Evaluation of the Strengthening a Palliative Approach in Long Term Care (SPA-LTC) programme: a protocol of a cluster randomised control trial.

INTRODUCTION: Despite the high mortality rates in long-term care (LTC) homes, most do not have a formalised palliative programme. Hence, our research team has developed the Strengthening a Palliative Approach in Long Term Care (SPA-LTC) programme. The goal of the proposed study is to examine the implementation and effectiveness of the SPA-LTC programme. METHODS AND ANALYSIS: A cross-jurisdictional, effectiveness-implementation type II hybrid cluster randomised control trial design will be used to assess the SPA-LTC programme for 18 LTC homes (six homes within each of three provinces). Randomisation will occur at the level of the LTC home within each province, using a 1:1 ratio (three homes in the intervention and control groups). Baseline staff surveys will take place over a 3-month period at the beginning for both the intervention and control groups. The intervention group will then receive facilitated training and education for staff, and residents and their family members will participate in the SPA-LTC programme. Postintervention data collection will be conducted in a similar manner as in the baseline period for both groups. The overall target sample size will be 594 (297 per arm, 33 resident/family member participants per home, 18 homes). Data collection and analysis will involve organisational, staff, resident and family measures. The primary outcome will be a binary measure capturing any emergency department use in the last 6 months of life (resident); with secondary outcomes including location of death (resident), satisfaction and decisional conflict (family), knowledge and confidence implementing a palliative approach (staff), along with implementation outcomes (ie, feasibility, reach, fidelity and perceived sustainability of the SPA-LTC programme). The primary outcome will be analysed via multivariable logistic regression using generalised estimating equations. Intention-to-treat principles will be used in the analysis. ETHICS AND DISSEMINATION: The study has received ethical approval. Results will be disseminated at various presentations and feedback sessions; at provincial, national and international conferences, and in a series of manuscripts that will be submitted to peer-reviewed, open access journals. TRIAL REGISTRATION NUMBER: NCT039359.

Comparison between enzyme-linked immunospot assay and intracellular cytokine flow cytometry assays for the evaluation of T cell response to SARS-CoV-2 after symptomatic COVID-19.

INTRODUCTION: Evaluation of different cell-based assays for the study of adaptive immune responses against SARS-CoV-2 is crucial for studying long-term and vaccine-induced immunity. METHODS: Enzyme-linked immunospot assay (ELISpot) and intracellular cytokine staining (ICS) using peptide pools spanning the spike protein and nucleoprotein of SARS-CoV-2 were performed in 25 patients who recovered from paucisymptomatic (n = 19) or severe COVID-19 (n = 6). RESULTS: The proportion of paucisymptomatic patients with detectable SARS-CoV-2 T cells was low, as only 44% exhibit a positive T cell response with the ICS and 67% with the ELISpot. The magnitude of SARS-CoV-2 T cell responses was low, both with ICS (median at 0.12% among total T cells) and ELISpot (median at 61 SFCs/million peripheral blood mononuclear cells [PBMC]) assays. Moreover, T cell responses in paucisymptomatic patients seemed lower than among patients with severe disease. In the paucisymptomatic patients, the two assays were well correlated with 76% of concordant responses and a Cohen's kappa of 55. Furthermore, in four patients SARS-CoV-2 T cells were detected by ELISpot but not with ICS. Short-term culture could improve the detection of specific T cells. CONCLUSIONS: In patients who recovered from paucisymptomatic COVID-19, the proportion of detectable anti-SARS-CoV-2 responses and their magnitude seemed lower than in patients with more severe symptoms. The ELISpot appeared to be more sensitive than the ICS assay. Short-term culture revealed that paucisymptomatic patients had nonetheless few SARS-CoV-2 T cells at a very low rate in peripheral blood. These data indicate that various ex-vivo assays may lead to different conclusions about the presence or absence of SARS-CoV-2 T cell immunity.

Using a self-directed workbook to support advance care planning with long term care home residents.

BACKGROUND: While advance care planning (ACP) has been shown to improve the quality of end-of-life (EOL) communication and palliative care, it is rarely practiced in long term care (LTC) homes, where staff time to support the process is limited. This study examines the potential of a publicly available self-directed ACP workbook distributed to LTC residents to encourage ACP reflection and communication. METHODS: Recruitment took place across three LTC homes, between June 2018 and July 2019. To be eligible, residents had to have medical stability, cognitive capacity, and English literacy. The study employed a mixed methods concurrent design using the combination of ranked (quantitative) and open (qualitative) workbook responses to examine documented care preferences and ACP reflections and communications. RESULTS: 58 residents initially agreed to participate in the study of which 44 completed self-directed ACP workbooks. Our combined quantitative and qualitative results suggested that the workbooks supported the elicitation of a range of resident care preferences of relevance for EOL care planning and decision making. For example, ranked data highlighted that most residents want to remain involved in decisions pertaining to their care (70%), even though less than half expect their wishes to be applied without discretion (48%). Ranked data further revealed many residents value quality of life over quantity of life (55%) but a sizable minority are concerned they will not receive enough care at EOL (20%). Open comments affirmed and expanded on ranked data by capturing care preferences not explored in the ranked data such as preferences around spiritual care and post mortem planning. Analysis of all open comments also suggested that while the workbook elicited many reflections that could be readily communicated to family/friends or staff, evidence that conversations had occurred was less evident in recorded workbook responses. CONCLUSIONS: ACP workbooks may be useful for supporting the elicitation of resident care preferences and concerns in LTC. Developing follow up protocols wherein residents are supported in communicating their workbook responses to families/friends and staff may be a critical next step in improving ACP engagement in LTC. Such protocols would require staff training and an organizational culture that empowers staff at all levels to engage in follow up conversations with residents.

[Performance criteria for the verification of IgE and tryptase assay methods: recommendations from the AllergoBioNet network]. / Critères de performance pour la vérification des méthodes de dosages des IgE et de la tryptase : recommandations du réseau AllergoBioNet.

Accreditation of an in vitro diagnostic assay according to the NF/EN/ISO 15189 standard requires to analyze its technical performance before implementation for routine use, and annually when reviewing effectiveness of quality controls. Performance is evaluated through repeatability, intermediate fidelity, accuracy and uncertainty of measurement. The coefficients of variation (CV) of the intra-assay and inter-assay precision tests must be compared with those of "peers" (results from laboratories employing the same method) and also with those obtained with "all methods", i.e., results from all laboratories performing the same assay, irrespective of the method. To our best knowledge, there is currently no French or international recommendation on what the acceptable limits of performance for specific IgE and tryptase assays should be. Therefore, the AllergoBioNet network of hospital allergy laboratories set out to characterize the performance of their current methods as a basis for the development of recommendations. The results provided by 24 centers were analyzed and led to consensus recommendations for specific IgE, total IgE and tryptase assays.

Condition-Specific Pamphlets to Improve End-of-life Communication in Long-term Care: Staff Perceptions on Usability and Use.

OBJECTIVES: This article reports findings on the usability and staff use of 5 condition- specific pamphlets of high prevalence in long-term care (LTC): dementia, heart failure, chronic obstructive pulmonary disease, renal failure, and frailty. The pamphlets were created in response to residents', families', and staff's recommendations for activating early reflections and communication about end-of-life care. DESIGN: A mixed-method (qualitative and quantitative) survey design was used. Step 1 collected survey data on the usability of the pamphlets. Step 2 collected survey data on pamphlet use. SETTINGS AND PARTICIPANTS: Two nurses with specialized palliative care training, 2 resident/family representatives, 10 condition-specific specialists, and 33 LTC palliative leads reviewed the pamphlets for usability prior to distribution. A total of 178 LTC home staff in 4 participating LTC homes reported on pamphlet use. MEASURES: Specialists and resident/family representatives were asked to provide open comments and LTC home palliative leads were asked to complete a survey on the accuracy, readability, and relevance of the pamphlets. After 6 months of distribution, all staff in participating LTC homes were asked to complete a survey on pamphlet use, usefulness, and comfort with distribution. RESULTS: The pamphlets were reportedly accurate, relevant, and easy to understand. Following 6 months of availability, most staff in LTC had read the pamphlets, found the information useful, and planned to share them. However, half of the staff questioned their role in pamphlet distribution and most had not distributed them. Regulated staff (ie, staff affiliated with a regulated profession) expressed more comfort sharing the pamphlets than care aides and support staff. CONCLUSIONS/IMPLICATIONS: Condition-specific pamphlets appear to hold promise in providing residents and families with relevant information that may activate early reflections and conversations about end-of-life care. However, structured implementation strategies, training, and discussions are required to improve staff comfort with distribution and explore roles in distribution and follow-up.

Soil and land use research in Europe: Lessons learned from INSPIRATION bottom-up strategic research agenda setting.

We introduce the INSPIRATION bottom-up approach for the development of a strategic research agenda for spatial planning, land use and soil-sediment-water-system management in Europe. Research and innovation needs were identified by more than 500 European funders, endusers, scientists, policy makers, public administrators and consultants. We report both on the concept and on the implementation of the bottom-up approach, provide a critique of the process and draw key lessons for the development of research agendas in the future. Based on identified strengths and weaknesses we identified as key opportunities and threats 1) a high ranking and attentiveness for the research topics on the political agenda, in press and media or in public awareness, 2) availability of funding for research, 3) the resources available for creating the agenda itself, 4) the role of the sponsor of the agenda development, and 5) the continuity of stakeholder engagement as bases for identification of windows of opportunity, creating ownership for the agenda and facilitating its implementation. Our derived key recommendations are 1) a clear definition of the area for which the agenda is to be developed and for the targeted user, 2) a conceptual model to structure the agenda, 3) making clear the expected roles, tasks, input formats regarding the involvement and communication with the stakeholders and project partners, 4) a sufficient number of iterations and checks of the agenda with stakeholders to insure completeness, relevance and creation of co-ownership for the agenda, and 5) from the beginning prepare the infrastructure for the network to implement the agenda.

Later-Life Homelessness as Disenfranchised Grief.

ABSTRACTAlthough interest on older homelessness is gaining momentum, little research has considered the experiences of first-time homelessness from the perspective of older adults themselves. This constructivist grounded-theory study addresses this gap by exploring how societal perceptions of homelessness and aging shape access to housing, services, and perceptions of self for 15 older adults residing in emergency homeless shelters in Montreal, (Quebec, Canada). Findings revealed that homelessness evoked a grief response characterized by shock, despair, anger, and in some cases, relief. Connecting and receiving support from other shelter residents and staff helped participants to acknowledge and grieve their losses. However, difficult shelter conditions, the stigma associated with aging and homelessness, and not having their grief recognized or validated served to disenfranchise grief experiences. Conceptualizing later-life homelessness as disenfranchised grief contributes to the aging and homelessness literature while providing new avenues for understanding and validating the experiences of a growing population of vulnerable older adults.

Broadening End-of-Life Comfort to Improve Palliative Care Practices in Long Term Care.

This study aimed to (1) explore how palliative care in long-term care (LTC) addresses the tensions associated with caring for the living and dying within one care community, and (2) to inform how palliative care practices may be improved to better address the needs of all residents living and dying in LTC as well as those of the families and support staff. This article reports findings from 19 focus groups and 117 participants. Study findings reveal that LTC home staff, resident, and family perspectives of end-of-life comfort applied to those who were actively dying and to their families. Our findings further suggest that eliciting residents' perceptions of end-of-life comfort, sharing information about a fellow resident's death more personally, and ensuring that residents, families, and staff can constructively participate in providing comfort care to dying residents could extend the purview of end-of-life comfort and support expanded integration of palliative principles within LTC.

Patterns of Shelter Use Among Men New to Homelessness in Later Life: Duration of Stay and Psychosocial Factors Related to Departure.

People who become homeless for the first time in late life are a growing but understudied population. This study draws on administrative data from one shelter (N = 1,214 first-time homeless) to assess the extent to which age is related to shelter stay and, to examine psychosocial factors that may be associated with shelter departure. Our bivariate and survival analysis results suggest that older homeless men stay in the shelter 2 weeks longer than younger clients. Older men with pending legal issues and mobility concerns were more likely to leave the shelter than those without such concerns. Findings highlight the impact of age and other psychosocial variables on shelter stay, and provide direction from which to address homelessness among men who are new to homelessness in later life.

'Growing Old' in Shelters and 'On the Street': Experiences of Older Homeless People.

Homelessness among older people in Canada is both a growing concern, and an emerging field of study. This article reports thematic results of qualitative interviews with 40 people aged 46 to 75, carried out as part of a mixed-methods study of older people who are homeless in Montreal, Quebec, Canada. Our participants included people with histories of homelessness (n = 14) and persons new to homelessness in later life (n = 26). Interviews focused on experiences at the intersections of aging and homelessness including social relationships, the challenges of living on the streets and in shelters in later life, and the future. This article outlines the 5 main themes that capture the experience of homelessness for our participants: age exacerbates worries; exclusion and isolation; managing significant challenges; shifting needs and realities; and resilience, strength, and hope. Together, these findings underscore the need for specific programs geared to the unique needs of older people who are homeless.

A Literature Review of Homelessness and Aging: Suggestions for a Policy and Practice-Relevant Research Agenda.

Homelessness among older people is a growing concern across Canada and is expected to rise with demographic change (Crane & Warnes, 2010; Culhane, Metraux, Byrne, Stino, & Bainbridge, 2013). Yet current knowledge, policies, and practices on homelessness largely focus on younger populations. Likewise, research and policies on aging typically overlook homelessness. Responses to homelessness among older people must address complex needs related to health, income security, and housing. Based on a comprehensive literature review, this article outlines the existing and needed research with regards to homelessness among older people. We clarify the intersections of aging and homelessness; review the relevant statistics, including estimated prevalence; discuss pathways and variations in experience; and identify gaps in knowledge. We conclude with a call for an inclusive research agenda that will help build policies and practices to reduce and ultimately to eliminate homelessness among older people in Canada.

A precise spacing between the NPA domains of aquaporins is essential for silicon permeability in plants.

The controversy surrounding silicon (Si) benefits and essentiality in plants is exacerbated by the differential ability of species to absorb this element. This property is seemingly enhanced in species carrying specific nodulin 26-like intrinsic proteins (NIPs), a subclass of aquaporins. In this work, our aim was to characterize plant aquaporins to define the features that confer Si permeability. Through comparative analysis of 985 aquaporins in 25 species with differing abilities to absorb Si, we were able to predict 30 Si transporters and discovered that Si absorption is exclusively confined to species that possess NIP-III aquaporins with a GSGR selectivity filter and a precise distance of 108 amino acids (AA) between the asparagine-proline-alanine (NPA) domains. The latter feature is of particular significance since it had never been reported to be essential for Si selectivity. Functionality assessed in the Xenopus oocyte expression system showed that NIPs with 108 AA spacing exhibited Si permeability, while proteins differing in that distance did not. In subsequent functional studies, a Si transporter from poplar mutated into variants with 109- or 107-AA spacing failed to import, and a tomato NIP gene mutated from 109 to 108 AA exhibited a rare gain of function. These results provide a precise molecular basis to classify higher plants into Si accumulators or excluders.

Dissemination of acrylamide monomer from polyacrylamide-based flocculant use--sand and gravel quarry case study.

Aggregate quarries play a major role in land settlement. However, like all industrial operations, they can have impacts on the environment, notably due to the use of polyacrylamide (PAM)-based flocculants, which contain residual acrylamide (AMD), a carcinogenic, mutagenic, and reprotoxic monomer. In this study, the dissemination of AMD throughout the environment has been investigated in a French quarry. The presence of AMD has been determined in the process water and in the sludge, as well as in the surrounding surface water and groundwater. From the results of several sampling campaigns carried out on this case study, we can (a) confirm that the AMD contained in the commercial product is found in the quarry's water circuit (0.41 to 5.66 µg/l); (b) show that AMD is transported to the surrounding environment, as confirmed by the contamination of a pond near the installation (0.07 to 0.08 µg/l) and the presence of AMD in groundwater (0.01 to 0.02 µg/l); and (c) show that the sludge in both the current and former settling basins contains AMD (between 4 and 26 µg/kg of dry sludge). Therefore, we demonstrated in this case study that using PAM-based flocculants leads to the release of AMD to the environment beyond the treatment plant and creates a reserve of AMD in sludge basins.

A Zoospore Inoculation Method with Phytophthora sojae to Assess the Prophylactic Role of Silicon on Soybean Cultivars.

The objective of this study was to evaluate whether silicon (Si) amendments, known to have a prophylactic role against biotrophic and hemibiotrophic pathogens, could protect soybean against Phytophthora sojae. To fulfill this objective, the initial challenge was to develop a method of inoculation that reproduced the natural infection process while allowing regular Si feeding to the plants. In a first set of experiments, inoculation of P. sojae zoospores directly into hydroponic solutions led to reproducible infections and expected phenotypes when using 'Williams' (rps), 'L75-6141' (Rps1a), 'haro15' (Rps1k), and 'L77-1863' (Rps1b) soybean challenged to races 3 and 7 of P. sojae. This approach offers the advantage of testing simultaneously many soybean cultivars against different races of P. sojae in a controlled environment, and the expression of partial and root resistance. In a second set of experiments aimed at testing the effect of Si, our results clearly showed that Si amendments had a significant effect on disease reduction and plant yield. The effect was particularly noticeable when combined with a cultivar displaying a certain level of resistance to the disease. These results demonstrate a useful method of direct inoculation of soybean plants with P. sojae zoospores through a hydroponic system and show that Si amendments can represent an alternative method of control of P. sojae against soybean.

Identification and functional characterization of silicon transporters in soybean using comparative genomics of major intrinsic proteins in Arabidopsis and rice.

Silicon (Si) confers several benefits to many plant species when absorbed as silicic acid through nodulin 26-like intrinsic proteins (NIPs). The NIPs belong to major intrinsic protein (MIP) family, members of which form channels with high selectivity to control transport of water and different solutes. Here, comparative genomic analysis of the MIPs was performed to investigate the presence of Si transporter MIPs in soybean. Thorough analysis of phylogeny, gene organization, transcriptome profiling and protein modeling was performed to characterize MIPs in rice, Arabidopsis and soybean. Based on several attributes, two putative Si transporter genes, GmNIP2-1 and GmNIP2-2, were identified, characterized and cloned from soybean. Expression of both genes was detected in shoot and root tissues, and decreased as Si increased. The protein encoded by GmNIP2-2 showed functionality for Si transport when expressed in Xenopus oocytes, thus confirming the genetic capability of soybean to absorb the element. Comparative analysis of MIPs in plants provides opportunities to decipher gene evolution, functionality and selectivity of nutrient uptake mechanisms. Exploitation of this strategy has helped to uncover unique features of MIPs in soybean. The identification and functional characterization of Si transporters can be exploited to optimize the benefits that plants can derive from Si absorption.

Fulminant viral myocarditis after rituximab therapy in pediatric nephrotic syndrome.

BACKGROUND: We report a 7-year-old boy with high-degree steroid-dependent idiopathic nephrotic syndrome (SDNS) who went into remission with rituximab (RTX) maintenance therapy. CASE-DIAGNOSIS/TREATMENT: Four months after this patient received his first RTX infusion, there was a progressive and sustained decrease of immunoglobulin (Ig)G and IgM levels. Thirteen months after the initiation of RTX therapy he was in sustained remission without any steroid or oral immunosuppressive therapy; however, B cell depletion was still present. At this time he developed a fulminant myocarditis due to enterovirus. Despite aggressive treatment and the administration of intravenous polyvalent immunoglobulins there was no clinical improvement. He successfully underwent heart transplant surgery. CONCLUSIONS: We conclude that B cell depletion with RTX is efficacious in the treatment of paediatric SDNS but that it may be associated with severe infectious complications. Therefore, we recommend a close monitoring of Ig levels in children who have received RTX therapy and a supplementation with intravenous Ig as soon as the Ig levels fall below the lower limit of the normal range.

Rituximab in steroid-dependent idiopathic nephrotic syndrome in childhood--follow-up after CD19 recovery.

Rituximab (RTX) is a new treatment strategy in high-degree steroid-dependent idiopathic nephrotic syndrome (SDNS) in childhood. Thirty patients (nine girls) with SDNS with steroid side effects and previously treated with immunosuppressive drugs, mostly calcineurin inhibitors, were treated with RTX and included in this non-controlled single-centre study. Patient age at first RTX infusion was 12.9 ± 0.7 years. Our aim was to evaluate disease outcome after a minimum CD19 depletion period of 15 months obtained by repeated RTX infusion. Minimum follow-up after initial CD19 depletion was 24 months. During the RTX treatment period, seven patients had nephrotic syndrome relapses, six among them at the time of an intermittent CD19 recovery and one patient relapsed under CD19 depletion. The risk for these patients to relapse after the RTX treatment period was higher than in those without intermittent relapses. After definitive CD19 recovery over a follow-up of 17.4 ± 1.9 months, 19 patients (63%) did not relapse and 11 (37%) relapsed 4.3 ± 1 months after defininitive CD19 recovery. Among these 11 patients, 6 already had intermittent relapses during the RTX treatment period. Steroid and immunosuppressive treatment could be discontinued in all patients during CD19 depletion and was re-introduced in two after CD19 recovery. Fourteen patients had mostly benign and transitory side effects, which did not require RTX discontinuation. In conclusion, RTX treatment with a 15-month CD19 depletion period induced long-term remission after definitive CD 19 recovery in almost two-thirds the of patients without oral immunosuppressive drugs.

Development of cytomegalovirus and adenovirus-specific memory CD4 T-cell functions from birth to adulthood.

Age-related changes in memory CD4 T cells (CD4) are poorly known. To address this issue, CD4 proliferative and cytokine responses to an anti-CD3 monoclonal (CD3), to cytomegalovirus (CMV), and to adenovirus (AdV) were assessed in 57 children (age, 0.07-17.16 y) and 17 adults. Results showed i) accumulation of memory CD4 with aging, with 2-3 times more central-memory T cell (TCM; CD45RA/CD62L) than effector-memory T cell (TEM; CD45RA/62L) CD4 at any age. ii) In children older than 2 y, CMV-specific CD4-secreting IFNγ alone predominated over CD4-secreting IL2 + IFNγ and a continuous increase, with aging, in IFNγ responses to the virus was observed. In contrast, in AdV infection, CD4-secreting IL2 + IFNγ predominated and IFNγ responses to the virus reached adult levels from 3 y of age. iii) In children aged 0-2 y, lower total IFNγ responses to CMV (p < 0.02), AdV (p = 0.05), and CD3 (p < 0.01) and lower IFNγ + IL2-responses (p = 0.1, p < 0.02, p < 0.05, respectively) contrasted with no decrease in CD4-secreting IFNγ alone. Defective proliferative responses to AdV (p = 0.03) were also observed. In conclusion, the development of memory CD4 differed in acute AdV and persistent CMV infections. Young age seemed to depress mostly polyfunctional (IL2 + IFNγ secreting) CD4 in both infections.

[Not Available]. / La souffrance en lien avec les écueils de la communication chez les femmes âgées atteintes de cancer incurable.

Among the older population in Canada, the majority of whom are women, incurable cancer is rampant. Having incurable cancer often implies suffering. Studies reveal that communication with one's circle is therefore often arduous, leading us to believe that it can cause suffering. To our knowledge, there has been no research that specifically explores the suffering related to communication among older women with incurable cancer: this will be the objective of our article.This exploratory qualitative research is in humanistic psychology. It is based on a phenomenological analysis of the conceptual categories that emerged from 19 semi-structured interviews among 10 women aged 65 years and over with incurable cancer.The results reveal both the dynamic of silence, desired in order to prevent increased suffering, and sometimes imposed and a source of further suffering. They also reveal that the absence of listening, the imposition of silence, and the minimization of what these women say, also cause suffering. The consequences of disclosing one's illness and its suffering are also explored.

Metal availability in a highly contaminated, dredged-sediment disposal site: field measurements and geochemical modeling.

Two complementary approaches were used to characterize arsenic and metal mobilizations from a dredged-sediment disposal site: a detailed field study combined with hydrogeochemical modeling. Contaminants in sediments were found to be mainly present as sulfides subject to oxidation. Secondary phases (carbonates, sulfates, (hydr)oxides) were also observed. Oxidative processes occurred at different rates depending on physicochemical conditions and contaminant contents in the sediment. Two distinct areas were identified on the site, each corresponding to a specific contaminant mobility behavior. In a reducing area, Fe and As were highly soluble and illustrated anoxic behavior. In well-oxygenated material, groundwater was highly contaminated in Zn, Cd and Pb. A third zone in which sediments and groundwater were less contaminated was also characterized. This study enabled us to prioritize remediation work, which should aim to limit infiltration and long-term environmental impact.