Timely diagnosis of dementia has a wide range of benefits including reduced hospital emergency department presentations, admissions and inpatient length of stay, and improved quality of life for ...patients and their carers by facilitating access to treatments that reduce symptoms, and allow time to plan for the future. Memory clinics can provide such services, however there is no 'gold standard' model of care. This study involved the co-creation of a model of care for a new multidisciplinary memory clinic with local community members, General Practitioners (GPs), policy-makers, community aged care workers, and service providers.
Data collection comprised semi-structured interviews (N = 98) with 20 GPs, and three 2-h community forums involving 53 seniors and community/local government representatives, and 25 community healthcare workers. Interviews and community forums were audio-recorded, transcribed verbatim, and coded by thematic analysis using Quirkos.
GPs' attitudes towards their role in assessing people with dementia varied. Many GPs reported that they found it useful for patients to have a diagnosis of dementia, but required support from secondary care to make the diagnosis and assist with subsequent management. Community forum participants felt they had a good knowledge of available dementia resources and services, but noted that these were highly fragmented and needed to be easier to navigate for the patient/carer via a 'one-stop-shop' and the provision of a dementia key worker. Expectations for the services and features of a new memory clinic included diagnostic services, rapid referrals, case management, education, legal services, culturally sensitive and appropriate services, allied health, research participation opportunities, and clear communication with GPs. Participants described several barriers to memory clinic utilisation including transportation access, funding, awareness, and costs.
This study demonstrates the importance of working with stakeholders to co-design models of care for people with dementia that take into account the local communities' needs. Findings pave the way for the development of a potential new "gold standard" memory clinic model of care and operationalise new national clinical guidelines.
Background
Peritoneal dialysis (PD) is a home-based therapy where nurses train patients in its use. There has been no published randomized controlled trial (RCT) evaluating any specific protocol for ...nurses delivering PD training. A standardized education package based upon the best available evidence and utilizing modern educational practices may lead to improved patient outcomes. The aim is to develop a standardized, evidence-based curriculum for PD trainers and patients aligned with guidelines from the International Society for Peritoneal Dialysis (ISPD), using best practice pedagogy.
Methods
A literature search and clinical audit were conducted to identify current practice patterns and best practice. Results were reviewed by a focus group of practitioners comprising PD nurses, nephrologists, consumers, a medical education expert, and an eLearning expert. From this, a training curriculum and modules were developed.
Results
A comprehensive PD training curriculum has been developed, which includes modules for training PD nurses (trainers) and patient training manuals. The package comprises 2 introductory modules and 2 clinical case modules. The curriculum is designed for both interactive digital media (trainers) and traditional paper-based teaching with practical demonstrations (patients). Assessment is also addressed.
Conclusion
The need for the development of a comprehensive and standardized curriculum for PD nurse trainers and their patients was confirmed. This paper outlines the process of the development of this curriculum. Pilot testing of the modules was launched in late 2017 to examine feasibility, and planning has commenced for a RCT in 2019 to investigate the effect of the modules on clinical outcomes, and their wider application across Australia and New Zealand.
Background:
There is substantial variation in peritonitis rates across peritoneal dialysis (PD) units globally. This may, in part, be related to the wide variability in the content and delivery of ...training for PD nurse trainers and patients.
Aim:
The aim of this study was to test the feasibility of implementing the Targeted Education ApproaCH to improve Peritoneal Dialysis Outcomes (TEACH-PD) curriculum in real clinical practice settings.
Methods:
This study used mixed methods including questionnaires and semi-structured interviews (pretraining and post-training) with nurse trainers and patients to test the acceptability and usability of the PD training modules implemented in two PD units over 6 months. Quantitative data from the questionnaires were analysed descriptively. Interviews were analysed using thematic analysis.
Results:
Ten PD trainers and 14 incident PD patients were included. Mean training duration to complete the modules were 10.9 h (range 6–17) and 24.9 h (range 15–35), for PD trainers and patients, respectively. None of the PD patients experienced PD-related complications at 30 days follow-up. Three (21%) patients were transferred to haemodialysis due to non-PD–related complications. Ten trainers and 14 PD patients participated in the interviews. Four themes were identified including use of adult learning principles (trainers), comprehension of online modules (trainers), time to complete the modules (trainers) and patient usability of the manuals (patient).
Conclusion:
This TEACH-PD study has demonstrated feasibility of implementation in a real clinical setting. The outcomes of this study have informed refinement of the TEACH-PD modules prior to rigorous evaluation of its efficacy and cost-effectiveness in a large-scale study.
Introduction
Up to a 10‐fold difference in clinical outcomes between Australian peritoneal dialysis (PD) units exists. There is an international focus on the harmonization of educational practices in ...PD to determine whether this may lead to improved patient outcomes.
Aims
The aim of this paper is to evaluate the current teaching practices of nurses and patients in Australian PD units.
Methods
An online survey with questions on nurse and patient training was made available to PD units in Australia.
Results
Thirty‐eight (70%) of 54 PD units in Australia completed the survey. A written standardized curricula was utilized in 21 units (55%) for nursing staff and 30 units (79%) for patients, with 23% and 12% including an electronic delivery component for each group, respectively. Universal teaching of adult learning principles was not demonstrated. The hours spent on teaching nursing staff ranged from <15 h in 24% to >100 h in 21% of units. The average number of hours spent by nurses each day to train patients ranged from <2 h in 14% to >6 h in 11% of units, with the average total training days ranging from 2 to 3 days in 14% to over 7 days in 14% of units. Staff and patient competency assessments were performed routinely in 37% and 74% of units, respectively.
Conclusions
Considerable differences exist amongst Australian PD units in the education of staff and patients. There is a general lack of delivery and competency assessment to meet educational standards. It remains to be seen if harmonization of educational curricula can translate to improved clinical outcomes.
Summary at a Glance
This is a qualitative study on the training methodology of patients and medical staff on peritoneal dialysis in Australian PD units. This study demonstrates significant differences in training curricula of the various units.
OBJECTIVE:To assess whether an average of 10 years of lifestyle intervention designed to reduce weight and increase physical activity lowers the prevalence of cognitive impairment among adults at ...increased risk due to type 2 diabetes and obesity or overweight.
METHODS:Central adjudication of mild cognitive impairment and probable dementia was based on standardized cognitive test battery scores administered to 3,802 individuals who had been randomly assigned, with equal probability, to either the lifestyle intervention or the diabetes support and education control. When scores fell below a prespecified threshold, functional information was obtained through proxy interview.
RESULTS:Compared with control, the intensive lifestyle intervention induced and maintained marked differences in weight loss and self-reported physical activity throughout follow-up. At an average (range) of 11.4 (9.5–13.5) years after enrollment, when participantsʼ mean age was 69.6 (54.9–87.2) years, the prevalence of mild cognitive impairment and probable dementia was 6.4% and 1.8%, respectively, in the intervention group, compared with 6.6% and 1.8%, respectively, in the control group (p = 0.93). The lack of an intervention effect on the prevalence of cognitive impairment was consistent among individuals grouped by cardiovascular disease history, diabetes duration, sex, and APOE ε4 allele status (all p ≥ 0.50). However, there was evidence (p = 0.03) that the intervention effect ranged from benefit to harm across participants ordered from lowest to highest baseline BMI.
CONCLUSIONS:Ten years of behavioral weight loss intervention did not result in an overall difference in the prevalence of cognitive impairment among overweight or obese adults with type 2 diabetes.
CLINICALTRIALS.GOV IDENTIFIER:NCT00017953 (Action for Health in Diabetes).
LEVEL OF EVIDENCE:This study provides Class II evidence that for overweight adults with type 2 diabetes, a lifestyle intervention designed to reduce weight and increase physical activity does not lower the risk of cognitive impairment.
Holoprosencephaly (HPE), the most common malformation of the human forebrain, may result from mutations in over 12 genes. Sonic Hedgehog (SHH) was the first such gene discovered; mutations in SHH ...remain the most common cause of non-chromosomal HPE. The severity spectrum is wide, ranging from incompatibility with extrauterine life to isolated midline facial differences.
To characterise genetic and clinical findings in individuals with SHH mutations.
Through the National Institutes of Health and collaborating centres, DNA from approximately 2000 individuals with HPE spectrum disorders were analysed for SHH variations. Clinical details were examined and combined with published cases.
This study describes 396 individuals, representing 157 unrelated kindreds, with SHH mutations; 141 (36%) have not been previously reported. SHH mutations more commonly resulted in non-HPE (64%) than frank HPE (36%), and non-HPE was significantly more common in patients with SHH than in those with mutations in the other common HPE related genes (p<0.0001 compared to ZIC2 or SIX3). Individuals with truncating mutations were significantly more likely to have frank HPE than those with non-truncating mutations (49% vs 35%, respectively; p=0.012). While mutations were significantly more common in the N-terminus than in the C-terminus (including accounting for the relative size of the coding regions, p=0.00010), no specific genotype-phenotype correlations could be established regarding mutation location.
SHH mutations overall result in milder disease than mutations in other common HPE related genes. HPE is more frequent in individuals with truncating mutations, but clinical predictions at the individual level remain elusive.
The Nordic countries have commonalities in gender equality, economy, welfare, and health care, but differ in culture and lifestyle, which might create country-wise health differences. This study ...compared life expectancy, disease burden, and risk factors in the Nordic region.
Life expectancy in years and age-standardised rates of overall, cause-specific, and risk factor-specific estimates of disability-adjusted life-years (DALYs) were analysed in the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2017. Data were extracted for Denmark, Finland, Iceland, Norway, and Sweden (ie, the Nordic countries), and Greenland, an autonomous area of Denmark. Estimates were compared with global, high-income region, and Nordic regional estimates, including Greenland.
All Nordic countries exceeded the global life expectancy; in 2017, the highest life expectancy was in Iceland among females (85·9 years 95% uncertainty interval UI 85·5–86·4 vs 75·6 years 75·3–75·9 globally) and Sweden among males (80·8 years 80·2–81·4 vs 70·5 years 70·1–70·8 globally). Females (82·7 years 81·9–83·4) and males (78·8 years 78·1–79·5) in Denmark and males in Finland (78·6 years 77·8–79·2) had lower life expectancy than in the other Nordic countries. The lowest life expectancy in the Nordic region was in Greenland (females 77·2 years 76·2–78·0, males 70·8 years 70·3–71·4). Overall disease burden was lower in the Nordic countries than globally, with the lowest age-standardised DALY rates among Swedish males (18 555·7 DALYs 95% UI 15 968·6–21 426·8 per 100 000 population vs 35 834·3 DALYs 33 218·2–38 740·7 globally) and Icelandic females (16 074·1 DALYs 13 216·4–19 240·8 vs 29 934·6 DALYs 26 981·9–33 211·2 globally). Greenland had substantially higher DALY rates (26 666·6 DALYs 23 478·4–30 218·8 among females, 33 101·3 DALYs 30 182·3–36 218·6 among males) than the Nordic countries. Country variation was primarily due to differences in causes that largely contributed to DALYs through mortality, such as ischaemic heart disease. These causes dominated male disease burden, whereas non-fatal causes such as low back pain were important for female disease burden. Smoking and metabolic risk factors were high-ranking risk factors across all countries. DALYs attributable to alcohol use and smoking were particularly high among the Danes, as was alcohol use among Finnish males.
Risk factor differences might drive differences in life expectancy and disease burden that merit attention also in high-income settings such as the Nordic countries. Special attention should be given to the high disease burden in Greenland.
Bill & Melinda Gates Foundation. The work on this paper was supported by the Research Council of Norway through FRIPRO (project number 262030) and by the Norwegian Institute of Public Health.
Peritoneal dialysis (PD)-related infections, such as peritonitis, exit site, and tunnel infections, substantially impair the sustainability of PD. Accordingly, PD-related infection is the ...top-priority research outcome for patients and caregivers. While PD nurse trainers teach patients to perform their own PD, PD training curricula are not standardized or informed by an evidentiary base and may offer a potential approach to prevent PD infections. The Targeted Education ApproaCH to improve Peritoneal Dialysis outcomes (TEACH-PD) trial evaluates whether a standardized training curriculum for PD nurse trainers and incident PD patients based on the International Society for Peritoneal Dialysis (ISPD) guidelines reduces PD-related infections compared to usual training practices.
The TEACH-PD trial is a registry-based, pragmatic, open-label, multi-center, binational, cluster-randomized controlled trial. TEACH-PD will recruit adults aged 18 years or older who have not previously undergone PD training at 42 PD treatment units (clusters) in Australia and New Zealand (ANZ) between July 2019 and June 2023. Clusters will be randomized 1:1 to standardized TEACH-PD training curriculum or usual training practice. The primary trial outcome is the time to the first occurrence of any PD-related infection (exit site infection, tunnel infection, or peritonitis). The secondary trial outcomes are the individual components of the primary outcome, infection-associated catheter removal, transfer to hemodialysis (greater than 30 days and 180 days), quality of life, hospitalization, all-cause death, a composite of transfer to hemodialysis or all-cause death, and cost-effectiveness. Participants are followed for a minimum of 12 months with a targeted average follow-up period of 2 years. Participant and outcome data are collected from the ANZ Dialysis and Transplant Registry (ANZDATA) and the New Zealand Peritoneal Dialysis (NZPD) Registry. This protocol follows the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines.
TEACH-PD is a registry-based, cluster-randomized pragmatic trial that aims to provide high-certainty evidence about whether an ISPD guideline-informed standardized PD training curriculum for PD nurse trainers and adult patients prevents PD-related infections.
ClinicalTrials.gov NCT03816111. Registered on 24 January 2019.
Five nests of Augochlora (Augochlora) esox (Vachal, 1911) were detected in the rosettes of bromeliads (Aechmaea nudicaulis and A. lindenii) on the island of Santa Catarina, Brazil. Two of the nests ...were constructed after manipulation of bromeliads as trap nests. Cells were built in the central funnel filled with moist black humus in a scattered way without a detectable pattern. One founding female and all brood stages from eggs to pupae as well as male and female imagines were found in the nests which contained between 3-16 cells each. The uppermost cells contained the youngest larvae whereas pupae and young imagines were found at the bottoms of the nests. Pollen carried by the provisioning female and present in provisions of two nests originated from 18 plant species, in particular Asteraceae and Melastomataceae. Nest architecture is compared to that of congeners, and the use of bromeliads as nest sites for bees is discussed.
For decades, scholars have repeatedly found the inequity of gender representations in informational and entertainment media. Beginning with the seminal work by Gaye Tuchman and colleagues, we have ...repeatedly seen a systemic underrepresentation and misrepresentation of women in media. Examining the latest research in discourse and content analyses trending in both domestic and international circles, Media Disparity: A Gender Battleground highlights the progress—or lack thereof—in media regarding portrayals of women, across genres and cultures within the twenty-first century. Blending both original studies and descriptive overviews of current media platforms, top scholars evaluate the portrayals of women in contemporary venues, including advertisements, videogames, political stories, health communication, and reality television.
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