1114 cases of thelaziosis were detected in 121 municipalities of Spain and 6 municipalities of Andorra. In 92 out these 127 municipalities, reports were of autochthonous cases. Six hundred twenty-three out of 1114 presented data collection sheet and were included in the statistical analysis: 510 cases identified by veterinarians in Spain and Andorra in Study 1, and 113 cases detected among the 234 dogs (48.3 %) examined in the prevalence study (Study 2). Prevalences were 61.3 % (84/137) for Cáceres and 29.9 % (29/97) for Madrid, being Site 1 significantly more risky (P <  0.0001, odds ratio: 3.72, CI: 2.14-4.47 %) compared to Site 2. Our study updates data for canine thelaziosis reported in the last decade in Spain and Andorra. Results highlight the urgent need for prevention strategies to control the spread of this potential zoonotic disease.

Changes in eggshell thickness and ultrastructure in the Bearded Vulture (Gypaetus barbatus) Pyrenean population: A long-term analysis.

The Spanish Bearded Vulture (Gypaetus barbatus) population has suffered from negative trends in a number of reproductive parameters that could jeopardize its long-term viability. From 1989 to 2012, 27 entire eggs and 63 eggshell fragments were collected from nests after breeding failure and/or fledging. Longer-term changes in eggshell thickness were made by examining 69 eggs collected in Spain from 1858 to 1911, and now held in European museums. Low levels of contamination with organochlorine pesticides and polychlorinated biphenyls were found in whole eggs and in conjunction with the high fertility rates observed in the field (66.7%) do not indicate a population suffering from the effects of organochlorine contamination. However, a decrease in the Ratcliffe Index and eggshell thickness were observed in eggs collected since 2001, increasingly so in samples post-2004, indicating an abrupt loss of egg quality. We found no significant relationship between organochlorine residues and eggshell in any of the variables measured. In contrast, we found a positive relationship between food availability and the Ratcliffe Index, eggshell thickness and eggshell surface area. A density-dependent explanation of reduced egg quality could arise from ecological constraints as the decrease of food resources. The impact of sudden changes in food availability due to sanitary regulations between 2006 and 2011 could be related with the loss of Bearded Vulture egg quality.

Seropositivity and risk factors associated with Toxoplasma gondii infection in wild birds from Spain.

Toxoplasma gondii is a zoonotic intracellular protozoan parasite of worldwide distribution that infects many species of warm-blooded animals, including birds. To date, there is scant information about the seropositivity of T. gondii and the risk factors associated with T. gondii infection in wild bird populations. In the present study, T. gondii infection was evaluated on sera obtained from 1079 wild birds belonging to 56 species (including Falconiformes (n=610), Strigiformes (n=260), Ciconiiformes (n=156), Gruiformes (n=21), and other orders (n=32), from different areas of Spain. Antibodies to T. gondii (modified agglutination test, MAT titer ≥1:25) were found in 282 (26.1%, IC(95%:)23.5-28.7) of the 1079 birds. This study constitute the first extensive survey in wild birds species in Spain and reports for the first time T. gondii antibodies in the griffon vulture (Gyps fulvus), short-toed snake-eagle (Circaetus gallicus), Bonelli's eagle (Aquila fasciata), golden eagle (Aquila chrysaetos), bearded vulture (Gypaetus barbatus), osprey (Pandion haliaetus), Montagu's harrier (Circus pygargus), Western marsh-harrier (Circus aeruginosus), peregrine falcon (Falco peregrinus), long-eared owl (Asio otus), common scops owl (Otus scops), Eurasian spoonbill (Platalea leucorodia), white stork (Ciconia ciconia), grey heron (Ardea cinerea), common moorhen (Gallinula chloropus); in the International Union for Conservation of Nature (IUCN) "vulnerable" Spanish imperial eagle (Aquila adalberti), lesser kestrel (Falco naumanni) and great bustard (Otis tarda); and in the IUCN "near threatened" red kite (Milvus milvus). The highest seropositivity by species was observed in the Eurasian eagle owl (Bubo bubo) (68.1%, 98 of 144). The main risk factors associated with T. gondii seropositivity in wild birds were age and diet, with the highest exposure in older animals and in carnivorous wild birds. The results showed that T. gondii infection is widespread and can be at a high level in many wild birds in Spain, most likely related to their feeding behaviour.

Assessing the risk of lead exposure for the conservation of the endangered Pyrenean bearded vulture (Gypaetus barbatus) population.

Acute and chronic lead (Pb) poisoning have been recognized as some of the most important causes of mortality for raptors worldwide. We simultaneously examined the recent, medium-term and long-term lead exposure of the endangered bearded vulture (Gypaetus barbatus) from the Pyrenees (northern Spain and southern France). One hundred and one blood samples from 87 captured individuals and tissue samples (liver and bone) from a further 43 dead individuals were analyzed for lead residues. The majority of individuals examined had very low lead concentrations in blood, liver and bone. However, two individuals showed elevated blood Pb levels, two individuals showed liver lead concentrations indicative of excessive lead exposure and one individual showed bone lead levels indicative of chronic lead poisoning, suggesting that the Pyrenean population is not free from the risk of poisoning. We found that Pb exposure was significantly higher in adult individuals as well as in the northern (France) and eastern (Catalonia) range of their distribution. These differences could be related to different feeding habits between age classes (pre-adults are more linked to supplementary feeding sites) and differences in hunting practices between regions (in some regions, carcasses and offal of game animals are not retrieved). Blood, liver and bone lead levels found were slightly higher during the hunting season than outside of the hunting season. Lead presents an unnecessary threat to adult birds and the only way to remove this risk is to ban all hunting with lead within the range of distribution of the endangered bearded vulture. Acute and chronic lead poisoning should be considered in differential diagnosis in any diseased or injured wild bearded vulture, especially subadult and adult individuals, and the potential risk of Pb poisoning should be considered in future reintroduction programs.

Focus group study of ethnically diverse low-income users of paid personal assistance services.

This study examined the experiences of ethnically diverse, low-income consumers of paid personal assistance services (PAS) to understand the successes and problems they faced setting up and maintaining their assistance. A thematic analysis was conducted with transcripts from eight focus groups of ethnically homogeneous consumers (n = 67): African American, Latino, Chinese, Native American, and non-Hispanic white. These experienced consumers were generally satisfied with their current PAS but noted significant difficulties: Getting access to appropriate care, obtaining enough paid care to avoid unmet need, and dealing with confusing bureaucracies and cultural differences between them and agency staff/attendants. They desired more control over their care, including the use of paid family attendants when possible. Respondents recommended improved screening and training of attendants, more attendant time, higher wages for attendants, improved cultural sensitivity of attendants and agency staff, and greater consumer control over PAS. Although these low-income PAS consumers are ethnically and geographically diverse, the similarity of findings points to their ongoing struggle to access adequate high quality assistance. The burden they have in obtaining and maintaining services is substantial.

Influence of contamination by organochlorine pesticides and polychlorinated biphenyls on the breeding of the spanish imperial eagle (Aquila adalberti).

We evaluated temporal and regional trends of organochlorine (OC) pesticide (including polychlorinated biphenyl [PCB]) levels in eggs of the Spanish Imperial Eagle (Aquila adalberti) collected in Spain between 1972 and 2003. Levels of p,p'-dichlorodiphenyldichloroethylene (DDE) and PCBs varied significantly (p = 0.022) among regions (central, western, and Doñana), being higher in Doñana than in the central and western populations (DDE: 1.64 +/- 5.56, 0.816 +/- 1.70, and 1.1 +/- 2.66 microg/g, respectively; PCBs: 1.189 +/- 5.0, 0.517 +/- 1.55, and 0.578 +/- 1.75 microg/g, respectively). Levels of DDE decreased with time, but a significant interaction was observed between region and time. In Doñana, egg volume and breadth as well as Ratcliffe Index were significantly lower after DDT use (p = 0.0018) than during the pre-DDT period (p = 0.0018); eggs were significantly smaller overall than in the other two regions (p = 0.04) and were smaller when DDE levels increased, even when controlling for regional differences (p = 0.04). Productivity in Doñana was significantly lower than in the other regions (p < 0.001). Clutch size in Doñana varied according to DDE concentrations (p = 0.01), with the highest DDE concentrations found in clutches consisting of one egg. When considering eggs with DDE levels greater than 3.5 microg/g, a significant effect of DDE on fertility was found (p = 0.03). Clutches with DDE levels greater than 4.0 microg/g had a higher probability of hatching failure (p = 0.07) and produced fewer fledglings (p = 0.03). If we consider 3.5 microg/g as the lowest-observable-adverse-effect level, the proportion of sampled clutches that exceeded that level in Doñana (29%) was significantly higher than in other regions (p < 0.001). These eggs showed a mean percentage of thinning of 16.72%. Contamination by OCs, mainly DDE, could explain, at least in part, the low productivity of the Spanish Imperial Eagles in Doñana.

Pesticide abuse in Europe: effects on the Cinereous vulture (Aegypius monachus) population in Spain.

A survey was carried out to investigate incidents of pesticide poisoning of the Cinereous vulture (Aegypius monachus) in Spain during the period 1990-2006. A total of 241 incidents affecting 464 vultures were investigated to establish their causes: approved use, misuse, or deliberate abuse. Other factors studied were compounds, other species affected by the incident, the mode of application, spatial and temporal variation and reasons for the pesticide abuse involved. Approved use was responsible for only a minor fraction (1.3%) of the incidents whereas up to 98% of the investigated incidents were intentional poisonings. Pesticide mortality mainly affects adult individuals (83%) and the implications of this for population dynamics could be important. Eleven different compounds were involved in these incidents although three compounds accounted for up to 88% of the poisoning cases: carbofuran, aldicarb, and strychnine. Most of the pesticide kills seem to be related to the illegal control of predators. Given the minor impact of labeled-use pesticides, currently approved pesticide use does not represent a problem for the Cinereous vulture. Nevertheless, availability of highly toxic pesticides may exacerbate illegal use. As a few compounds, mainly granular insecticides, are responsible for most pesticide kills, stronger regulation and control of these in the EU could result in a decrease of mortality related to pesticide abuse in several endangered species without a significant effect on agriculture.

PACE: has it changed the chronic care paradigm?

The Program of All-inclusive Care for the Elderly (PACE) grew out of a small community organization in San Francisco and has been replicated by non-profit organizations in a number of other communities across the country. The authors review the successes of PACE as reported in the literature and discuss reasons for its limited growth as well as its significant influence on state and federal long term care policy. They argue that PACE has significantly changed how we think of long term care through its pioneering work fully integrating medical and long term care. PACE has also provided an influential model for breaking down the funding silos that characterize the medical and long term care services arena. State Medicaid agencies and Medicare have learned from PACE. Health plans and private long term insurers may also still learn from PACE. However, the fact that only a little more than 10,000 elders have enrolled in PACE nationwide prevents the authors from finding that PACE has brought about significant structural change in a long term care industry dominated by for-profit nursing homes.

Assisted living and special populations: what do we know about differences in use and potential access barriers?

PURPOSE: The purpose of this article was to review existing knowledge about assisted living (AL) use by traditionally underserved populations, including people of color, low-income people, and those living in rural communities. DESIGN AND METHODS: We reviewed methodologies and findings of research on AL and residential care up to June 2004. RESULTS: Some studies suggested that low-income people and people of color either are less likely to utilize AL or receive AL in settings with less space and amenities and/or lower scores in selected quality measures. Generalizations from national or multistate studies to the population have methodological limitations. Numerous topics remain unstudied, including the pricing of AL, the experience of choosing an AL facility, the presence of discriminatory admission and retention practices, and the role of resident preferences. Data on access to AL in rural areas are inconclusive. IMPLICATIONS: We offer recommendations for national surveys to better classify supportive housing settings. Furthermore, we suggest quantitative and qualitative studies to illuminate the experience of low-income, racial/ethnic minority, and rural populations in AL settings.

Assisted living and residential care in Oregon: two decades of state policy, supply, and Medicaid participation trends.

PURPOSE: The study describes Oregon state policy and supply developments for licensed long-term-care settings, particularly apartment-style assisted living facilities and more traditional residential care facilities. DESIGN AND METHODS: Data came from a variety of sources, including state agency administrative records, other secondary data sources, and key informant interviews. Descriptive statistics examined public financing, Medicaid reimbursement, and licensed bed supply trends from 1986 to 2004, as well as Medicaid resident use between 1990 and 2004. RESULTS: Residential care expansion, combined with nursing facility contraction, has transformed Oregon's supply of licensed long-term-care settings in favor of less institutional options. State financing, reimbursement, and licensing policies varied across provider type, with greater public resources supporting growth of assisted living facilities. By 2004, such settings were more likely to be Medicaid providers than residential care facilities and had a higher proportion of Medicaid residents relative to available bed supply. IMPLICATIONS: State financing and reimbursement policies may play a role in stimulating the supply of apartment-style assisted living available to low-income and/or rural service users. Less favorable policy conditions may have unintended consequences for the supply and use of other residential care settings.

Nickel and vanadium metal ions induce apoptosis of T-lymphocyte Jurkat cells.

Metal alloys are used as prosthetic components in the orthopaedic and dental field. However, there is growing concern over the reported leaching of metal ions from implants. Ions released from metals have been thought to be associated with local immune dysfunction, inflammation, and tissue cell death. The objective of our study was to investigate whether nickel(II) and vanadium(V), present at a smaller percentage in most alloys, are cytotoxic to T-lymphocyte cell models. Jurkat T cells possess characteristics similar to human T-lymphocytes and proliferate at a faster rate. Jurkat T cells were incubated with control media alone or with concentrations of 1, 10, and 100 microg/mL of Ni(II) or V(V) for 24 h. Both types of metal ions reduced cell viability and proliferation in a dose-dependent manner. Ni(II) at 10 microg/mL and V(V) at 100 microg/mL activated Caspase-3 expression. Hoechst 33258 staining and transmission electron microscopy revealed chromatin condensation, as well as nuclear blebbing and fragmentation. Induction of DNA fragmentation by Ni(II) at 100 microg/mL was also indicated by agarose electrophoresis. Our observations indicate that Ni and V ions kill T cells via apoptotic and nonapoptotic pathways.

Residential care provision in Medicaid home- and community-based waivers: a national study of program trends.

PURPOSE: While state policy and market factors are known to have contributed to the increased supply of residential care, little is known about efforts to accommodate demand from lower-income consumers. This study describes participation and expenditure trends for residential care services funded by Medicaid waivers and examines variation across programs. DESIGN AND METHODS: We collected annually reported Center for Medicare and Medicaid Services (CMS) Form 372 data from state officials for each waiver that provides residential care services for the period 1995 to 2002. Descriptive statistics examined waiver program participation and expenditures while adjusting for population changes and inflation. RESULTS: Between 1995 and 2002, national Medicaid waiver-funded residential care participants increased by almost threefold to 120,000 and expenditures more than quadrupled to 2.3 billion dollars. However, Medicaid waiver program participation and spending varied considerably by state, by target population, and by level of care. IMPLICATIONS: This study highlights three important policy concerns: (a) Medicaid-supported residents remain underrepresented in residential care, (b) large interstate variation persists in Medicaid residential care service provision, and (c) state policy choices favor Medicaid spending on residential care for persons with mental retardation or developmental disabilities.

Tratamento adjuvante da síndrome coronária aguda com supradesnivelamento do segmento ST / ST elevation myocardial infarction adjuvant treatment

Este capítulo discute o tratamento do infarto agudo do miocárdio com supradesnivelamento do segmento 8T na Unidade de Terapia Intensiva e está dividido em medidas gerais e tratamento medicamentoso. As medidas gerais incluem restriçãodas atividades físicas e dieta na fase hospitalar e destacam a necessidade de fornecer informações ao paciente sobre sua doença e as providências que serão tomadas. Cada tópico do tratamento medicamentoso aborda de forma sucinta o mecanismo de ação do fármaco e as evidências científicas para sua utilização, enfatizando as informações úteis para a prática diária.

Consumer discourse in assisted living.

OBJECTIVES: The aim of this article is to discuss the cultural construction of the assisted living consumer. Based on theories of consumer studies, it focuses on organizational strategies employed by assisted living practitioners to promote consumer choice and independence while mediating potential risks. METHODS: Data include field notes, participation in manager-training programs, and interviews with residents and family members during a 22-month study of three Oregon facilities. RESULTS: Consumer discourse is evident in four primary sources, including the state rules, manager-training programs, organizational practices, and an institutional belief in specific consumer demands like independence and choice. DISCUSSION: Personal care is a complex consumer "good" further complicated by residents with cognitive impairments, family demands, payment sources, and the very novelty of the assisted living philosophy. We conclude with a discussion of benefits and pitfalls based on the use of consumer discourse that represents older persons as active consumers, rather than recipients, of long-term care services.

Angina estável: como escolher entre as diferentes formas de investigação? / Stable angina: how to choose between the different diagnosis methods?

A manifestação mais comum da doença isquêmica do coração é a angina estável, que apresenta amplo espectro clínico, de acordo com a idade, a gravidade dos sintomas e a função ventricular esquerda. Atualmente grande variedade de métodos diagnósticos está disponível para avaliação desses pacientes. Os objetivos do presente capítulo são: discutir como optar entre os diferentes recursos disponíveis na prática diária, quais são os critérios utilizados para a escolha entre os diferentes métodos e qual é a seqüência que se deve obedecer buscando racionalizar o atendimento desses pacientes com suspeita de doença arterial coronária.