Identifying the generalizable controls on insect associations of native and non-native trees.

Trees growing outside their native geographic ranges often exhibit exceptional growth and survival due in part to the lack of co-evolved natural enemies that may limit their spread and suppress population growth. While most non-native trees tend to accumulate natural enemies over time, it remains uncertain which host and insect characteristics affect these novel associations and whether novel associations follow patterns of assembly similar to those of native hosts. Here, we used a dataset of insect-host tree associations in Europe to model which native insect species are paired with which native tree species, and then tested the model on its ability to predict which native insects are paired with which non-native trees. We show that native and non-native tree species closely related to known hosts are more likely to be hosts themselves, but that native host geographic range size, insect feeding guild, and sampling effort similarly affect insect associations. Our model had a strong ability to predict which insect species utilize non-native trees as hosts, but evolutionarily isolated tree species posed the greatest challenge to the model. These results demonstrate that insect-host associations can be reliably predicted, regardless of whether insect and host trees have co-evolved, and provide a framework for predicting future pest threats using a select number of easily attainable tree and insect characteristics.

Shared decision-making with older adults with cancer: Adaptation of a model through literature review and expert opinion.

OBJECTIVE: To provide a literature overview of characteristics of Shared Decision Making (SDM) with specific importance to the older adult population with cancer and to tailor an existing model of SDM in patients with cancer to the needs of older adults. METHODS: A systematic search of several databases was conducted. Eligible studies described factors influencing SDM concerning cancer treatment with adults aged 65 years or above, with any type of cancer. We included qualitative or mixed-methods studies. Themes were identified and discussed in an expert panel, including a patient-representative, until consensus was reached on an adjusted model. RESULTS: Overall 29 studies were included and nine themes were identified from the literature. The themes related to the importance of goal setting, need for tailored information provision, the role of significant others, uncertainty of evidence, the importance of time during and outside of consultations, the possible ill-informed preconceptions that health care professionals (HCPs) might have about older adults and the specific competencies they need to engage in the SDM process with older adults. No new themes emerged from discussion with expert panel. This study presents a visual model of SDM with older patients with cancer based on the identified themes. CONCLUSIONS: Our model shows key elements that are specific to SDM with older adults. Further research needs to focus on how to educate HCPs on the competencies needed to engage in SDM with older patients, and how to implement the model into everyday practice.

Synergistic effects of methyl jasmonate treatment and propagation method on Norway spruce resistance against a bark-feeding insect.

Utilizing plants with enhanced resistance traits is gaining interest in plant protection. Two strategies are especially promising for increasing resistance against a forest insect pest, the pine weevil (Hylobius abietis): exogenous application of the plant defense hormone methyl jasmonate (MeJA), and production of plants through the clonal propagation method somatic embryogenesis (SE). Here, we quantified and compared the separate and combined effects of SE and MeJA on Norway spruce resistance to pine weevil damage. Plants produced via SE (emblings) and nursery seedlings (containerized and bare-root), were treated (or not) with MeJA and exposed to pine weevils in the field (followed for 3 years) and in the lab (with a non-choice experiment). Firstly, we found that SE and MeJA independently decreased pine weevil damage to Norway spruce plants in the field by 32-33% and 53-59%, respectively, compared to untreated containerized and bare-root seedlings. Secondly, SE and MeJA together reduced damage to an even greater extent, with treated emblings receiving 86-87% less damage when compared to either untreated containerized or bare-root seedlings in the field, and by 48% in the lab. Moreover, MeJA-treated emblings experienced 98% lower mortality than untreated containerized seedlings, and this high level of survival was similar to that experienced by treated bare-root seedlings. These positive effects on survival remained for MeJA-treated emblings across the 3-year experimental period. We conclude that SE and MeJA have the potential to work synergistically to improve plants' ability to resist damage, and can thus confer a strong plant protection advantage. The mechanisms underlying these responses merit further examination.

Cold winters drive consistent and spatially synchronous 8-year population cycles of cabbage stem flea beetle.

Population cycles have been observed in mammals as well as insects, but consistent population cycling has rarely been documented in agroecosystems and never for a beetle. We analysed the long-term population patterns of the cabbage stem flea beetle Psylliodes chrysocephala in winter oilseed rape over 50 years. Psylliodes chrysocephala larval density from 3045 winter oilseed rape fields in southern Sweden showed strong 8-year population cycles in regional mean density. Fluctuations in larval density were synchronous over time across five subregional populations. Subregional mean environmental variables explained 90.6% of the synchrony in P. chrysocephala populations at the 7-11 year time-scale. The number of days below -10°C showed strong anti-phase coherence with larval densities in the 7-11 year time-scale, such that more cold days resulted in low larval densities. High levels of the North Atlantic Oscillation weather system are coherent and anti-phase with cold weather in Scania, Sweden. At the field-scale, later crop planting date and more cold winter days were associated with decreased overwintering larval density. Warmer autumn temperatures, resulting in greater larval accumulated degree days early in the season, increased overwintering larval density. Despite variation in environmental conditions and crop management, 8-year cycles persisted for cabbage stem flea beetle throughout the 50 years of data collection. Moran effects, influenced by the North Atlantic Oscillation weather patterns, are the primary drivers of this cycle and synchronicity. Insect pest data collected in commercial agriculture fields is an abundant source of long-term data. We show that an agricultural pest can have the same periodic population cycles observed in perennial and unmanaged ecosystems. This unexpected finding has implications for sustainable pest management in agriculture and shows the value of long-term pest monitoring projects as an additional source of time-series data to untangle the drivers of population cycles.

Effects of retained dead wood on predation pressure on herbivores in young pine forests.

Retention of logging residue as dead wood could be a method to simultaneously increase biodiversity and predation rates of pest insects, in managed forests. Managed forests are generally low in diversity, and dead wood has been demonstrated to increase species diversity. Moreover, managed forests are predicted to suffer from higher frequency of insect outbreaks in the future, particularly in the northern hemisphere. In this study, we explore the effect of dead wood removal and addition in managed pine forest stands in Sweden on arthropod diversity and abundance and predation rates. We performed a controlled field experiment, focusing on logging residue type of dead wood. We used pitfall traps and sticky traps to measure arthropod diversity and abundance and plasticine larvae to assess predation rates. We specifically targeted generalist arthropods (i.e. non-wood living species), and predation rate on tree-dwelling larvae (corresponding to defoliating outbreak pests). We found no effect of dead wood addition on arthropod abundance or diversity, neither did we find an effect on predation rate. Despite the lack of effects in our study, we argue that dead wood can be an important component for both biodiversity of generalist arthropod and for pest control, but the effect may depend on both the specific arthropod group targeted and the specific life stage of the pest insect as well as on inherent components of the dead wood, such as age.

Northward range expansion of rooting ungulates decreases detritivore and predatory mite abundances in boreal forests.

In the last few decades wild boar populations have expanded northwards, colonizing boreal forests. The soil disturbances caused by wild boar rooting may have an impact on soil organisms that play a key role in organic matter turnover. However, the impact of wild boar colonization on boreal forest ecosystems and soil organisms remains largely unknown. We investigated the effect of natural and simulated rooting on decomposer and predatory soil mites (total, adult and juvenile abundances; and adult-juvenile proportion). Our simulated rooting experiment aimed to disentangle the effects of (i) bioturbation due to soil mixing and (ii) removing organic material (wild boar food resources) on soil mites. Our results showed a decline in the abundance of adult soil mites in response to both natural and artificial rooting, while juvenile abundance and the relative proportion of adults and juveniles were not affected. The expansion of wild boar northwards and into new habitats has negative effects on soil decomposer abundances in boreal forests which may cascade through the soil food web ultimately affecting ecosystem processes. Our study also suggests that a combined use of natural and controlled experimental approaches is the way forward to reveal any subtle interaction between aboveground and belowground organisms and the ecosystem functions they drive.

Trends in quality of care and dying perceived by family caregivers of nursing home residents with dementia 2005-2019.

BACKGROUND: Dementia palliative care is increasingly subject of research and practice improvement initiatives. AIM: To assess any changes over time in the evaluation of quality of care and quality of dying with dementia by family caregivers. DESIGN: Combined analysis of eight studies with bereaved family caregivers' evaluations 2005-2019. SETTING/PARTICIPANTS: Family caregivers of nursing home residents with dementia in the Netherlands (n = 1189) completed the End-of-Life in Dementia Satisfaction With Care (EOLD-SWC; quality of care) and Comfort Assessment in Dying (EOLD-CAD, four subscales; quality of dying) instruments. Changes in scores over time were analysed using mixed models with random effects for season and facility and adjustment for demographics, prospective design and urbanised region. RESULTS: The mean total EOLD-SWC score was 33.40 (SD 5.08) and increased by 0.148 points per year (95% CI, 0.052-0.244; adjusted 0.170 points 95% CI, 0.055-0.258). The mean total EOLD-CAD score was 30.80 (SD 5.76) and, unadjusted, there was a trend of decreasing quality of dying over time of -0.175 points (95% CI, -0.291 to -0.058) per year increment. With adjustment, the trend was not significant (-0.070 EOLD-CAD total score points, 95% CI, -0.205 to 0.065) and only the EOLD-CAD subscale 'Well being' decreased. CONCLUSION: We identified divergent trends over 14 years of increased quality of care, while quality of dying did not increase and well-being in dying decreased. Further research is needed on what well-being in dying means to family. Quality improvement requires continued efforts to treat symptoms in dying with dementia.

Interacting effects of insect and ungulate herbivory on Scots pine growth.

Most plants are subjected to damage from multiple species of herbivores, and the combined impact on plant growth can be non-additive. Since plant response to herbivores tends to be species specific, and change with repeated damage, the outcome likely depend on the sequence and number of attacks. There is a high likelihood of non-additive effects on plant growth by damage from mammals and insects, as mammalian herbivory can alter insect herbivore damage levels, yet few studies have explored this. We report the growth response of young Scots pine trees to sequential mammal and insect herbivory, varying the sequence and number of damage events, using an ungulate-pine-sawfly system. Combined sawfly and ungulate herbivory had both additive and non-additive effects on pine growth-the growth response depended on the combination of ungulate browsing and sawfly defoliation (significant interaction effect). Repeated sawfly herbivory reduced growth (compared to single defoliation) on un-browsed trees. However, on browsed trees, depending on when sawfly defoliation was combined with browsing, trees exposed to repeated sawfly herbivory had both higher, lower and the same growth as trees exposed to a single defoliation event. We conclude that the sequence of attacks by multiple herbivores determine plant growth response.

Experiences with the Liverpool care pathway for the dying patient in nursing home residents: a mixed-method study to assess physicians' and nurse practitioners' perceptions.

BACKGROUND: The Liverpool care pathway for the dying patient (LCP) is a multidisciplinary tool developed for the dying phase for use in palliative care settings. The literature reports divergent experiences with its application in a nursing home setting related to its implementation and staff competencies. The aim of this study is to understand how the LCP is being used in the context of the nursing home, including for residents with dementia, and experienced from the perspectives of those responsible for medical treatment in nursing homes. METHODS: A mixed-methods approach was used, consisting of a survey followed by interviews. A link to a 9-item online survey with closed and open-ended questions was emailed to all physicians and nurse practitioners of 33 care organisations with nursing homes in three regions of the Netherlands (North, West and South). In addition, 10 respondents with particularly positive or negative experiences were selected for semi-structured interviews. RESULTS: The survey was completed by 159 physicians and nurse practitioners. The respondents were very positive on the content and less positive on the use of the LCP, although they reported difficulties identifying the right time to start the LCP, especially in case of dementia. Also using the LCP was more complicated after the implementation of the electronic health record. The LCP was judged to be a marker of quality for the assessment of symptoms in the dying phase and communication with relatives. CONCLUSION: An instrument that prompts regular assessment of a dying person was perceived by those responsible for (medical) care to contribute to good care. As such, the LCP was valued, but there was a clear need to start it earlier than in the last days or hours of life, a need for a shorter version, and for integration of the LCP in the electronic health record. Regular assessments with an instrument that focusses on quality of care and good symptom control can improve palliative care for nursing home residents with and without dementia.

Trait-mediated indirect interactions: Moose browsing increases sawfly fecundity through plant-induced responses.

Induced responses in plants, initiated by herbivory, create potential for trait-mediated indirect interactions among herbivores. Responses to an initial herbivore may change a number of plant traits that subsequently alter ecological processes with additional herbivores. Although common, indirect interactions between taxonomically distant herbivores, such as mammals and insects, are less studied than between taxonomically related species (i.e., insect-insect). In terms of mammal-insect interactions, effects on insect numbers (e.g., density) are relatively well studied, whereas effects on performance (e.g., fecundity) are rarely explored. Moreover, few studies have explored mammal-insect interactions on coniferous plants.The aim of this study was to investigate the effect of mammalian induced responses on insect performance. We specifically investigated the effect of moose (Alces alces) browsing on Scots pine (Pinus sylvestris) and subsequent effects on sawfly (Neodiprion sertifer) performance.Sawfly larvae were reared on browsed, clipped, and unbrowsed control pine trees in a controlled field experiment. Afterward, cocoon weight was measured. Needle C:N ratio and di-terpene content were measured in response to browsing.Sawfly performance was enhanced on trees browsed by moose. Cocoon weight (proxy for fecundity) was 9 and 13% higher on browsed and clipped trees compared to unbrowsed trees. Cocoon weight was weakly related to needle C:N ratio, and browsed trees had lower a C:N ratio compared to unbrowsed trees. Needle di-terpene content, known to affect sawfly performance, was neither affected by the browsing treatments nor did it correlate with sawfly weight.We conclude that mammalian herbivory can affect insect herbivore performance, with potential consequences for ecological communities and with particular importance for insect population dynamics. The measured plant variables could not fully explain the effect on sawfly performance providing a starting point for the consideration of additional plant responses induced by mammalian browsing affecting insect performance.

The effect of multiple natural enemies on a shared herbivore prey.

Natural enemy diversity is thought to be important for effective suppression of herbivores in production systems. Studies investigating the importance of the diversity and composition of the natural enemy complex often use within-year empirical studies or experimental exclusion setups.However, within-year population suppression might not translate in long-term population regulation. Therefore, I used a combination of long-term data collection and an exclusion experiment to investigate mechanisms behind year-to-year population changes and potential effects of disturbance of the natural enemy complex.Using the holly leaf miner study system in Wytham Woods, I find that the dominant predator in the system does not necessarily contribute the most to the reduction in year-to-year changes in mine density or within-patch fluctuations. Using the exclusion experiment, it becomes clear that parasitism later in the prey life cycle can to a certain level compensate for disruption of mortality in the earlier life stage of the prey.Thus, for host suppression in perennial systems the mortality pressure over the whole life cycle is important and disturbance during one part of the life cycle might not necessarily be buffered by mortality in other parts of the life cycle, especially if the natural enemy complex consists of multiple predator guilds.

Change in quality of life after a multidisciplinary intervention for people with dementia: A cluster randomized controlled trial.

OBJECTIVE: The objective of this study was to examine whether implementation of a stepwise multicomponent intervention (STA OP!) for challenging behavior and pain affects quality of life (QoL) of nursing home residents with moderate to severe dementia after 3 and 6 months. METHODS: A cluster randomized controlled trial was conducted in 12 nursing homes. Both control (n = 140) and intervention group (=148) received training, the intervention group was also treated using the STA OP! INTERVENTION: At baseline, 3 and 6 months QoL was assessed using the 6 QUALIDEM domains applicable to moderate and severe dementia. Linear mixed models were used to compare changes in QoL domains between the 2 groups over time. RESULTS: After both 3 and 6 months, there was no change, and no difference in change, between the 2 groups in the domains Care relationship, Positive affect, Negative affect, and Social relations. Between 0 and 3 months, a positive effect was seen in the domain Restless tense behavior with a regression coefficient of ß: 0.95 (95% confidence interval [CI], 0.36-1.54). Between 3 and 6 months, a negative effect was seen on the domain Restless tense behavior ß: -0.98 (95% CI, -1.60 to -0.36) and a positive effect in the domain Social isolation, ß: 0.64 (95% CI, 0.12-1.17). CONCLUSIONS: The stepwise intervention STA OP! affects the QUALIDEM domains in different ways: there was a lowering of Restless tense behavior in the short term, which reverted back to the initial level in the longer term, and a lowering of Social isolation in the longer term.

Transient synchrony among populations of five foliage-feeding Lepidoptera.

Studies of transient population dynamics have largely focused on temporal changes in dynamical behaviour, such as the transition between periods of stability and instability. This study explores a related dynamic pattern, namely transient synchrony during a 49-year period among populations of five sympatric species of forest insects that share host tree resources. The long time series allows a more comprehensive exploration of transient synchrony patterns than most previous studies. Considerable variation existed in the dynamics of individual species, ranging from periodic to aperiodic. We used time-averaged methods to investigate long-term patterns of synchrony and time-localized methods to detect transient synchrony. We investigated transient patterns of synchrony between species and related these to the species' varying density dependence structures; even species with very different density dependence exhibited at least temporary periods of synchrony. Observed periods of interspecific synchrony may arise from interactions with host trees (e.g., induced host defences), interactions with shared natural enemies or shared impacts of environmental stochasticity. The transient nature of synchrony observed here raises questions both about the identity of synchronizing mechanisms and how these mechanisms interact with the endogenous dynamics of each species. We conclude that these patterns are the result of interspecific interactions that act only temporarily to synchronize populations, after which differences in the endogenous population dynamics among the species acts to desynchronize their dynamics.

General Public Acceptance of Forest Risk Management Strategies in Sweden: Comparing Three Approaches to Acceptability.

Global change calls for more active approaches to forest risk management. To avoid unforeseen backlashes, it is necessary to examine the general public's acceptance of the risk management strategies. By drawing on different theoretical approaches (threat and prevention, performance evaluations, and forest cognitions), the present study examines predictors of acceptability in the general public in three counties in Sweden (N = 1,026). As expected, appraisals of threat mediated the effect of threat awareness on belief in risk prevention, and when examining performance evaluations, trust in responsible actors influenced acceptability via procedural satisfaction. However, the threat and prevention approach and the performance evaluation approach only explained low levels of the variance in acceptability of the examined strategies. Nevertheless, stronger ecological forest values, and favoring broadleaved forests, were found to be important to the acceptability of proactively implementing a more diverse forest to meet the expected challenges associated with global climate change.

Methods to identify the prey of invertebrate predators in terrestrial field studies.

Predation is an interaction during which an organism kills and feeds on another organism. Past and current interest in studying predation in terrestrial habitats has yielded a number of methods to assess invertebrate predation events in terrestrial ecosystems. We provide a decision tree to select appropriate methods for individual studies. For each method, we then present a short introduction, key examples for applications, advantages and disadvantages, and an outlook to future refinements. Video and, to a lesser extent, live observations are recommended in studies that address behavioral aspects of predator-prey interactions or focus on per capita predation rates. Cage studies are only appropriate for small predator species, but often suffer from a bias via cage effects. The use of prey baits or analyses of prey remains are cheaper than other methods and have the potential to provide per capita predation estimates. These advantages often come at the cost of low taxonomic specificity. Molecular methods provide reliable estimates at a fine level of taxonomic resolution and are free of observer bias for predator species of any size. However, the current PCR-based methods lack the ability to estimate predation rates for individual predators and are more expensive than other methods. Molecular and stable isotope analyses are best suited to address systems that include a range of predator and prey species. Our review of methods strongly suggests that while in many cases individual methods are sufficient to study specific questions, combinations of methods hold a high potential to provide more holistic insights into predation events. This review presents an overview of methods to researchers that are new to the field or to particular aspects of predation ecology and provides recommendations toward the subset of suitable methods to identify the prey of invertebrate predators in terrestrial field research.

Habitat heterogeneity affects predation of European pine sawfly cocoons.

Habitat heterogeneity is thought to affect top-down control of herbivorous insects and contribute to population stability by providing a more attractive microhabitat for natural enemies, potentially leading to reduced population fluctuations. Identifying the parameters that contribute to habitat heterogeneity promoting top-down control of herbivorous insects by natural enemies could facilitate appropriate management decisions, resulting in a decreased risk of pest insect outbreaks because of a higher level of predation. In our study, we measured the top-down pressure exerted by small mammals on the cocoons of a notorious pest insect in pine forests, the European pine sawfly (Neodiprion sertifer), which is known to be regulated by small mammal predation. The forest stands used differed in heterogeneity measured in terms of differences in tree diversity and density, understory vegetation height, presence/absence, and density of dead wood. We found higher predation in more dense spots within forest stands. Further, the effect of dead wood on sawfly cocoon predation depended on the pine proportion in forest stands. The addition of dead wood in a manipulation experiment had a slight positive effect on cocoon predation, while dead wood removal caused a clear decrease in predation rate, and the decrease was more pronounced when the proportion of pine increased. Our results show that habitat heterogeneity affects predation by generalist predators on herbivorous insects. This knowledge could be applied to reduce the risk of insect outbreaks by applying management methods that increase heterogeneity in perennial systems such as forests and orchards, thus decreasing the levels of insect damage.

Characteristics Associated with Quality of Life in Long-Term Care Residents with Dementia: A Cross-Sectional Study.

BACKGROUND: To determine which characteristics are associated with quality of life (QOL) in residents with moderate to very severe dementia in long-term care facilities (LTCFs). MATERIAL AND METHODS: This was a cross-sectional analysis of a cluster randomized controlled study in 12 Dutch LTCFs that enrolled 288 residents, with moderate to severe dementia assessed with the Reisberg Global Deterioration Scale (Reisberg GDS) and QOL with the QUALIDEM. Characteristics that were hypothesized to be associated with the six domains of QOL (applicable to very severe dementia) included demographic variables, activities of daily living (Katz ADL), cognitive performance (Cognitive Performance Scale; CPS), pain (Pain Assessment Checklist for Seniors with Limited Ability to Communicate; PACSLAC-D), neuropsychiatric symptoms (Neuropsychiatric Inventory-Nursing Home Version; NPI-NH) and comorbidities. RESULTS: Multivariate logistic regression modelling showed associations with age in the domain Social isolation [odds ratio, OR, 0.95 (95% confidence interval, CI, 0.91-0.99)], ADL level in the domain Positive affect [OR 0.89 (95% CI 0.83-0.95)] and the domain Social relations [OR 0.87 (95% CI 0.81-0.93)], severity of dementia in the domain Social relations [OR 0.28 (95% CI 0.12-0.62)] and in the domain Social isolation [OR 2.10 (95% CI 1.17-3.78)], psychiatric disorders in the domain Positive affect [OR 0.39 (95% CI 0.17-0.87)] and pulmonary diseases in the domain Negative affect [OR 0.14 (95% CI 0.03-0.61)] of the QUALIDEM. Neuropsychiatric symptoms were independently associated with all six domains of the QUALIDEM [OR 0.93 (95% CI 0.90-0.96) to OR 0.97 (95% CI 0.95-0.99)]. Pain was associated with the domains Care relationship [OR 0.92 (95% CI 0.84-1.00)] and Negative affect [OR 0.92 (95% CI 0.85-1.00)]. CONCLUSION: QOL in dementia is independently associated with age, ADL, dementia severity, pain, psychiatric disorders, pulmonary diseases and neuropsychiatric symptoms. It is possible to detect persons with dementia at risk for a lower QOL. This information is important for developing personalized interventions to improve QOL in persons with dementia in LTCFs.

Replacing monocultures with mixed-species stands: Ecosystem service implications of two production forest alternatives in Sweden.

Whereas there is evidence that mixed-species approaches to production forestry in general can provide positive outcomes relative to monocultures, it is less clear to what extent multiple benefits can be derived from specific mixed-species alternatives. To provide such insights requires evaluations of an encompassing suite of ecosystem services, biodiversity, and forest management considerations provided by specific mixtures and monocultures within a region. Here, we conduct such an assessment in Sweden by contrasting even-aged Norway spruce (Picea abies)-dominated stands, with mixed-species stands of spruce and birch (Betula pendula or B. pubescens), or spruce and Scots pine (Pinus sylvestris). By synthesizing the available evidence, we identify positive outcomes from mixtures including increased biodiversity, water quality, esthetic and recreational values, as well as reduced stand vulnerability to pest and pathogen damage. However, some uncertainties and risks were projected to increase, highlighting the importance of conducting comprehensive interdisciplinary evaluations when assessing the pros and cons of mixtures.

Reducing the risk of invasive forest pests and pathogens: Combining legislation, targeted management and public awareness.

Intensifying global trade will result in increased numbers of plant pest and pathogen species inadvertently being transported along with cargo. This paper examines current mechanisms for prevention and management of potential introductions of forest insect pests and pathogens in the European Union (EU). Current European legislation has not been found sufficient in preventing invasion, establishment and spread of pest and pathogen species within the EU. Costs associated with future invasions are difficult to estimate but past invasions have led to negative economic impacts in the invaded country. The challenge is combining free trade and free movement of products (within the EU) with protection against invasive pests and pathogens. Public awareness may mobilise the public for prevention and detection of potential invasions and, simultaneously, increase support for eradication and control measures. We recommend focus on commodities in addition to pathways, an approach within the EU using a centralised response unit and, critically, to engage the general public in the battle against establishment and spread of these harmful pests and pathogens.

Symptoms and treatment when death is expected in dementia patients in long-term care facilities.

BACKGROUND: Although dementia at the end of life is increasingly being studied, we lack prospective observational data on dying patients. In this study symptoms were observed in patients with dementia in the last days of life. METHODS: When the elderly care physicians in two Dutch nursing homes expected death within one week, symptoms of (dis)comfort, pain and suffering were observed twice daily. For this the Pain Assessment in Advanced Dementia (PAINAD; range 0-10), Discomfort Scale-Dementia of Alzheimer Type (DS-DAT; range 0-27), End-Of-Life in Dementia-Comfort Assessment in Dying (EOLD-CAD; range 14-42) and an adapted version of the Mini-Suffering State Examination (MSSE; range 0-9), were used. Information on care, medical treatment and treatment decisions were also collected. RESULTS: Twenty-four participants (median age 91 years; 23 females), were observed several times (mean of 4.3 observations (SD 2.6)), until they died. Most participants (n = 15) died from dehydration/cachexia and passed away quietly (n = 22). The mean PAINAD score was 1.0 (SD 1.7), DS-DAT 7.0 (SD 2.1), EOLD-CAD 35.1 (SD 1.7), and MSSE 2.0 (SD 1.7). All participants received morphine, six received antibiotics, and rehydration was prescribed once. CONCLUSION: In these patients with dementia and expected death, a low symptom burden was observed with validated instruments, also in dehydrated patients without aggressive treatment. A good death is possible, but might be enhanced if the symptom burden is regularly assessed with validated instruments. The use of observation tools may have influenced the physicians to make treatment decisions.