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Background: Nearly three out of four older people will use the emergency department (ED) during their last year of life. However, most of them do not benefit from palliative care. Providing palliative care is a real challenge for ED clinicians who are trained in acute, life-saving medicine. Our aim is to understand the ED's role in providing palliative care for this population. Methods: We designed a qualitative study based on 1) interviews – conducted with older patients (≥ 75 years) with a palliative profile and their informal caregivers – and 2) focus groups – conducted with ED and primary care nurses and physicians. Palliative profiles were defined by the Supportive and Palliative Indicators tool (SPICT). Qualitative data was collected in French-speaking Belgium between July 2021 and July 2022. We used a constant inductive and comparative analysis. Results: Five older patients with a palliative profile, four informal caregivers, 55 primary and ED caregivers participated in this study. A priori, the participants did not perceive any role for the ED in palliative care. In fact, there is widespread discomfort with caring for older patients and providing palliative care. This is explained by multiple areas of tensions. Palliative care is an approach fraught with pitfalls, i.e.: knowledge and know-how gaps, their implementation depends on patients'(co)morbidity profile and professional values, experiences and type of practice. In ED, there are constant tensions between emergency and palliative care requirements, i.e.: performance, clockwork and needs for standardised procedures versus relational care, time and diversity of palliative care projects. However, even though the ED's role in palliative care is not recognised at first sight, we highlighted four roles assumed by ED caregivers: 1) Investigator, 2) Objectifier, 3) Palliative care provider, and 4) Decision-maker on the intensity of care. A common perception among participants was that ED caregivers can assist in the early identification of patients with a palliative profile. Conclusions: Currently, there is widespread discomfort regarding ED caregivers caring for older patients and providing palliative care. Nonetheless, ED caregivers play four roles in palliative care for older patients. In the future, ED caregivers might also perform the role of early identifier. [ABSTRACT FROM AUTHOR]

Environmental DNA (eDNA) metabarcoding has the potential to revolutionize conservation planning by providing spatially and taxonomically comprehensive data on biodiversity and ecosystem conditions, but its utility to inform the design of protected areas remains untested. Here, we quantify whether and how identifying conservation priority areas within coral reef ecosystems differs when biodiversity information is collected via eDNA analyses or traditional visual census records. We focus on 147 coral reefs in Indonesia's hyper-diverse Wallacea region and show large discrepancies in the allocation and spatial design of conservation priority areas when coral reef species were surveyed with underwater visual techniques (fishes, corals, and algae) or eDNA metabarcoding (eukaryotes and metazoans). Specifically, incidental protection occurred for 55% of eDNA species when targets were set for species detected by visual surveys and 71% vice versa. This finding is supported by generally low overlap in detection between visual census and eDNA methods at species level, with more overlap at higher taxonomic ranks. Incomplete taxonomic reference databases for the highly diverse Wallacea reefs, and the complementary detection of species by the two methods, underscore the current need to combine different biodiversity data sources to maximize species representation in conservation planning. [ABSTRACT FROM AUTHOR]

Background: Measuring quality is essential to drive improvement initiatives in hospitals. An instrument that measures healthcare quality multidimensionally and integrates patients', kin's and professionals' perspectives is lacking. We aimed to develop and validate an instrument to measure healthcare quality multidimensionally from a multistakeholder perspective. Methods: A multi-method approach started by establishing content and face validity, followed by a multi-centre study in 17 Flemish (Belgian) hospitals to assess construct validity through confirmatory factor analysis, criterion validity through determining Pearson's correlations and reliability through Cronbach's alpha measurement. The instrument FlaQuM-Quickscan measures 'Healthcare quality for patients and kin' (part 1) and 'Healthcare quality for professionals' (part 2). This bipartite instrument mirrors 15 quality items and 3 general items (the overall quality score, recommendation score and intention-to-stay score). A process evaluation was organised to identify effective strategies in instrument distribution by conducting semi-structured interviews with quality managers. Results: By involving experts in the development of quality items and through pilot testing by a multi-stakeholder group, the content and face validity of instrument items was ensured. In total, 13,615 respondents (5,891 Patients/kin and 7,724 Professionals) completed the FlaQuM-Quickscan. Confirmatory factor analyses showed good to very good fit and correlations supported the associations between the quality items and general items for both instrument parts. Cronbach's alphas supported the internal consistency. The process evaluation revealed that supportive technical structures and approaching respondents individually were effective strategies to distribute the instrument. Conclusions: The FlaQuM-Quickscan is a valid instrument to measure healthcare quality experiences multidimensionally from an integrated multistakeholder perspective. This new instrument offers unique and detailed data to design sustainable quality management systems in hospitals. Based on these data, hospital management and policymakers can set quality priorities for patients', kin's and professionals' care. Future research should investigate the transferability to other healthcare systems and examine between-stakeholders and between-hospitals variation. [ABSTRACT FROM AUTHOR]

In tropical marine ecosystems, the coral-based diet of benthic-feeding reef fishes provides a window into the composition and health of coral reefs. In this study, for the first time, we compare multi-assay metabarcoding sequences of environmental DNA (eDNA) isolated from seawater and partially digested gut items from an obligate corallivore butterflyfish (Chaetodon lunulatus) resident to coral reef sites in the South China Sea. We specifically tested the proportional and statistical overlap of the different approaches (seawater vs gut content metabarcoding) in characterizing eukaryotic community composition on coral reefs. Based on 18S and ITS2 sequence data, which differed in their taxonomic sensitivity, we found that gut content detections were only partially representative of the eukaryotic communities detected in the seawater based on low levels of taxonomic overlap (3 to 21%) and significant differences between the sampling approaches. Overall, our results indicate that dietary metabarcoding of specialized feeders can be complimentary to, but is no replacement for, more comprehensive environmental DNA assays of reef environments that might include the processing of different substrates (seawater, sediment, plankton) or traditional observational surveys. These molecular assays, in tandem, might be best suited to highly productive but cryptic oceanic environments (kelp forests, seagrass meadows) that contain an abundance of organisms that are often small, epiphytic, symbiotic, or cryptic. [ABSTRACT FROM AUTHOR]

Background: As emergency department (ED) leaders started integrating geriatric emergency guidelines on a facultative basis, important variations have emerged between EDs in care for older patients. The aim of this study was to establish a consensus on minimum operational standards for Geriatric ED care in Belgium. Methods: A two-stage modified Delphi study was conducted. Twenty panellists were recruited from Dutch and French speaking regions in Belgium to join an interdisciplinary expert panel. In the first stage, an online survey was conducted to identify and define all possible elements of geriatric emergency care. In the second stage, an online survey and online expert panel meeting were organized consecutively to determine which elements should be recognized as minimum operational standards. Results: Between March 2020 and February 2021, the expert panel developed a broad consensus including ten statements focusing on the target population, specific goals, availability of geriatric practitioners and quality assurance. Additionally, the expert panel also determined which protocols, materials and accommodation criteria should be available in conventional EDs (39 standards) and in observational EDs (57 standards). Conclusions: This study presents a consensus on minimum operational standards for geriatric emergency care in two ED types: the conventional ED and the observational ED. These findings may serve as a starting point towards broadly supported minimum standards of care stipulated by legislation in Belgium or other countries. [ABSTRACT FROM AUTHOR]

Background: Older patients are increasingly showing multi-comorbidities, including advanced chronic diseases. When admitted to the emergency department (ED), the decision to pursue life-prolonging treatments or to initiate a palliative care approach is a challenge for clinicians. We test for the first time the diagnostic accuracy of the Supportive and Palliative Care Indicators Tool (SPICT) in the ED to identify older patients at risk of deteriorating and dying, and timely address palliative care needs. Methods: We conducted a prospective bicentric cohort study on 352 older patients (≥ 75 years) admitted to two EDs in Belgium between December 2019 and March 2020 and between August and November 2020. SPICT (French version, 2019) variables were collected during the patients' admission to the ED, along with socio-demographic, medical and functional data. The palliative profile was defined as a positive SPICT assessment. Survival, symptoms and health degradation (≥ 1 point in ADL Katz score or institutionalisation and death) were followed at 12 months by phone. Main accuracy measures were sensitivity, specificity and likelihood ratios (LR) as well as cox regression, survival analysis using the Kaplan Meier method, and ordinal regression. Results: Out of 352 patients included in the study (mean age 83 ± 5.5 years, 43% male), 167 patients (47%) had a positive SPICT profile. At one year follow up, SPICT positive patients presented significantly more health degradation (72%) compared with SPICT negative patients (35%, p < 0.001). SPICT positivity was correlated with 1-year health degradation (OR 4.9; p < 0.001). The sensitivity and specificity of SPICT to predict health degradation were 0.65 (95%CI, 0.57–0.73) and 0.72 (95%CI, 0.64–0.80) respectively, with a negative LR of 0.48 (95%CI, 0.38–0.60) and a positive LR of 2.37 (1.78–3.16). The survival time was shorter in SPICT positive patients than in SPICT negative ones (p < 0.001), the former having a higher 1-year mortality rate (HR = 4.21; p < 0.001). Conclusions: SPICT successfully identifies older patients at high risk of health degradation and death. It can support emergency clinicians to identify older patients with a palliative profile and subsequently initiate a palliative care approach with a discussion on goals of care. [ABSTRACT FROM AUTHOR]

Context: The health of coral reefs is declining rapidly across the world because of anthropogenic impacts. In the mega-diverse Coral Triangle, the consequences of chronic overfishing and human use are worst near coastal population centres. Aims: The remote islands and reefs in the centre of the Banda Sea (Indonesia) remain largely unstudied, but their distance from populated areas could provide protection from fishing. Methods: We conducted the first visual census surveys of coral-reef communities at the uninhabited Lucipara group in the Banda Sea. Key results: Sites showed medium to high coral cover and fish assemblages with high biomass, including abundant large predatory species. All sites exceeded the fish biomass conservation target of 1150 kg ha−1 proposed by McClanahan et al. (2015) , by a factor of ~2–10. Benthic cover explained >50% of variance in fish abundance and diversity, with submassive corals, Dendrophyllia spp., and bare rock as key predictors. Conclusions: Our results suggested that Lucipara's reefs are among the healthiest in Indonesia, likely owing to their remoteness. However, this remoteness might also hamper policing against destructive fishing practices, highlighting a conservation gap. Implications: Lucipara's reef communities should be protected in a time of global coral-reef declines. The health of coral reefs is declining rapidly because of human impacts, especially of those close to population centres. We surveyed the coral reefs at a remote, uninhabited island group in Indonesia, which were expected to be less damaged. We found reasonably healthy coral reefs and importantly, very healthy fish stocks with many large predatory species. Our study suggested that Lucipara's reefs are among the healthiest in Indonesia and should be protected in a time of declining coral-reef health. [ABSTRACT FROM AUTHOR]

This study aimed to identify determinants of adherence to lifestyle and body weight recommendations for cancer prevention among Lynch Syndrome (LS) patients. Cross-sectional baseline data of LS patients participating in the Lifestyle & Lynch (LiLy) study was used to assess determinants of adherence to the World Cancer Research Fund cancer prevention recommendations on body weight, physical activity, and red and processed meat intake. Adherence and potential determinants of adherence were assessed using questionnaires. Multivariable logistic regression analyses were conducted to identify determinants of adherence. Of the 211 participants, 50.2% adhered to the body weight recommendation, 78.7% adhered to the physical activity recommendation, and 33.6% adhered to the red and processed meat recommendation. Being younger and having a higher level of education were associated with adherence to the recommendation on body weight. Having knowledge about the recommendation was associated with adherence to the recommendations on physical activity and red and processed meat. Results confirm that knowledge about recommendations for cancer prevention is an important determinant for adherence and suggest that strategies to increase knowledge should be included in lifestyle promotion targeted at LS patients, along with behavior change techniques influencing other modifiable determinants. [ABSTRACT FROM AUTHOR]

Poly(lactic acid)-poly(hydroxybutyrate) (PLA-PHB)-based nanocomposite films were prepared with bio-based additives (CNCs and ChNCs) and oligomer lactic acid (OLA) compatibilizer using extrusion and then blown to films at pilot scale. The aim was to identify suitable material formulations and nanocomposite production processes for film production at a larger scale targeting food packaging applications. The film-blowing process for both the PLA-PHB blend and CNC-nanocomposite was unstable and led to non-homogeneous films with wrinkles and creases, while the blowing of the ChNC-nanocomposite was stable and resulted in a smooth and homogeneous film. The optical microscopy of the blown nanocomposite films indicated well-dispersed chitin nanocrystals while the cellulose crystals were agglomerated to micrometer-size particles. The addition of the ChNCs also resulted in the improved mechanical performance of the PLA-PHB blend due to well-dispersed crystals in the nanoscale as well as the interaction between biopolymers and the chitin nanocrystals. The strength increased from 27 MPa to 37 MPa compared to the PLA-PHB blend and showed almost 36 times higher elongation at break resulting in 10 times tougher material. Finally, the nanocomposite film with ChNCs showed improved oxygen barrier performance as well as faster degradation, indicating its potential exploitation for packaging applications. [ABSTRACT FROM AUTHOR]

Legislative efforts for renewables-based energy decarbonisation hinge upon the support and commitment from different stakeholders holding often conflicting positions regarding disruptive processes of socio-technical transformation. However, the evolving acceptance of market actors on the policy-driven promotion of renewables over time remains under-scrutinised. Simultaneously, despite growing attention to power and politics in sustainability transitions, limited efforts remain invested for elucidating the political-economic nature of the market-based selection environments they are operationalised through, highlighting the need for a more systematic comprehension of the "politics of selection". To address these shortcomings, this paper provides a more refined understanding of the role of policy-driven markets and its participating agents in facilitating/hindering innovation diffusion and broader (system-wide) sustainability transitions. To do so, it showcases a longitudinal case study of the politics underlying Germany's evolving feed-in policy support framework for orchestrating a market-mediated diffusion of renewables (1980s–2020). Based on policy analysis and semi-structured interviews, the study traces the changing acceptance and ensuing strategic (re)actions of market actors to the emergence and evolution of Germany's market for electricity from renewable energy sources. Results show how different market participants effectively shape the selection environments they operate in by proactively contesting/deluding the design features of the support policies organising their economised relations (e.g., market entry conditions, exchange rules, remuneration levels, pricing schemes, etc.). Such efforts are undertaken through legal means and market framing strategies targeting the affordability of policy support costs, coupled with the strategic use of policy instrumentation as a vehicle to further expand/retain their market shares to the detriment of competing actors. [ABSTRACT FROM AUTHOR]

Background: Managing older people in the emergency department remains a challenge. We aimed to identify the factors influencing the care quality of older patients in the emergency department, to fine-tune future interventions for older people, considering the naturalistic context of the ED.Methods: This is a qualitative study of some 450 h of observations performed in three emergency departments selected for their diverse contexts. We performed seventy observations of older patient trajectories admitted to the emergency department. Themes were extracted from the material using an inductive reasoning approach, to highlight factors positively or negatively influencing management of patient's trajectories, in particular those presenting with typically geriatric syndromes.Results: Four themes were developed: no geriatric flow routine; risk of discontinuity of care; unmet basic needs and patient-centered care; complex older patients are unwelcome in EDs.Conclusions: The overall process of care was based on an organ- and flow-centered paradigm, which ignored older people's specific needs and exposed them to discontinuity of care. Their basic needs were neglected and, when their management slowed the emergency department flow, older people were perceived as unwelcome. Findings of our study can inform the development of interventions about the influence of context and organizational factors. [ABSTRACT FROM AUTHOR]

Background: With the improvement of life expectancy, the world faces increasing demands for care of older persons. In this manuscript, we define the characteristics of primary informal caregivers (PIC) of patients aged 75 years and older admitted to geriatric day hospitals (GDH) in Belgium. A PIC is defined as the person who most often provides care and assistance to persons who need to be cared for. We describe PIC socio-demographic characteristics, satisfaction, burden and wishes about caring; the type of assistance provided and received, their self-rated health, socio-demographic and medical characteristics of proxies, in particular the presence of behavioural disorders.Methods: We conducted a cross-sectional study in 25 GDH.Participants: Four hundred seventy-five PIC of patients ≥75 years and their proxies. PIC completed a questionnaire at the GDH assessing burden by Zarit Burden Index-12 (ZBI-12), self-rated health, social restriction due to caregiving and financial participation. We compared the characteristics of PIC with high and low burden, and the characteristics of spouses and adult children PIC. We also analyzed factors associated with a high burden in a multivariable logistic regression model.Results: PIC were mainly women (72%), adult children (53.8%) and spouses (30.6%). The mean age was 64 ± 14 years for PIC and 84 ± 5 years for care recipients. PIC helped for most of Activities in Daily Living (ADL) and Instrumental ADL (iADL). The median ZBI-12 score was 10 [IQR 5-18]. In multivariable regression analysis, a high burden was positively associated in the total group with living with the relative (p = 0.045), the difficulty to take leisure time or vacation (p <  0.001), behavioral and mood disorders (p <  0.001;p = 0.005), and was negatively associated with bathing the relative (p = 0.017) and a better subjective health status estimation (p <  0.001).Conclusion: Primary informal caregivers, who were predominantly women, were involved in care for ADL and iADL. A high burden was associated with living with the relative, the difficulty to take leisure time or vacation and the relative's behavioral and mood disorders. Bathing the relative and a subjective health status estimated as good as or better than people the same age, were protective factors against a high burden. [ABSTRACT FROM AUTHOR]

Due to difficulties with surveying, cryptobenthic fishes are understudied, which limits assessments of their extinction risk. Using a novel survey method (a combination of underwater visual census and underwater biofluorescence census), we surveyed the densities of two gorgonian seafan-associated pygmy seahorses (Hippocampus bargibanti and H. denise) in 63 sites across Indonesia. Densities were low for both seahorses (≤ 0.4 seahorses/host) and their hosts (≤ 0.25 seafans/200 m2). These low densities, combined with habitat specialisation, increase extinction risk. We failed to detect regional or depth patterns in seahorse abundance per host or group size in occupied hosts. Host occupancy rates were low (< 13.7%), suggesting that other factors than habitat availability constrain pygmy seahorse population size. The low densities found in this study highlight the high extinction vulnerability for habitat specialists on coral reefs. [ABSTRACT FROM AUTHOR]

Loss of biodiversity from lower to upper trophic levels reduces overall productivity and stability of coastal ecosystems in our oceans, but rarely are these changes documented across both time and space. The characterisation of environmental DNA (eDNA) from sediment and seawater using metabarcoding offers a powerful molecular lens to observe marine biota and provides a series of 'snapshots' across a broad spectrum of eukaryotic organisms. Using these next-generation tools and downstream analytical innovations including machine learning sequence assignment algorithms and co-occurrence network analyses, we examined how anthropogenic pressures may have impacted marine biodiversity on subtropical coral reefs in Okinawa, Japan. Based on 18 S ribosomal RNA, but not ITS2 sequence data due to inconsistent amplification for this marker, as well as proxies for anthropogenic disturbance, we show that eukaryotic richness at the family level significantly increases with medium and high levels of disturbance. This change in richness coincides with compositional changes, a decrease in connectedness among taxa, an increase in fragmentation of taxon co-occurrence networks, and a shift in indicator taxa. Taken together, these findings demonstrate the ability of eDNA to act as a barometer of disturbance and provide an exemplar of how biotic networks and coral reefs may be impacted by anthropogenic activities. [ABSTRACT FROM AUTHOR]

A new species and the first confirmed record of a true pygmy seahorse from Africa, Hippocampus nalu sp. nov., is herein described on the basis of two specimens, 18.9-22 mm SL, collected from flat sandy coral reef at 14-17 meters depth from Sodwana Bay, South Africa. The new taxon shares morphological synapomorphies with the previously described central Indo-Pacific pygmy seahorses, H. colemani, H. japapigu, H. pontohi, and H. satomiae, and H. waleananus, including diminutive size, twelve trunk rings, prominent cleithral ring and supracleithrum, spines on the fifth and twelfth superior and lateral trunk ridges, respectively, and prominent wing-like protrusions present on the first and/or second superior trunk rings posterior to the head. Hippocampus nalu sp. nov. is primarily distinguished from its pygmy seahorse congeners by highly distinct spine morphology along the anterior segments of the superior trunk ridge. Comparative molecular analysis reveals that the new species demonstrates significant genetic divergence in the mitochondrial COI gene from the morphologically similar H. japapigu and H. pontohi (estimated uncorrected p-distances of 16.3% and 15.2%, respectively). Hippocampus nalu sp. nov. represents the eighth member of the pygmy seahorse clade to be described from the Indo-Pacific, the first confirmed record from the African continent and the Indian Ocean, and an extension of more than 8000 km beyond the previously known range of pygmy seahorses from the Central and Western Indo-Pacific. [ABSTRACT FROM AUTHOR]

Background: Effective biodiversity monitoring is fundamental in tracking changes in ecosystems as it relates to commercial, recreational, and conservation interests. Current approaches to survey coral reef ecosystems center on the use of indicator species and repeat surveying at specific sites. However, such approaches are often limited by the narrow snapshot of total marine biodiversity that they describe and are thus hindered in their ability to contribute to holistic ecosystem-based monitoring. In tandem, environmental DNA (eDNA) and next-generation sequencing metabarcoding methods provide a new opportunity to rapidly assess the presence of a broad spectrum of eukaryotic organisms within our oceans, ranging from microbes to macrofauna. Methods: We here investigate the potential for rapid universal metabarcoding surveys (RUMS) of eDNA in sediment samples to provide snapshots of eukaryotic subtropical biodiversity along a depth gradient at two coral reefs in Okinawa, Japan based on 18S rRNA. Results: Using 18S rRNA metabarcoding, we found that there were significant separations in eukaryotic community assemblages (at the family level) detected in sediments when compared across different depths ranging from 10 to 40 m (p = 0.001). Significant depth zonation was observed across operational taxonomic units assigned to the class Demospongiae (sponges), the most diverse class (contributing 81% of species) within the phylum Porifera; the oldest metazoan phylum on the planet. However, zonation was not observed across the class Anthozoa (i.e., anemones, stony corals, soft corals, and octocorals), suggesting that the former may serve as a better source of indicator species based on sampling over fine spatial scales and using this universal assay. Furthermore, despite their abundance on the examined coral reefs, we did not detect any octocoral DNA, which may be due to low cellular shedding rates, assay sensitivities, or primer biases. Discussion: Overall, our pilot study demonstrates the importance of exploring depth effects in eDNA and suggest that RUMS may be applied to provide a baseline of information on eukaryotic marine taxa at coastal sites of economic and conservation importance. [ABSTRACT FROM AUTHOR]

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Mutualisms are pivotal in shaping ecological communities. Iconic images of cleaner fish entering the mouths of predatory fish clients to remove ectoparasites epitomize their mutual benefit. Experimental manipulations of cleaner wrasse reveal declines in fish size and growth, and population abundance and diversity of client fishes in the absence of cleaner wrasse. Fishes grow more slowly and are less abundant and diverse on reefs without cleaner wrasse, both for larger species that are regularly cleaned and have high ectoparasite loads (“attractive species”), and for those smaller species that are rarely cleaned and are rarely infested with parasites (“unattractive species”). We therefore considered whether these previously observed declines in individual and population parameters on reefs without cleaners were related to increased ectoparasite infestation using an attractive species (Hemigymnus melapterus, Labridae) and an unattractive species (Pomacentrus amboinensis, Pomacentridae). Traps with these fish as a form of bait were deployed to sample blood-sucking gnathiid ectoparasites (Gnathiidae: Isopoda) on reefs from which cleaners (Labroides dimidiatus, Labridae) have been removed for 13 yr. Cleaner fish could not enter traps to access the clients/hosts, but gnathiids could enter the traps to infest hosts; thus, this method sampled the indirect effect of cleaners on gnathiid infestation of fish. Infestation was higher on reefs without cleaners than on those with them. The effect was only detected during the daytime when cleaners are active and only on the attractive species (H. melapterus). Thus, cleaner presence indirectly reduced fish exposure to parasites in a species that is highly susceptible to parasites, but not in one that is rarely infested with parasites. This suggests that cleaner presence indirectly reduces exposure of a common fish species to harmful parasites, which may explain some observed benefits in fishes at this location. [ABSTRACT FROM AUTHOR]

Background: In the Emergency Department (ED), early and rapid identification of older people at risk of adverse outcomes, who could best benefit from complex geriatric intervention, would avoid wasting time, especially in terms of prevention of adverse outcomes, and ensure optimal orientation of vulnerable patients. We wanted to test the predictive ability of a screening tool assessing risk of functional decline (FD), named SHERPA, 10 years after its conception, and to assess the added value of other clinical or biological factors associated with FD.Methods: A prospective cohort study of older patients (n = 305, ≥ 75 years) admitted through the emergency department, for at least 48 h in non-geriatric wards (mean age 82.5 ± 4.9, 55% women). SHERPA variables (i.e. age, pre-admission instrumental Activity of Daily Living (ADL) status, falls within a year, self-rated health and 21-point MMSE) were collected within 48 h of admission, along with socio-demographic, medical and biological data. Functional status was followed at 3 months by phone. FD was defined as a decrease at 3 months of at least one point in the pre-admission basic ADL score. Predictive ability of SHERPA was assessed using c-statistic, predictive values and likelihood ratios. Measures of discrimination improvement were Net Reclassification Improvement and Integrated Discrimination Improvement.Results: One hundred and five patients (34%) developed 3-month FD. Predictive ability of SHERPA decreased dramatically over 10 years (c = 0.73 vs. 0.64). Only two of its constitutive variables, i.e. falls and instrumental ADL, were significant in logistic regression analysis for functional decline, while 21-point MMSE was kept in the model for clinical relevance. Demographic, comorbidity or laboratory data available upon admission did not improve the SHERPA predictive yield.Conclusions: Prediction of FD with SHERPA is difficult, but predictive factors, i.e. falls, pre-existing functional limitation and cognitive impairment, stay consistent across time and with literature. As accuracy of SHERPA and others existing screening tools for FD is moderate, using these predictors as flags instead of using composite scales can be a way to screen for high-risk patients. [ABSTRACT FROM AUTHOR]

Background: Older people in the emergency department (ED) represent a growing population and increasing proportion of the workload in the ED. This study investigated the support for frail older people in the ED, by exploring the collaboration between the geriatric services (GS) and the EDs in Belgian hospitals.Methods: An electronic cross-sectional survey in all Belgian hospitals with an ED (n = 100) about care aspects, collaboration, education and infrastructure for older patients in the ED was collected. Descriptive analyses were performed at national level.Results: Forty-nine of 100 surveys were completed by the GS. The heads of the ED returned only 12 incomplete questionnaires and these results are therefore not reported. Twenty-six of the 49 heads of GSs (53%) indicated that there was an agreement, mainly informal, between the geriatric and the emergency department concerning the management of older people on the ED. A geriatrician was available for specific problems, by phone or in person, in 96% of the EDs during daytime on weekdays. Almost all responding hospitals (96%) had an inpatient geriatric consultation team, of which 85% was available for specific problems at the ED, by phone or bedside during the daytime on weekdays. Twenty-nine heads of the GSs (59%) reported that older patients were screened at ED admission during the day to identify 'at risk' patients. The results of the screening were used in the context of further treatment (76%), to decide on hospital admission (27%), or to justify admission on a geriatric ward (55%). In the year preceding the survey, 25% of the responding hospitals had organised geriatric training for ED healthcare workers. Thirty-four heads of the GS (69%) felt that the infrastructure of the ED was insufficient to give high-quality care for older persons.Conclusion: Collaborations between EDs and GS are emerging in Belgium, but are currently rather limited and not yet sufficiently embedded in the ED care. Exploratory studies are necessary to identify how these collaborations can be improved. [ABSTRACT FROM AUTHOR]

Study Objective: In the present study, we evaluated the leukocyte esterase (LE) area of a reagent strip designed for urinalysis for the semiquantitative measurement of the percentage of polymorphonuclear neutrophils (PMNs) in BAL fluid.Design: Prospective. The relative PMN counts (obtained by conventional microscopy and expressed as a percentage of a 500 cell count) of consecutive BAL fluid samples were compared with the corresponding LE categories as read with a urine chemistry reader. LE categories were graded as follows: negative, trace, +, + +, and + + +.Results: A total of 153 BAL fluid samples were included. The mean PMN counts of the negative LE category (4.1 +/- 4.3%; n = 43) and the + + + category (81.8 +/- 16.3%; n = 37) differed significantly from each other and from the mean PMN counts of the other categories. Within the trace, +, and + + categories, a considerable overlap of PMN counts was noted. Assignment of a BAL fluid to the negative LE category consistently predicted a PMN count < 20%. At a threshold value of 50% PMNs, the + + + LE category predicted the BAL fluid samples to the correct group (PMNs > 50% vs < 50%) with a sensitivity of 70.8% and a specificity of 97.1%.Conclusions: The reagent strips proved to be useful as a rapid test for semiquantitative measurement of the relative PMN counts in BAL fluid. However, the low predictive value for the exclusion of a high PMN count may limit their application. [ABSTRACT FROM AUTHOR]

We determined the prevalence and spread of antibiotic resistance and the characteristics of ESBL producing and/or multi drug resistant (MDR) Escherichia coli isolates collected from urine samples from urology services in the Euregio Meuse-Rhine, the border region of the Netherlands (n = 176), Belgium (n = 126) and Germay (n = 119). Significant differences in resistance between the three regions were observed. Amoxicillin-clavulanic acid resistance ranged from 24% in the Netherlands to 39% in Belgium (p = 0.018), from 20% to 40% (p<0.004) for the fluoroquinolones and from 20% to 40% (p = 0.018) for the folate antagonists. Resistance to nitrofurantoin was less than 5%. The prevalence of ESBL producing isolates varied from 2% among the Dutch isolates to 8% among the German ones (p = 0.012) and were mainly CTX-M 15. The prevalence of MDR isolates among the Dutch, German and Belgian isolates was 11%, 17% and 27%, respectively (p<= 0.001 for the Belgian compared with the Dutch isolates). The majority of the MDR and ESBL producing isolates belonged to ST131. This study indicates that most antibiotics used as first choice oral empiric treatment for UTIs (amoxicillin-clavulanic acid, fluoroquinolones and folate antagonists) are not appropriate for this purpose and that MDR strains such as CTX-M producing ST131 have spread in the entire Euregion. Our data stress the importance of ward specific surveillance to optimize empiric treatment. Also, prudent use of antibiotics and further research to alternative agents are warranted. [ABSTRACT FROM AUTHOR]

Until now, error and conflict adaptation have been studied extensively using simple laboratory tasks. A common finding is that responses slow down after errors. According to the conflict monitoring theory, performance should also improve after an error. However, this is usually not observed. In this study, we investigated whether the characteristics of the experimental paradigms normally used could explain this absence. More precisely, these paradigms have in common that behavioural adaptation has little room to be expressed. We therefore studied error and conflict adaptation effects in a task that encounters the richness of everyday life's behavioural adaptation—namely, mental arithmetic, where multiple solution strategies are available. In accordance with our hypothesis, we observed that posterror accuracy increases after errors in mental arithmetic. No support for conflict adaptation in mental arithmetic was found. Implications for current theories of conflict and error monitoring are discussed. [ABSTRACT FROM PUBLISHER]

Background and aims: Hip fracture in older persons is a frequent reason for hospital admission and a substantial workload in orthopedic wards for geriatric liaison teams. However, robust patients who do not present in-hospital complications may not need geriatric liaison. For the sake of triage, we studied the ability of usual admission scores to identify patients who will not develop in-hospital complications, and who may therefore not be included in the overworked geriatric liaison teams. Methods: A retrospective cohort of consecutive community-living elderly patients (age>75 yrs), admitted for traumatic hip fracture in the orthopedic divisions of a teaching hospital over 18 months was examined. The predictive value of commonly used frailty scores (ISAR, VIP, KATZ) to rule out the incidence of three frequent and preventable in-hospital acute geriatric events (major behavioral problems, pressure sores, falls) was assessed by ROC curves and negative likelihood ratio (-LR). Results: Of 145 older persons with hip fracture (median age 84 years; 76% women; 57% living alone, 44% with pre-existing geriatric syndromes), 81 (56%) presented some acute geriatric events (AGE), i.e. major behavioral problems (46%), pressure sores (19%) and/or falls (5%). The three frailty admission scores showed low power for AGE prediction (area under the ROC curve: 53- 58%) and identification of patients who will not present in-hospital AGE (-LR>0.5 at the most sensitive cut-off). Conclusions: None of the three scores helped in the triage of patients according to their risk of future in-hospital AGE. All older patients with hip fracture, irrespective of their admission frailty-robustness profile, should receive geriatric evaluation and intervention. [ABSTRACT FROM AUTHOR]

Background and aims: Hip fracture in older persons is a frequent reason for hospital admission and a substantial workload in orthopedic wards for geriatric liaison teams. However, robust patients who do not present in-hospital complications may not need geriatric liaison. For the sake of triage, we studied the ability of usual admission scores to identify patients who will not develop in-hospital complications, and who may therefore not be included in the overworked geriatric liaison teams. Methods: A retrospective cohort of consecutive community-living elderly patients (age>75 yrs), admitted for traumatic hip fracture in the orthopedic divisions of a teaching hospital over 18 months was examined. The predictive value of commonly used frailty scores (ISAR, VIP, KATZ) to rule out the incidence of three frequent and preventable in-hospital acute geriatric events (major behavioral problems, pressure sores, falls) was assessed by ROC curves and negative likelihood ratio (-LR). Results: Of 145 older persons with hip fracture (median age 84 years; 76% women; 57% living alone, 44% with pre-existing geriatric syndromes), 81 (56%) presented some acute geriatric events (AGE), i.e. major behavioral problems (46%), pressure sores (19%) and/or falls (5%). The three frailty admission scores showed low power for AGE prediction (area under the ROC curve: 53- 58%) and identification of patients who will not present in-hospital AGE (-LR>0.5 at the most sensitive cut-off). Conclusions: None of the three scores helped in the triage of patients according to their risk of future in-hospital AGE. All older patients with hip fracture, irrespective of their admission frailty-robustness profile, should receive geriatric evaluation and intervention. [ABSTRACT FROM AUTHOR]

Background We evaluated the effectiveness of eradication of methicillin-resistant Staphylococcus aureus (MRSA) carriage in the Netherlands after the introduction of a guideline in 2006. The guideline distinguishes complicated (defined as the presence of MRSA infection, skin lesions, foreign-body material, mupirocin resistance and/or exclusive extranasal carriage) and uncomplicated carriage (not meeting criteria for complicated carriage). Mupirocin nasal ointment and chlorhexidine soap solution are recommended for uncomplicated carriers and the same treatment in combination with two oral antibiotics for complicated carriage. Methods A prospective cohort study was performed in 18 Dutch centres from 1 October 2006 until 1 October 2008. Results Six hundred and thirteen MRSA carriers underwent one or more decolonization treatments during the study period, mostly after hospital discharge. Decolonization was achieved in 367 (60%) patients with one eradication attempt and ultimately 493 (80%) patients were decolonized, with a median time until decolonization of 10 days (interquartile range 7–43 days). Three hundred and twenty-seven (62%) carriers were treated according to the guideline, which was associated with an absolute increase in treatment success of 20% [from 45% (91/203) to 65% (214/327)]. Conclusions Sixty percent of MRSA carriers were successfully decolonized after the first eradication attempt and 62% were treated according to the guideline, which was associated with an increased treatment success. [ABSTRACT FROM PUBLISHER]

Background Using data from an observational study in which the effectiveness of a guideline for eradication of methicillin-resistant Staphylococcus aureus (MRSA) carriage was evaluated, we identified variables that were associated with treatment failure. Methods A multivariate logistic regression model was performed with subgroup analyses for uncomplicated and complicated MRSA carriage (the latter including MRSA infection, skin lesions, foreign-body material, mupirocin resistance and/or exclusive extranasal carriage) and for those treated according to the guideline (i.e. mupirocin nasal ointment and chlorhexidine soap solution for uncomplicated carriage, in combination with two oral antibiotics for complicated carriage). Results Six hundred and thirteen MRSA carriers were included, of whom 333 (54%) had complicated carriage; 327 of 530 patients (62%) with known complexity of carriage were treated according to the guideline with an absolute increase in treatment success of 20% (95% confidence interval 12%–28%). Among those with uncomplicated carriage, guideline adherence [adjusted odds ratio (ORa) 7.4 (1.7–31.7)], chronic pulmonary disease [ORa 44 (2.9–668)], throat carriage [ORa 2.9 (1.4–6.1)], perineal carriage [ORa 2.2 (1.1–4.4)] and carriage among household contacts [ORa 5.6 (1.2–26)] were associated with treatment failure. Among those with complicated carriage, guideline adherence was associated with treatment success [ORa 0.2 (0.1–0.3)], whereas throat carriage [ORa 4.4 (2.3–8.3)] and dependence in activities of daily living [ORa 3.6 (1.4–8.9)] were associated with failure. Conclusions Guideline adherence, especially among those with complicated MRSA carriage, was associated with treatment success. Adding patients with extranasal carriage or dependence in daily self-care activities to the definition of complicated carriage, and treating them likewise, may further increase treatment success. [ABSTRACT FROM PUBLISHER]

Because the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) differs among the 3 countries forming the Euregio Meuse-Rhin (EMR) region (Belgium, Germany, and the Netherlands), cross-border healthcare requires information about the spread of MRSA in the EMR. We investigated the emergence, dissemination, and diversity of MRSA clones in the EMR by using several typing methods. MRSA associated with clonal complexes 5, 8, 30, and 45 was disseminated throughout the EMR. Dutch isolates, mainly associated with sequence types (ST) ST5-MRSA-II, ST5-MRSA-IV, ST8-MRSA-IV, and ST45-MSRAIV had a more diverse genetic background than the isolates from Belgium and Germany, associated with ST45-MRSAIV and ST5-MRSA-II, respectively. MRSA associated with pigs (ST398-MRSA-IV/V) was found in the Dutch area of the EMR. Five percent of the MRSA isolates harbored Panton-Valentine leukocidin and were classified as communityassociated MRSA associated with ST1, 8, 30, 80, and 89. [ABSTRACT FROM AUTHOR]

This study focuses on the use of pilot-scale produced polyhydroxy butyrate (PHB) biopolymer and chitin nanocrystals (ChNCs) in two different concentrated (1 and 5 wt.%) nanocomposites. The nanocomposites were compounded using a twin-screw extruder and calendared into sheets. The crystallization was studied using polarized optical microscopy and differential scanning calorimetry, the thermal properties were studied using thermogravimetric analysis, the viscosity was studied using a shear rheometer, the mechanical properties were studied using conventional tensile testing, and the morphology of the prepared material was studied using optical microscopy and scanning electron microscopy. The results showed that the addition of ChNCs significantly affected the crystallization of PHB, resulting in slower crystallization, lower overall crystallinity, and smaller crystal size. Furthermore, the addition of ChNCs resulted in increased viscosity in the final formulations. The calendaring process resulted in slightly aligned sheets and the nanocomposites with 5 wt.% ChNCs evaluated along the machine direction showed the highest mechanical properties, the strength increased from 24 to 33 MPa, while the transversal direction with lower initial strength at 14 MPa was improved to 21 MPa. [ABSTRACT FROM AUTHOR]

We present new evidence that word translation involves semantic mediation. It has been shown that participants react faster to small numbers with their left hand and to large numbers with their right hand. This SNARC (spatial-numerical association of response codes) effect is due to the fact that in Western cultures the semantic number line is oriented from left (small) to right (large). We obtained a SNARC effect when participants had to indicate the parity of second-language (L2) number words, but not when they had to indicate whether L2 number words contained a particular sound. Crucially, the SNARC effect was also obtained in a translation verification task, indicating that this task involved the activation of number magnitude. [ABSTRACT FROM AUTHOR]

The aim of the study presented here was to evaluate an enrichment broth-enhanced commercial PCR procedure for excluding the presence of meticillin-resistant Staphylococcus aureus (MRSA) in patient samples in less than 36 h. In The Netherlands to date, all MRSA epidemics have been successfully controlled with the Dutch search-and-destroy policy. However, PCR facilitates more rapid screening for MRSA than traditional culture. One commercial PCR option is the hyplex StaphyloResist® PCR assay (Biologische Analysensystem GmbH, Lich, Germany), which detects Staphylococcus aureus and the mecA gene in MRSA as well as in coagulase-negative staphylococci (CoNS). This assay was used to test a total of 939 specimens obtained from 346 individuals. Following resolution of all discrepancies, the prevalence, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for all separate specimens were 9.0, 97.6, 83.7, 37.4 and 99.7%, respectively, and for specimens grouped according to daily episode submitted per individual, they were 7.5, 97.4, 77.2, 26.2 and 99.7%, respectively. These results led to the introduction of this PCR into the hospital laboratory’s routine for the purpose outlined above. [ABSTRACT FROM AUTHOR]

The use of concentrated platelet-rich plasma (cPRP) as a source of growth factors is reported to be beneficial for an enhanced osteogenesis in spine surgery. Today both bovine and autologous thrombin is used for activating the platelets and thus releasing the growth factors. In order to prevent transmission of organisms and the development of antibodies, autologous thrombin seems to be the logical choice. However, the preparation of autologous thrombin is cumbersome and consumes a part of the cPRP. In order to overcome this problem, a commercial autologous thrombin kit (activAT, Dideco, a Sorin Group company, Italy) has been developed which produces autologous thrombin out of platelet-poor plasma. A possible disadvantage of this kit could be the rest fraction of 1.18% of ethanol in the platelet gel. In a pig model, the influence of different ethanol concentrations on the ischiadic nerve was studied. The study consisted out of four groups; a control group ( n=6), a group with platelet gel 0% ethanol ( n=6), a group with platelet gel 1.18% ethanol ( n=6) and a group with platelet gel 3.8% ethanol ( n=7). In all the groups, the ischiadic nerve was dissected and the myelin sheet opened after which the wound was closed (control group) or one of the three therapies was applied. After 12 h, the animal was sacrificed and the ischiadic nerve was submitted for histological examination. Myelin sheaths appeared normal in all cases. No axonal swelling was observed. No statistically significant differences were observed for neutrophilic and eosinophilic infiltration nor for collagen necrosis between groups. Platelet gel prepared by the use of a commercial autologous thrombin kit and containing 1.18% of ethanol can be safely used on nerves. [ABSTRACT FROM AUTHOR]