A Review of Clinical Signs and Symptoms of Imminent End-of-Life in Individuals With Advanced Illness.

Background: World population is not only aging but suffering from serious chronic illnesses, requiring an increasing need for end-of-life care. However, studies show that many healthcare providers involved in the care of dying patients sometimes express challenges in knowing when to stop non-beneficial investigations and futile treatments that tend to prolong undue suffering for the dying person. Objective: To evaluate the clinical signs and symptoms that show end-of-life is imminent in individuals with advanced illness. Design: Narrative review. Methods: Computerized databases, including PubMed, Embase, Medline,CINAHL, PsycInfo, and Google Scholar were searched from 1992 to 2022 for relevant original papers written in or translated into English language that investigated clinical signs and symptoms of imminent death in individuals with advanced illness. Results: 185 articles identified were carefully reviewed and only those that met the inclusion criteria were included for review. Conclusion: While it is often difficult to predict the timing of death, the ability of healthcare providers to recognize the clinical signs and symptoms of imminent death in terminally-ill individuals may lead to earlier anticipation of care needs and better planning to provide care that is tailored to individual's needs, and ultimately results in better end-of-life care, as well as a better bereavement adjustment experience for the families.

Ethics, law, and politics in palaeontological research: The case of Myanmar amber.

Fossil material in amber from Myanmar can provide important insights into mid-Cretaceous forest ecosystems. However, Myanmar amber has been receiving increased international attention due to reported links between amber mining and the ongoing humanitarian crisis in northern Myanmar, as well as the legal issues associated with its exportation. Here, we conduct a bibliometric analysis of Myanmar amber publications (1990-2021) and demonstrate how research interest in Myanmar amber is explicitly linked to major political, legal, and economic changes. An analysis of the authorship networks for publications on amber inclusions reveals how current research practices have excluded Myanmar researchers from the field. In addition, the international trade of Myanmar amber with fossil inclusions falls into a legal 'grey-zone' which continues to be exploited. This case study vividly demonstrates that systemic changes, alongside an increased awareness of inequitable research practices amongst the broader scientific and allied communities, are urgently needed to curb illegal practices in palaeontology.

In-Hospital Utilization and Outcomes of Palliative Care Consultation in Patients With Advanced Heart Failure Complicated by Cardiogenic Shock Requiring Mechanical Circulatory Support.

Prior studies have shown that the early inclusion of palliative care (PC) specialist is associated with better end-of-life experiences. The National Inpatient Sample Database was queried from 2012 to 2017 for relevant of ICD)-9 and -10 procedural and diagnostic codes to identify patients above 18 years with advanced heart failure (HF) admitted with cardiogenic shock (CS) requiring mechanical circulatory support (MCS). Baseline characteristics, utilization trends and invasive procedures and complications were compared among patients evaluated by PC and those who were not. There were 65,230 patients hospitalized for advanced HF complicated by CS requiring MCS, of these a PC consult was placed in in 9,200 patients (14.1%) and trended upward from 9.4 to 16.8%, between 2012 to 2017. The majority of patients, (37.3%) from the total population died in hospital. In reference to patients who were discharged alive, PC consultation was associated with a lower incidence of invasive procedures such as mechanical ventilation, pacemaker implantation, defibrillator implantation, insertion of percutaneous feeding tubes and tracheostomies performed (p <0.05 for all) whereas complications such as major bleeding, septic shock, transfusion of any blood product were comparable between both cohorts (nonsignificant p value for all). On the other hand, in those patients who died in hospital PC was associated with a lower incidence of pacemaker implantation, defibrillator implantation and insertion of percutaneous feeding tubes (p <0.05 for all). Despite the high morbidity and mortality associated with advanced HF patients with CS requiring MCS, the overall prevalence of PC consultation is exceedingly low. When utilized, the incidence of invasive procedures was lower. This study highlights the underutilization of PC services in this patient population, precluding any perceived benefit in end-of-life experiences.

Genetic identification of medicinally used Salacia species by nrDNA ITS sequences and a PCR-RFLP assay for authentication of Salacia-related health foods.

ETHNOPHARMACOLOGICAL RELEVANCE: The roots and stems of several Salacia species have been used as traditional medicines, especially in Ayurvedic medical system for the treatment of diabetes, rheumatism, gonorrhea, amenorrhea, skin diseases, etc. Due to reported evidence supporting Salacia's beneficial effects in early-stage diabetes and other lifestyle-related diseases, Salacia-based dietary supplements and health foods have been gaining popularity in Japan and other countries in recent years. However, due to the morphological similarities between Salacia plants, particularly in the medicinally used parts (roots and stems), the authentication of the botanical identities of Salacia-derived products is challenging. AIM OF THIS STUDY: This study aims to develop a genetic approach to authenticate the medicinally used Salacia species and to determine the botanical sources of the commercially available Salacia-derived products. MATERIALS AND METHODS: The sequences of nuclear DNA internal transcribed spacer (ITS) and chloroplast trnK-rps16 region were determined and compared between 10 plant specimens from three medicinally used Salacia species as well as 48 samples of commercial crude drugs. Moreover, a PCR-restriction fragment length polymorphism (RFLP) assay was developed for rapid identification based on the ITS sequences. RESULTS: The plant specimens from the three medicinally used Salacia species showed three main types of sequences in both ITS (types I, II, III) and trnK-rps16 (i, ii, iii) regions. Combined the sequences of ITS and trnK-rps16 regions, S. reticulata and S. oblonga had type I-i and type III-iii or similar sequences, respectively. S. chinensis had type II-ii or II(536M)-i sequences. Forty-eight samples of commercial crude drugs were identified based on ITS and trnK-rps16 DNA barcode. A convenient PCR-RFLP assay using Cac8I restriction enzyme was established and applied to identify the botanical sources of health food products purchased from online retailers. All the twelve samples were identified as S. chinensis. CONCLUSION: The nrDNA ITS sequences provided useful information to authenticate Salacia species and to elucidate the phylogenetic relationship within the Salacia genus. Genetic identification results revealed that S. chinensis and S. reticulata are the major sources of commercially available Salacia-products. Based on the ITS sequences, a convenient PCR-RFLP assay was established for the identification of the medicinally used Salacia species as well as their derived health food products.

Molecular Characterization of Species of the Subgenus Mus from Myanmar.

The species composition and genetic diversity of the subgenus Mus in Myanmar are not yet fully understood. In this study, mice were trapped in rural areas near the Ayeyarwady River basin, spanning five Myanmar cities from north to south: Mandalay, Bagan, Magway, Pyay, and Yangon. Mitochondrial cytochrome b (Cytb) and nuclear melanocortin 1 receptor (Mc1r) gene sequences were determined for mice sampled and revealed a widespread occurrence of Mus nitidulus in central Myanmar in addition to its previously known occurrence in the Yangon district of southern Myanmar. Analyses of Cytb revealed two haplogroups with a genetic distance of 2.0%, suggestive of divergence several hundred thousand years ago. Mus caroli and M. musculus were confined to Yangon and Mandalay/Bagan/Magway, respectively. Mice collected from a locality on the eastern side of the Ayeyarwady River in Pyay were identified using Cytb and Mc1r sequences as M. fragilicauda, which was previously identified only in Laos and Thailand. The species M. booduga and M. cervicolor previously predicted to be common in the study area were not found. These findings elucidate the species and genetic diversity of the subgenus Mus in the Indo-Malayan Region.

Association of ZFHX3 gene variation with atrial fibrillation, cerebral infarction, and lung thromboembolism: An autopsy study.

AIM: We aimed to study a single nucleotide polymorphism (SNP), rs2106261, in the transcription factor gene, ZFHX3, in atrial fibrillation (AF) and other related phenotypes by phenome scanning in a Japanese population. METHOD: We retrieved consecutive autopsy data (n=2433, mean age=80 years) from the Japanese SNP database for geriatric diseases (JG-SNP). Clinical data, including an AF diagnosis, were collected from medical charts. Genotyping was performed with the DNA chip method. We also analyzed 42 pathological and 26 clinical phenotypes, including cerebral infarctions (CIs) and lung thromboembolisms (LTs), diagnosed by macroscopic inspection during the autopsy. RESULT: Among the 2433 patients with available data, 18.6% had AF, 29.4% had CI, and 4.9% had LT phenotypes. The A allele of the rs2106261 SNP was significantly associated with AF, after adjusting for age, sex, diabetes, hypertension, and smoking (AA+AG/GG, OR=1.51, 95%CI: 1.16-1.97, p=0.002). In the entire cohort, CI was not associated with rs2106261 (p=0.14). However, among patients under 80 years old, rs2106261 was significantly associated with CI (AA+AG/GG, OR=1.57, 95%CI: 1.09-2.26, p=0.01). LT was also associated with rs2106261 (AA+AG/GG, OR=1.99, 95%CI: 1.31-3.01, p=0.001). Associations between rs2106261 and CI and LT remained positive after adjusting for the presence of AF, which indicated that this SNP variant might serve as an independent risk marker. CONCLUSION: We showed that the ZFHX3 polymorphism, rs2106261 (A allele), was a risk marker for AF and AF-related phenotypes. The roles of this variant in the development of AF and its related phenotypes warrant further investigation.

The positive attitudes and perceptions of care managers about advance directives.

In a previous intervention, we found that reminders from care managers failed to increase the number of their homebound older adult clients with advance directives. Thus, in the current study, we looked at the perceptions and attitudes of care managers about the need to discuss advance directives with their clients. Ninety-five care managers serving community-based nursing home-eligible older adults completed an 18-question survey, which found that care managers overwhelmingly believe it is important to address advance directives. Only 3.2% reported that discussing advance directives is time consuming. No attitudinal barriers were identified. Given their positive attitudes about advance directives, care managers need educational interventions that will provide the knowledge and skills to interact effectively with clients who are resistant to addressing end-of-life issues.

Avatar-mediated training in the delivery of bad news in a virtual world.

BACKGROUND: Delivering bad news to patients is an essential communication skill for physicians. Educators commonly use standardized patient (SP) encounters to train physicians in the delivery of bad news. It is expensive to use actors, for logistical reasons such as travel and scheduling, and there are limits to the characters and conditions an actor can portray in teaching encounters. Thus we studied the feasibility of creating SP avatars in a virtual world for the task of training medical trainees to deliver bad news. The SP avatars are easily customized for different scenarios and amenable to distance learning. METHODS: We recruited 10 medical trainees to interact with a standardized female avatar in a three-dimensional simulated clinic, where the trainee was to inform the avatar of her newly diagnosed breast cancer. The trainee evaluated his or her self-efficacy in delivering bad news via an affective competency score (ACS) before and after the encounter. Two palliative care specialists evaluated each trainee's performance using the Bad News Assessment Schedule and the performance ACS. RESULTS: The self-efficacy ACS scores of the trainees improved overall: before, 20 ± 4, versus after, 24 ± 3, p = 0.001 (maximum score = 30). All participants considered the experience positive and commended the novel approach, although noting that the avatars were not able to portray body language cues. CONCLUSION: Participants viewed the avatar-mediated training as an excellent approach for learning how to deliver bad news but believed it could not substitute for real patient interactions. However, participant self-efficacy improved, which suggests that avatar-mediated training in a virtual world is a viable educational approach for skill training in delivering bad news.

Rapid identification of elastic modulus of the interface tissue on dental implants surfaces using reduced-basis method and a neural network.

This paper proposes a rapid inverse analysis approach based on the reduced-basis method (RBM) and neural network (NN) to identify the "unknown" elastic modulus (Young's modulus) of the interfacial tissue between a dental implant and the surrounding bones. In the present RBM-NN approach, a RBM model is first built to compute displacement responses of dental implant-bone structures subjected to a harmonic loading for a set of "assumed" Young's moduli. The RBM model is then used to train a NN model that is used for actual inverse analysis in real-time. Actual experimental measurements of displacement responses are fed into the trained NN model to inversely determine the "true" elastic modulus of the interfacial tissue. As an example, a physical model of dental implant-bone structure is built and inverse analysis is conducted to verify the present RBM-NN approach. Based on numerical simulation and actual experiments, it is confirmed that the identified results are very accurate, reliable, and the computational saving is very significant. The present RBM-NN approach is found robust and efficient for inverse material characterizations in noninvasive and/or nondestructive evaluations.

Developing a national tiger action plan for The Union of Myanmar.

A century ago, tigers were considered pests in Myanmar. Hunters claimed thousands, yet populations persisted. In the past century, because of habitat loss and prey depletion, coupled with the recent demand for traditional medicines, tiger populations have been reduced to a few hundred individuals. As a first step toward long-term planning for tigers, and to guide efforts to increase protected area coverage, the Myanmar government in 1998 initiated a project to develop a revised National Tiger Action Plan. Extensive surveys confirmed tigers in only 4 of 17 survey locations. Significant populations are thought to persist in the far North and far South of the country, where large, intact forests offer the potential for tiger recovery. With partnerships and collaborations, tiger populations can be protected in the short term (<5 years) by expanding protected areas and corridors, mobilizing enforcement staff to reduce poaching of tigers and prey, and amending existing wildlife legislation in accordance with international laws. Over the long term (5-20 years), recovery of Myanmar's tiger populations will depend on increasing support from local people, zoning tiger areas to reduce habitat loss and disturbance, and maintaining connectivity of existing national and transboundary forests. This article reviews the development of a new National Tiger Action Plan for the Union of Myanmar and discusses a blueprint for conservation measures aimed at saving tigers from extinction.

Case and discussion of Lyme disease.

Lyme disease is a multisystem disease with prominent neurological involvement, primarily affecting the nervous system, skin, joints, and heart. We report the case of a patent with Lyme Disease and discuss the background as treatment of this condition.

Amiodarone-induced thyrotoxicosis presenting as hypokalemic periodic paralysis.

Thyroid disorder is a well-recognized side effect of amiodarone therapy. Thyrotoxicosis is less common than hypothyroidism. Hypokalemic periodic paralysis is one manifestation of thyrotoxicosis, and is more often seen in Oriental and Latin American men than in other demographic groups. This phenomenon, however, has not been previously described in thyrotoxicosis due to amiodarone usage. We describe a case of amiodarone-induced thyrotoxicosis in a 34-year-old man who presented with sudden lower extremity weakness, heat intolerance, and weight loss. Physical examination demonstrated fine tremors. Serum potassium level was 2.2 mEq/L on admission. Gastrointestinal and renal causes of potassium loss were excluded by history and physical examination. Further biochemical testing demonstrated abnormal thyroid function. The urinary potassium and serum bicarbonate, magnesium, and calcium levels were within normal limits. Lower extremity weakness resolved immediately after potassium replacement therapy. Methimazole therapy was initiated, and the patient was clinically euthyroid on discharge.