Use of palliative care and hospice among surgical and medical specialties in the Veterans Health Administration.

IMPORTANCE: Many hospitals have undertaken initiatives to improve care during the end of life, recognizing that some individuals have unique needs that are often not met in acute inpatient care settings. Studies of surgical patients have shown this population to receive palliative care at reduced rates in comparison with medical patients. OBJECTIVE: To determine differences in the use of palliative care and hospice between surgical and medical patients in an integrated health care system. DESIGN, SETTING, AND PARTICIPANTS: Veterans Health Administration (VHA) enrollment data and administrative data sets were used to identify 191,280 VHA patients who died between October 1, 2008, and September 30, 2012, and who had an acute inpatient episode in the VHA system in the last year of life. Patients were categorized as surgical if at any time during the year preceding death they underwent a surgical procedure (n = 42,143) or medical (n = 149,137) if the patient did not receive surgical treatment in the last year of life. MAIN OUTCOMES AND MEASURES: Receipt of palliative or hospice care and the number of days from palliative or hospice initiation to death were determined using VHA administrative inpatient, outpatient, and fee-based encounter-level data files. RESULTS: Surgical patients were significantly less likely than medical patients to receive either hospice or palliative care (odds ratio = 0.91; 95% CI, 0.89-0.94; P < .001). When adjusting for demographics and medical comorbidities, this difference was even more pronounced (odds ratio = 0.84; 95% CI, 0.81-0.86). Yet, among patients who received hospice or palliative care, surgical patients lived significantly longer than their medical counterparts (a median of 26 vs 23 days, respectively; P < .001) yet had similar relative use of these services after risk adjustment. CONCLUSIONS AND RELEVANCE: In the VHA population, surgical patients are less likely to receive either hospice or palliative care in the year prior to death compared with medical patients, yet surgical patients have a longer length of time in these services. Determining criteria for higher-risk medical and surgical patients may help with increasing the relative use of these services. Potential barriers and differences may exist among surgical and medical services that could impact the use of palliative care or hospice in the last year of life.

Barriers to breastfeeding in a resident clinic.

Despite the known health benefits for mother and infant, compliance with exclusive breastfeeding continues to challenge many healthcare providers. In an ongoing attempt to maintain the goals of the Healthy People 2010 initiative, our institution set out to identify patients with suboptimal breastfeeding rates in order to recognize potential barriers. Review of breastfeeding rates at the time of discharge noted significantly lower participation by clinic patients. In order to develop successful interventions, the aim of this study was to survey clinic patients to determine their intentions, attitudes, and obstacles to the practice of exclusive breastfeeding. In total, 188 surveys were completed during a 2-month time period. Respondents were primarily Hispanic (76.4% vs. 9.6% black and 8.4% white) and multiparous (57.5%) with a mean age of 25.7 years (range, 15-39 years old). Although 95.3% of respondents indicated that they believed breastmilk provided adequate nutrition, only 35.3% planned on exclusively breastfeeding. Access to free formula through the Special Supplemental Nutrition Program for Women, Infants and Children was the most common reason not to breastfeed (48.3%), followed by fear of pain and the need to return to work/school. Patients reported that the person with the greatest influence on their decision to breastfeed was their partner/spouse. Access to a lactation counselor was the most popular intervention requested, even among experienced multiparous patients (78.9% of whom had previously breastfed). In conclusion, the survey indicated that planned exclusive breastfeeding rates are low among this inner-city resident clinic and interventions should include involvement of the partners/spouses and access to lactational support.

Effect of pH on surface characteristics of switchgrass-derived biochars produced by fast pyrolysis.

Surface properties of switchgrass-derived biochars produced at fast pyrolysis temperatures of 450, 600 and 800 °C were characterized at different solution pHs in order to determine the structural and chemical changes of artificially-weathered biochars when incorporated into soil. As biochars were acidified from pH 7 to 3, crystalline minerals dissolved slowly releasing nutrients; however, residual minerals were still detected in biochars produced at higher pyrolysis temperatures after pH treatment. Moreover, the amount of exchangeable bases and other inorganic compounds released from the biochars increased when pH decreased. As minerals dissolved from the biochars, total surface area and pore volume were found to increase. Surface functional groups and water vapor adsorption capacity at 0.8 P/Po also increased, whereas the potential CEC of biochars decreased due to the replacement of exchangeable sites by hydrogen ion. Therefore, during the aging process, it is predicted that soil-incorporated biochars will slowly release nutrients with changes in surface functionality and porosity, which are expected to enhance water holding capacity of soil and provide a beneficial habitat for microbial colonization.

NEUROPSYCHOLOGICAL PREDICTORS OF SAFETY IN URBAN LEFT-TURN SCENARIOS.

Left turns at urban intersections can be dangerous, especially when views are obstructed or pedestrians are present. Impairments in driver vision, motor, and cognition functions may further increase left-turn risk. We examined this problem in a simulated environment that included left-turn scenarios to study the driving behaviors of 28 drivers, ages 37 to 88 years, six of whom had "Useful Field of View" (UFOV) impairments. Subjects also completed a battery of neuropsychological tests. The simulated drive included an urban section with six left turns in three types of scenarios: 1) a semi truck blocking the view of oncoming traffic, 2) a lead vehicle obstruction, and 3) a pedestrian crossing ahead of the turning driver. Results showed a mean (SD) of 1.46 (1.60) collisions per driver (range 0 to 7), 83% of which occurred at intersections with semi trucks. Far visual acuity, contrast sensitivity, UFOV, Mini Mental State Examination, Trail-Making Test Part B, the Wisconsin Card Sort task, and age were all associated with the total number of collisions (Pearson correlation magnitudes between 0.37 to 0.77; p-values<0.05). Spearman correlations were less significant. Findings indicate that visual obstruction by on oncoming semi-truck is a particularly dangerous left-turn situation.

Reported experiences with prenatal care: is there a difference in patient satisfaction based on racial and ethnic background?

Pregnant women were queried to determine if racial and ethnic disparities exist in prenatal care by assessing their satisfaction in private and clinic practices. An anonymous survey was distributed in both English and Spanish and focused on demographics, satisfaction and cultural sensitivity. A total of 273 surveys were collected. Demographics of clinic patients (Hispanic 62%, Black 26.4%, and Caucasian 5%) varied significantly (P < 0.001) from private patients (Caucasian 62.5%, Black 14.1%, and Hispanic 18.8%). Significant differences were noted between clinic and private patients' in their country of birth, education, income, insurance, employment status, home ownership, and planned pregnancies. Patients reported that their prenatal care was influenced by race (27% clinic vs 5% private, P < 0.001) and language (24.9% clinic vs 4.9% private, P = 0.004). Race andlanguagewere morelikelyto influence clinic patients' perceptions of the prenatal care received as compared to those seeking care in private practices.

Neuropsychological assessment of driving safety risk in older adults with and without neurologic disease.

Decline in cognitive abilities can be an important contributor to the driving problems encountered by older adults, and neuropsychological assessment may provide a practical approach to evaluating this aspect of driving safety risk. The purpose of the present study was to evaluate several commonly used neuropsychological tests in the assessment of driving safety risk in older adults with and without neurological disease. A further goal of this study was to identify brief combinations of neuropsychological tests that sample performances in key functional domains and thus could be used to efficiently assess driving safety risk. A total of 345 legally licensed and active drivers over the age of 50, with no neurologic disease (N = 185), probable Alzheimer's disease (N = 40), Parkinson's disease (N = 91), or stroke (N = 29), completed vision testing, a battery of 10 neuropsychological tests, and an 18-mile drive on urban and rural roads in an instrumented vehicle. Performances on all neuropsychological tests were significantly correlated with driving safety errors. Confirmatory factor analysis was used to identify 3 key cognitive domains assessed by the tests (speed of processing, visuospatial abilities, and memory), and several brief batteries consisting of one test from each domain showed moderate corrected correlations with driving performance. These findings are consistent with the notion that driving places demands on multiple cognitive abilities that can be affected by aging and age-related neurological disease, and that neuropsychological assessment may provide a practical off-road window into the functional status of these cognitive systems.

Differential contribution of dendritic cell CD1d to NKT cell-enhanced humoral immunity and CD8+ T cell activation.

CD1d-restricted type I NKT cells provide help for specific antibody production. B cells, which have captured and presented a T-dependent, antigen-derived peptide on MHC class II and CD1d-binding glycolipid α-GC on CD1d, respectively, activate Th and NKT cells to elicit B cell help. However, the role of the DC CD1d in humoral immunity remains unknown. We therefore constructed mixed bone marrow chimeras containing CD1d-expressing, DTR-transgenic DCs and CD1d(+) or CD1d(-) nontransgenic DCs. Following DT-mediated DC ablation and immunization, we observed that the primary and secondary antibody responses were equivalent in the presence of CD1d(+) and CD1d(-) DCs. In contrast, a total ablation of DCs delayed the primary antibody response. Further experiments revealed that depletion of CD1d(+) DCs blocked in vivo expansion of antigen-specific cytotoxic (CD8(+)) T lymphocytes. These results provide a clear demonstration that although CD1d expression on DCs is essential for NKT-enhanced CD8(+) T cell expansion, it is dispensable for specific antibody production.

Distracted driving in elderly and middle-aged drivers.

Automobile driving is a safety-critical real-world example of multitasking. A variety of roadway and in-vehicle distracter tasks create information processing loads that compete for the neural resources needed to drive safely. Drivers with mind and brain aging may be particularly susceptible to distraction due to waning cognitive resources and control over attention. This study examined distracted driving performance in an instrumented vehicle (IV) in 86 elderly (mean=72.5 years, SD=5.0 years) and 51 middle-aged drivers (mean=53.7 years, SD=9.3 year) under a concurrent auditory-verbal processing load created by the Paced Auditory Serial Addition Task (PASAT). Compared to baseline (no-task) driving performance, distraction was associated with reduced steering control in both groups, with middle-aged drivers showing a greater increase in steering variability. The elderly drove slower and showed decreased speed variability during distraction compared to middle-aged drivers. They also tended to "freeze up", spending significantly more time holding the gas pedal steady, another tactic that may mitigate time pressured integration and control of information, thereby freeing mental resources to maintain situation awareness. While 39% of elderly and 43% of middle-aged drivers committed significantly more driving safety errors during distraction, 28% and 18%, respectively, actually improved, compatible with allocation of attention resources to safety critical tasks under a cognitive load.

Predictors of driving outcomes in advancing age.

This study aimed to develop predictive models for real-life driving outcomes in older drivers. Demographics, driving history, on-road driving errors, and performance on visual, motor, and neuropsychological test scores at baseline were assessed in 100 older drivers (ages 65-89 years [72.7]). These variables were used to predict time to driving cessation, first moving violation, or crash. Using Cox proportional hazards regression models, significant individual predictors for driving cessation were greater age and poorer scores on Near Visual Acuity, Contrast Sensitivity, Useful Field of View, Judgment of Line Orientation, Trail Making Test-Part A, Benton Visual Retention Test, Grooved Pegboard, and a composite index of overall cognitive ability. Greater weekly mileage, higher education, and "serious" on-road errors predicted moving violations. Poorer scores from Trail Making Test-Part B or Trail Making Test (B-A) and serious on-road errors predicted crashes. Multivariate models using "off-road" predictors revealed (a) age and Contrast Sensitivity as best predictors for driving cessation; (b) education, weekly mileage, and Auditory Verbal Learning Task-Recall for moving violations; and (c) education, number of crashes over the past year, Auditory Verbal Learning Task-Recall, and Trail Making Test (B-A) for crashes. Diminished visual, motor, and cognitive abilities in older drivers can be easily and noninvasively monitored with standardized off-road tests, and performances on these measures predict involvement in motor vehicle crashes and driving cessation, even in the absence of a neurological disorder.

Cognitive functioning predicts driver safety on road tests 1 and 2 years later.

OBJECTIVES: To describe longitudinal changes in mean level and evaluate rank-order stability in potential predictors of driving safety (visual sensory, motor, visual attention, and cognitive functioning) and safety errors during an 18-mile on-road driving test in older adults and to evaluate the relative predictive power of earlier visual sensory, motor, visual attention, and cognitive functioning on future safety errors, controlling for earlier driving capacity. DESIGN: Three-year longitudinal observational study. SETTING: Large teaching hospital in the Midwest. PARTICIPANTS: One hundred eleven neurologically normal older adults (60-89 at baseline). MEASUREMENTS: Safety errors based on video review of a standard 18-mile on-road driving test served as the outcome measure. A comprehensive battery of tests on the predictor side included visual sensory functioning, motor functioning, cognitive functioning, and a measure of useful field of view. RESULTS: Longitudinal changes in mean levels of safety errors and cognitive functioning were small from year to year. Relative rank-order stability between consecutive assessments was moderate in overall safety errors and moderate to strong in visual attention and cognitive functioning. Although prospective bivariate correlations between safety errors and predictors ranged from fair to moderate, only functioning in the cognitive domain predicted future driver performance 1 and 2 years later in multivariate analyses. CONCLUSION: Normative aging-related declines in driver performance as assessed using on-road tests emerge slowly. Even in the presence of conservative controls, such as previous driving ability, age, and visual sensory and motor functioning, cognitive functioning predicted future on-road driving performance 1 and 2 years later.

Global biogeography and quantitative seasonal dynamics of Gemmatimonadetes in soil.

Bacteria belonging to phylum Gemmatimonadetes comprise approximately 2% of soil bacterial communities. However, little is known of their ecology due to a lack of cultured representation. Here we present evidence from biogeographical analyses and seasonal quantification of Gemmatimonadetes in soils, which suggests an adaptation to low soil moisture.

Reduction of CD1d expression in vivo minimally affects NKT-enhanced antibody production but boosts B-cell memory.

The CD1d-binding glycolipid α-galactosylceramide exerts potent adjuvant effects on T-dependent humoral immunity. The mechanism is driven by cognate interaction between CD1d-expressing B cells and TCR-expressing type I CD1d-restricted NKT cells. Thus, far positive effects of alpha-galactosylceramide have been observed on initial and sustained antibody titers as well as B-cell memory. Following vaccination, each of these features is desirable, but good B-cell memory is of paramount importance for long-lived immunity. We therefore tested the hypothesis that CD1d expression in vivo differentially affects initial antibody titers versus B-cell memory responses. CD1d(+/+) and CD1d(+/-) mice were generated and immunized with antigen plus CD1d ligand before analysis of cytokine expression, CD40L expression, initial and longer term antibody responses and B-cell memory. As compared with CD1d(+/+) controls, CD1d(+/-) mice had equivalent numbers of total NKT cells, lower cytokine production, fewer CD40L-expressing NKT cells, lower initial antibody responses, similar long-term antibody responses and higher B-cell memory. Our data indicate that weak CD1d antigen presentation may facilitate good B-cell memory without compromising antibody responses. This work may impact vaccine design since over-stimulation of NKT cells at the time of vaccination may not lead to optimal B-cell memory.

Neuropsychological predictors of driving errors in older adults.

OBJECTIVES: To identify neuropsychological factors associated with driving errors in older adults. DESIGN: Cross-sectional observational study. SETTING: Neuropsychological assessment laboratory and an instrumented vehicle on a 35-mile route on urban and rural roads. PARTICIPANTS: One hundred eleven older adult drivers (aged 65-89; mean age 72.3) and 80 middle-aged drivers (aged 40-64; mean age 57.2). MEASUREMENTS: Explanatory variables included age, neuropsychological measures (cognitive, visual, and motor), and a composite cognitive score (COGSTAT). The outcome variable was the safety error count, as classified according to video review using a standardized taxonomy. RESULTS: Older drivers committed an average of 35.8 +/- 12.8 safety errors per drive, compared with an average of 27.8 +/- 9.8 for middle-aged drivers (P<.001). For older drivers, there was an increase of 2.6 errors per drive observed for each 5-year age increase (P=.03). After adjustment for age, education, and sex, COGSTAT was a significant predictor of safety errors in older drivers (P=.005), with an approximately 10% increase in safety errors observed for a 10% decrease in cognitive function. Individual significant predictors of more safety errors in older drivers included poorer scores on the Complex Figure Test--Copy, the Complex Figure Test--Recall, Block Design, Near Visual Acuity, and the Grooved Pegboard task. CONCLUSION: Driving errors in older adults tend to increase, even in the absence of neurological diagnoses. Age-related decline in cognitive abilities, vision, and motor skills can explain some of this increase. Changes in visuospatial and visuomotor abilities appear to be particularly associated with unsafe driving in old age.

Gender preferences in ObGyn clinic vs private patients.

PURPOSE: To determine whether clinic patients, compared to private practice patients, are more likely to prefer seeing a female physician. METHOD: Connecticut women were surveyed from August through September 2001, inclusive, about the attributes they desire in an ObGyn provider. Clinic patient responses were analyzed in comparison to private patients. RESULTS: A total of 262 women completed the survey (32 clinic and 232 private practice patients). Demographics of the subgroups differed, as the clinic patients more likely to be younger, not married, and were primarily Hispanic. Clinic patients reported a decreased opportunity to choose the gender of their provider (33.4% vs 62.8%) and were more likely to prefer a female provider (79.3% vs 36.9%). Unlike the private patients, most clinic patients responded that female providers are more knowledgeable and understanding of women's health issues. CONCLUSIONS: Clinic patients have a stronger preference for female ObGyn's compared to private patients. Medical students who rotate through outpatient ObGyn clinic's are likely to have different patient encounter experiences than students who spend time in private ObGyn offices.

ASCERTAINMENT OF ON-ROAD SAFETY ERRORS BASED ON VIDEO REVIEW.

Using an instrumented vehicle, we have studied several aspects of the on-road performance of healthy and diseased elderly drivers. One goal from such studies is to ascertain the type and frequency of driving safety errors. Because the judgment of such errors is somewhat subjective, we applied a taxonomy system of 15 general safety error categories and 76 specific safety error types. We also employed and trained professional driving instructors to review the video data of the on-road drives. In this report, we illustrate our rating system on a group of 111 drivers, ages 65 to 89. These drivers made errors in 13 of the 15 error categories, comprising 42 of the 76 error types. A mean (SD) of 35.8 (12.8) safety errors per drive were noted, with 2.1 (1.7) of them being judged as serious. Our methodology may be useful in applications such as intervention studies, and in longitudinal studies of changes in driving abilities in patients with declining cognitive ability.

Qualities and attributes desired in menopause clinicians.

OBJECTIVE: To assess the qualities and attributes desired in menopause clinicians. DESIGN: Women > or =45 years of age (n=72) were surveyed about the qualities and attributes desired in their physician. Surveys were performed in physician waiting rooms in Connecticut. RESULTS: Although fewer men are entering the practice of ObGyn, more than 88% of peri- and post-menopausal women believe that gender does not affect the quality of their women's health provider. Among the 68 women from whom valid data were obtained, experience (95.6%), knowledge (95.6%), and ability (92.6%) were the most important qualities. Only 4.2% listed gender in the top three most important qualities. If the patient's visit was for wellness- and screening-related issues, 6.6% (n=4) preferred a male, 13.1% (n=8) preferred a female, and 80.3% (n=49) had no preference for gender. The percentage of patients preferring to see a female was slightly higher (29.2%) if the visit was for a pelvic exam, while the percentage preferring to see a male (14.5%) was greater if care involved gynecological surgery. CONCLUSIONS: As medical practices meet the increasing demand of menopausal women, it is helpful to know the qualities and attributes that patients desire. Menopause clinicians should seek to convey experience, knowledge, and competence to their patients. A menopause practice should strive for a well-diversified team that will bring these qualities to menopausal patients. Given the shifting balance of male and female ObGyn providers, when hiring providers or establishing a menopause clinic, it is helpful to know that gender diversification is of minor importance.

Predicted impact and evaluation of North Carolina's phosphorus indexing tool.

Increased concern about potential losses of phosphorus (P) from agricultural fields receiving animal waste has resulted in the implementation of new state and federal regulations related to nutrient management. In response to strengthened nutrient management standards that require consideration of P, North Carolina has developed a site-specific P indexing system called the Phosphorus Loss Assessment Tool (PLAT) to predict relative amounts of potential P loss from agricultural fields. The purpose of this study was to apply the PLAT index on farms throughout North Carolina in an attempt to predict the percentage and types of farms that will be forced to change management practices due to implementation of new regulations. Sites from all 100 counties were sampled, with the number of samples taken from each county depending on the proportion of the state's agricultural land that occurs in that county. Results showed that approximately 8% of producers in the state will be required to apply animal waste or inorganic fertilizer on a P rather than nitrogen basis, with the percentage increasing for farmers who apply animal waste (approximately 27%). The PLAT index predicted the greatest amounts of P loss from sites in the Coastal Plain region of North Carolina and from sites receiving poultry waste. Loss of dissolved P through surface runoff tended to be greater than other loss pathways and presents an area of concern as no best management practices (BMPs) currently exist for the reduction of in-field dissolved P. The PLAT index predicted the areas in the state that are known to be disproportionately vulnerable to P loss due to histories of high P applications, high densities of animal units, or soil type and landscapes that are most susceptible to P loss.

Do women prefer care from female or male obstetrician-gynecologists? A study of patient gender preference.

OBJECTIVE: To determine whether men should be encouraged to enter the medical specialty of obstetrics and gynecology. METHODS: A self-administered survey was designed for and distributed to patients (N=264) in 13 obstetrics and gynecology waiting rooms in Connecticut. The survey was used to determine whether there were any patient preferences with regard to the gender of physicians providing obstetric and gynecologic care within this population. In addition, the rationale for any preferences was analyzed. RESULTS: The majority of patients (66.6%) had no gender bias when selecting an obstetrician-gynecologist, and an even larger majority (198, 80.8%) felt that physician gender does not influence quality of care. There was no statistical difference in patient satisfaction based on physician sex. Respondents self-reporting gender bias rarely selected obstetrician-gynecologists based solely on this factor and frequently choose physicians of the sex that was not their indicated preference, suggesting that several factors other than gender preference are more important in physician selection. CONCLUSIONS: The majority of women surveyed did not select their obstetrician-gynecologists based solely on physician gender. Although a small percentage of survey respondents did indicate a gender preference, it rarely influenced physician selection and was only a minor consideration when compared with other desirable physician attributes.