Drilling on the edge.

To understand the glaciers holding back meters of sea level rise, climate scientists swoop in to extract ice from Antarctica's remote west coast.

Care Partner Confidence and Experiences in Legal Planning for People Living with Dementia: A Mixed Methods Study.

BACKGROUND AND OBJECTIVES: Care partners of persons living with dementia perform complex legal planning tasks. The purpose of this study was to survey care partners in the United States to understand their confidence and experience in performing legal planning tasks. RESEARCH DESIGN AND METHODS: This study used a parallel-mixed methods research design. We administered a web-based survey to 318 adults who self-identified as care partners of persons living with dementia. The survey contained Likert scale questions and open-ended questions about legal planning tasks. Multivariate linear regression was used to analyze quantitative data and inductive thematic analysis was used to analyze qualitative data. RESULTS: Care partners were on average 53 years of age and 78% female. The three topics in which participants were least confident were: protecting oneself legally as a care partner; options when legal documents are not in place and a family member is not legally competent; and circumstances when legal documents should be updated or renewed. We observed significant differences in legal planning confidence between newer and more experienced care partners (p<.001); lower- and higher-income care partners (p=.01); and adult child versus spousal care partners (p<.001). Thematic analysis revealed that legal planning challenges include initiating a conversation with the person living with dementia, understanding and using legal materials, and accessing materials that accommodate individual differences. DISCUSSION AND IMPLICATIONS: It is vital to develop legal planning interventions that are tailored to specific subgroups of care partners, and to maximize the clarity, comprehensiveness, and accessibility of available legal planning education.

Myth of Alaskan city's immunity to tsunamis dispelled.

Lucky low tide helped Anchorage dodge catastrophic 1964 tsunami, first analysis of location's risk finds.

Co-Design of a Financial and Legal Planning Tool for Care Partners of People Living With Alzheimer's Disease and Related Dementias.

Background and Objectives: Care partners of people living with Alzheimer's disease and related dementias (ADRD) are faced with substantial legal and financial planning related to their care partner role. However, many care partners lack the legal and financial support needed to manage this role. The purpose of this study was to engage ADRD care partners in a remote participatory design process to create a technology-based financial and legal planning tool that meets care partner needs. Research Design and Methods: We formed 2 researcher-facilitated co-design teams comprised of n = 5 ADRD care partners each. We conducted a series of 5 parallel co-design sessions aimed to engage co-designers in interactive discussions and design activities to create the financial and legal planning tool. We used inductive thematic analysis of design session recordings to identify design requirements. Results: Co-designers were 70% female with a mean age of 67.3 years (standard deviation 9.07) and cared for a spouse (80%) or a parent (20%). Between Sessions 3 and 5, the average system usability scale score of the prototype increased from 89.5 to 93.6, indicating high usability. Analyses yielded 7 overarching design requirements for a legal and financial planning tool: support for action now (eg, prioritized to-do lists); support for action later (eg, reminders for keeping legal documents up-to-date); knowledge when I need it (eg, tailored learning modules); connection to resources I need (eg, state-specific financial support opportunities); everything where I can see it (eg, comprehensive care budgeting tool); sense of privacy and security (eg, password protection); and accessibility for all (eg, tailoring for low-income care partners). Discussion and Implications: The design requirements identified by co-designers provide a foundation from which we can build technology-based solutions to support ADRD care partners in financial and legal planning.

Credibility dilemmas under the Paris agreement: explaining fossil fuel subsidy reform references in INDCs.

Fossil fuel subsidies are a market distortion commonly identified as an obstacle to decarbonization. Yet  due to trenchant political economic risks, reform attempts can be fraught for governments. Despite these concerns, an institutionally and economically diverse group of states included references to fossil fuel subsidy reform (FFSR) in their Intended Nationally Determined Contributions (INDCs) under the Paris Agreement. What conditions might explain why some states reference politically risky reforms within treaty commitments, while most others would not? We argue that the Article 4 process under the Paris Agreement creates a "credibility dilemma" for states-articulating ambitious emissions reduction targets while also defining national climate plans engenders a need to seek out appropriate policy ideas that can justify overarching goals to international audiences. Insomuch as particular norms are institutionalized and made salient in international politics, a window of opportunity is opened: issue advocates can "activate" norms by demonstrating how related policies can make commitments credible. Using mixed methods, we find support for this argument. We identify contextual factors advancing FFSR in the lead-up to the Paris Agreement, including norm institutionalization in regimes and international organization programs as well as salience-boosting climate diplomacy. Further, we find correspondences between countries targeted by transnational policy advocates and FFSR references in INDCs, building on the momentum in international politics more generally. Though drafting INDCs and NDCs is a government-owned process, the results suggest that understanding their content requires examining international norms alongside domestic circumstances.

Correction: A Web-Based Platform (CareVirtue) to Support Caregivers of People Living With Alzheimer Disease and Related Dementias: Mixed Methods Feasibility Study.

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"It made me feel like I wasn't alone in the darkness": exploring dementia care network communication and coordination through a digital health platform.

OBJECTIVE: To explore the use of a shared communication and coordination platform-the CareVirtue journal feature-for care networks of people living with Alzheimer's disease and related dementias to inform the design of care network support technologies. MATERIALS AND METHODS: In the primary study, care networks comprised the primary caregiver and other caregivers they invited to participate (eg, family members, in-home aides) used CareVirtue, for 60 days followed by a semistructured interview to explore primary caregivers' perceptions of usefulness. This secondary analysis focused on use of the shared journal feature of CareVirtue, which allowed care networks to communicate through posts that were shared with the network and to which network members could respond. Journal posts were analyzed using a deductive/inductive content analysis to categorize information behavior. We also conducted a thematic analysis of the interviews to identify primary caregivers' perceptions of the journal's usefulness. RESULTS: Care networks used the journal for: (1) information acquisition, (2) information sharing, (3) strategy development, and (4) information feedback. Thematic analysis revealed that caregivers felt the journal was useful at the individual, care network, and relational levels and that journal integration was influenced by care network structure and relationships. DISCUSSION: Care networks used the journal to document, share, and acquire information; co-create strategies; and provide support. The usefulness of this shared communication and coordination platform included individual and care network level benefits. CONCLUSION: These findings point to the importance of caregiver-centered technologies that support both the individual primary caregiver and the care network.

A Web-Based Platform (CareVirtue) to Support Caregivers of People Living With Alzheimer Disease and Related Dementias: Mixed Methods Feasibility Study.

BACKGROUND: People living with Alzheimer disease and related dementias (ADRD) require prolonged and complex care that is primarily managed by informal caregivers who face significant unmet needs regarding support for communicating and coordinating across their informal care network. To address this unmet need, we developed CareVirtue, which provides (1) the ability to invite care network members; (2) a care guide detailing the care plan; (3) a journal where care network members can document, communicate, and coordinate; (4) a shared calendar; and (5) vetted geolocated caregiver resources. OBJECTIVE: This study aims to evaluate CareVirtue's feasibility based on: (1) Who used CareVirtue? (2) How did caregivers use CareVirtue? (3) How did caregivers perceive the acceptability of CareVirtue? (4) What factors were associated with CareVirtue use? METHODS: We conducted a feasibility study with 51 care networks over a period of 8 weeks and used a mixed methods approach that included both quantitative CareVirtue usage data and semistructured interviews. RESULTS: Care networks ranged from 1 to 8 members. Primary caregivers were predominantly female (38/51, 75%), White (44/51, 86%), married (37/51, 73%), college educated (36/51, 71%), and were, on average, 60.3 (SD 9.8) years of age, with 18% (9/51) living in a rural area. CareVirtue usage varied along 2 axes (total usage and type of usage), with heterogeneity in how the most engaged care networks interacted with CareVirtue. Interviews identified a range of ways CareVirtue was useful, including practically, organizationally, and emotionally. On the Behavioral Intention Scale, 72% (26/36) of primary caregivers reported an average score of at least 3, indicating an above average intention to use. The average was 81.8 (SD 12.8) for the System Usability Scale score, indicating "good" usability, and 3.4 (SD 1.0) for perceived usefulness, suggesting above average usefulness. The average confidence score increased significantly over the study duration from 7.8 in week 2 to 8.9 in week 7 (P=.005; r=0.91, 95% CI 0.84-0.95). The following sociodemographic characteristics were associated with posting in the journal: retired (mean 59.5 posts for retired caregivers and mean 16.9 for nonretired caregivers), income (mean 13 posts for those reporting >US $100K and mean 55.4 for those reporting

Models for Access to Maternal Smoking cessation Support (MAMSS): a study protocol of a quasi-experiment to increase the engagement of pregnant women who smoke in NHS Stop Smoking Services.

BACKGROUND: Maternal smoking is a key cause of poor outcomes for mothers, babies and children and Wales has higher rates of smoking in pregnancy than any other UK country. Despite various improvements within the NHS Stop Smoking Service to strengthen the intervention for pregnant women, referrals and successful quit attempts for this group have continued to remain extremely low. A key element of UK national guidance for smoking cessation during pregnancy is to provide a flexible and tailored service to help increase levels of engagement. This study aims to test the effectiveness of three different models of service delivery to address the gap in the evidence base about how to deliver a flexible, tailored smoking cessation service to pregnant women. METHODS: This study will adopt a quasi-experimental design over a 12 month period. The setting is four of Wales' seven Health Boards using an integrated approach between maternity services, local public health teams and the NHS Stop Smoking Service. Core recommendations from UK public health guidance are being implemented across intervention and usual care sites. Stop smoking support for pregnant women in intervention sites is being delivered more flexibly than in usual care sites. Both qualitative and quantitative approaches will be adopted to capture important contextual information and consider multiple perspectives. A health economic analysis will be undertaken using a cost-consequences analysis approach. The primary outcome measure is engagement with stop smoking services (defined as having at least one face-to-face therapeutic contact with a clinician). DISCUSSION: Supporting pregnant women to stop smoking is a challenging area of public health. The proposed study will address several areas where there are key evidence gaps relating to smoking cessation interventions for pregnant women. Specifically, how best to encourage pregnant women to attend a specialist stop smoking support service, how to deliver the service and who should provide it.

Proposal for a bariatric mortality risk classification system for patients undergoing bariatric surgery.

BACKGROUND: An obesity surgery mortality risk score derived from a single clinical series can be used to stratify the mortality risk of patients undergoing gastric bypass. However, such a scoring system does not take into account 2 important factors in contemporary bariatric surgery--increased use of the laparoscopic approach and laparoscopic adjustable gastric banding. The present study analyzed the preoperative factors that might predict in-hospital mortality after bariatric surgery using data from academic medical centers and proposes a classification system for predicting mortality. METHODS: Using the "International Classification of Diseases, 9th revision," diagnosis and procedural codes, the data for all patients who underwent bariatric surgery for the treatment of morbid obesity from 2002 to 2009 were obtained from the University HealthSystem Consortium database. The limitations of this database included the lack of the body mass index and the underestimation of some co-morbidities, such as sleep apnea. Multiple regression analyses were performed to determine the factors predictive of greater in-hospital mortality. The factors examined included race, gender, age, co-morbidities, surgical technique (laparoscopic versus open), bariatric operation (gastric bypass versus nongastric bypass), and payer type. A scoring system was devised by assigning 1 point for each major factor (those with an adjusted odds ratio [AOR] of ≥2.0) and .5 point for each minor factor (those with an AOR <2.0). Using contemporary data from 2007 to 2009, the in-hospital mortality was analyzed according to the classification: class I, 0-0.5 point; class II, 1.0-1.5 points; class III, 2.0-3.0 points; and class IV, ≥3.5 points. RESULTS: During the 8-year period, 105,287 patients underwent bariatric surgery. The operations included laparoscopic gastric bypass (45%), open gastric bypass (41%), and laparoscopic gastric banding or gastroplasty (14%). The overall in-hospital mortality rate was .17%. The number of deaths per 1000 bariatric operations decreased from 4.0 in 2002 to .6 in 2009. Using regression analyses, the factors predictive of greater in-hospital mortality were male gender (AOR 3.2), gastric bypass procedure (AOR 5.8), open surgical technique (AOR 4.8), Medicare payer (AOR 3.0), diabetes (AOR 1.6), and age >60 years (AOR 1.9). The mortality rate was .10% for class I patients, .15% for class II, .33% for class III, and .70% for class IV (P < .05 among all classes). CONCLUSION: Within the context of academic centers, the mortality after bariatric surgery has decreased substantially since 2002, with an increase in the use of the laparoscopic technique and laparoscopic gastric banding. A bariatric mortality risk classification system was developed to stratify mortality, given the limits of this database, which does not include the body mass index and underestimates the incidence of sleep apnea. It might be useful to aid surgeons in surgical decision-making, to inform patients of their risks, and for quality improvement reporting purposes.

Minimally invasive esophagectomy with and without gastric ischemic conditioning.

BACKGROUND: Esophagectomy can be associated with significant morbidity such as leaks and strictures. Preoperative gastric ischemic conditioning is a concept aimed at inducing an ischemic insult to the gastric fundus and cardia prior to esophagectomy, thus leading to improvement of gastric perfusion. METHODS: This retrospective study compared outcome data from 81 patients who underwent esophagectomy after laparoscopic gastric ischemic conditioning with that from 71 patients who underwent esophagectomy without conditioning. Gastric ischemic conditioning consisted of laparoscopic division of the left gastric vessels ± the short gastric vessels. The time interval from gastric ischemic conditioning to esophagectomy ranged from 2 to 75 days. Main outcome measures included demographics, mean time interval between staging and esophagectomy, and the rate of leaks and strictures following esophagectomy. RESULTS: The two groups were comparable with respect to gender and age. In the gastric ischemic conditioning procedures, there were no conversions; the mean operative time was 57 ± 15 min, the mean length of hospital stay was 1.0 ± 1.1 days, and the rate of postoperative complications was 3.7%. The mean time interval between gastric ischemic conditioning and esophagectomy was 6.0 ± 5.4 days. There were no significant differences in the leak rate (11.1% for conditioning vs. 8.5% without conditioning) or stricture rate (29.6% for conditioning vs. 25.3% without conditioning) between the two groups. CONCLUSIONS: Laparoscopic gastric ischemic conditioning is feasible and safe. However, the use of gastric ischemic conditioning in this study did not alter the clinical rate of postoperative leaks and strictures.

Outcome of laparoscopic adjustable gastric banding and prevalence of band revision and explantation at academic centers: 2007-2009.

BACKGROUND: Laparoscopic adjustable gastric banding is gaining in popularity in the United States. Our objective was to examine the outcomes of laparoscopic adjustable gastric banding and the prevalence of band revision and explantation at academic medical centers. METHODS: Using the "International Classification of Diseases, 9th revision," diagnosis and procedure codes, data were obtained from the University Health System Consortium Clinical Database for all laparoscopic adjustable gastric banding procedures performed from 2006 to 2009. The outcome measures included demographics, length of hospital stay, perioperative morbidity, mortality, and the prevalence of band revision and explantation. RESULTS: A total of 10,151 laparoscopic gastric banding procedures were performed from January 2007 to December 2009. The mean length of stay was 1.2 days. The perioperative morbidity rate was 3.0%, and the in-hospital mortality rate was .03%. The prevalence of band revision was .76% and of band explantation was .87%. Compared with the outcome of primary gastric banding, gastric band revision or explantation was associated with a longer length of hospital stay, greater perioperative morbidity, and greater cost. CONCLUSION: Within the context of the 3-year period of analysis, laparoscopic gastric banding was associated with low perioperative morbidity and mortality and a low prevalence of band revision and explantation.

Laparoscopic enucleation or wedge resection of benign gastric pathology: analysis of 44 consecutive cases.

Laparoscopic resection of gastric submucosal tumors has been described, but the role of laparoscopy for tumors within the esophagus or near the gastroesophageal junction is not clearly defined. The aim of this study was to examine the outcomes of laparoscopic or thoracoscopic enucleation or wedge resection of benign gastric tumors. The charts of 44 patients who underwent minimally invasive resection of benign esophagogastric tumors were reviewed. Surgical approaches included thoracoscopic enucleation (n = 2), laparoscopic enucleation (n = 6), transgastric enucleation (n = 2), and laparoscopic gastric wedge resection (n = 34). There were 23 males with a mean age of 57 years. There was one conversion (2.5%) to laparotomy. Mean operative time was 97 ± 52 minutes. The mean length of hospital stay was 2.6 ± 2.0 days. One patient developed gastric outlet obstruction requiring Roux-en-Y reconstruction. There were no leaks and the 90-day mortality was zero. Pathology demonstrated gastrointestinal stromal tumor (n = 31), leiomyoma (n = 6), and other benign pathology (n = 7). There has been one tumor recurrence at a mean follow-up of 4.3 years. The laparoscopic approaches to local resection of gastric tumors are safe and feasible. The type of minimally invasive surgical approaches should be tailored based on the location and size of the lesion.