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As biocrude exhibits inferior properties for it to be used as a high-value fuel, upgrading is needed. Thermochemical upgrading methods prove to be the most successful in terms of oxygen removal and stabilisation of biocrude; however, heavy organics in biocrude have the tendency to polymerise upon thermal treatment. This results in catalyst deactivation and coking during hydrotreatment of biocrude. Chemical upgrading, such as conventional esterification at mild reaction conditions, is also ineffective as the esterification reaction is incomplete due to the carboxylic acid-water equilibrium reaction. In this study, the enzymatic upgrading route was evaluated by studying the conversion of fatty acids to methyl esters in the biocrude. A fatty acid conversion of 94.6 mass % at 30 ֯C was obtained, showing that moisture and other components present in biocrude do not have a negative effect on fatty acid esterification using lipase catalysis. The difference in oil-to-oil molar ratio between 1:2 and 1:18 is not significant due to the presence of hydroxyl groups in the oil which contributes to the esterification reaction. No heavy fraction formation was observed in the boiling curves which is an indication that no significant coking occurred. Although the fuel value of the produced biodiesel at 34.9 MJ/kg is lower than that of petroleum fuel, the biodiesel in this study can be used in blends for heating, cooking and electricity generation applications.

L’épidémie de COVID 19 a nécessité un renforcement en moyens techniques comme en personnel dans le cadre des activités de régulation médicale mais aussi pour les interventions pré hospitalières non médicalisées ou des SMUR. Ce renforcement a été adapté à l’évolution de l’activité. Au SAMU de Paris, l’activité a imposé le doublement des postes de régulation dès la deuxième semaine de mars afin de répondre à la fois aux appels habituels mais aussi à la demande liée au COVID. Des étudiants en médecine de diplôme de formation approfondie en sciences médicales (DFASM) de 1re, 2e et 3e années volontaires ont été mobilisés pour venir renforcer la régulation médicale et assurer les réponses au sein d’une salle supplémentaire installée pour répondre aux appels COVID. Seuls, les étudiants en médecine du 2ème cycle ont donc été intégrés à cette organisation, ils bénéficiant à leur arrivée d’une formation adaptée à leur niveau d’étude et aux fonctions à accomplir au sein de la régulation médicale et aussi tout au long de leur activité d’un encadrement par un médecin sénior de l’aide médicale d’urgence et /ou de la permanence des soins ambulatoires. Cette activité était donc sécurisée par des médecins séniors comme dans tout stage hospitalier. Cette organisation a contribué notamment à Paris, à la réponse à l’afflux des appels au SAMU. Ce renfort a ensuite été maintenu, aussi bien dans le cadre de la crise que dans l’activité quotidienne et dans le déploiement du Service d’Accès aux Soins (SAS).

Introduction Studies have shown that the use of total shoulder arthroplasty is increasing every year in the United Stated at a rate higher than that of total hip or total knee arthroplasty. As the population of the United States continues to age, it is becoming more important for surgeons to understand the true impact of age on outcomes and complications following procedures such a total shoulder arthroplasty. The purpose of this study was to determine if octogenarians have poorer outcomes after total shoulder arthroplasty compared to a younger, matched control group. Methods Data was obtained through the American College of Surgeons National Surgical Quality Improvement Program database (ACS NSQIP). Patients who had undergone total shoulder arthroplasty were identified by Current Procedural Terminology code (23472). Indication for arthroplasty was determined by ICD9/10 code (osteoarthritis, fracture, other). Each octogenarian was matched 1:1 to a non-octogenarian based on sex, BMI, ASA class, medical comorbidities, functional status, and surgical indication for arthroplasty by propensity scoring. A subgroup analysis was performed to compare outcomes between only those patients who underwent TSA for osteoarthritis.Outcomes of interest were assessed between the two groups for statistical significance using a chi-squared test or fisher exact test for expected values of less than 5. Statistical significance was set at p

Biomass from microalgae is a potential feedstock for biofuels production. It poses no threat to food security as it does not compete with agricultural crops for arable land. Scenedesmus acutus was used as feedstock to produce bio-oil in a large liquefaction reactor. The influence of reaction temperature (280–360ºC), reaction atmosphere (N2 or CO2) and solvent on bio-oil yield, C-16 fatty acid yield and oil properties were investigated. Oils were characterised using gas chromatography, Fourier transform infrared (FTIR) spectroscopy and ultimate analysis. Higher bio-oil yields were obtained in a CO2 atmosphere (250 g.kg-1 dry microalgae) than in a N2 atmosphere (210 g.kg-1 dry microalgae) whilst higher C16 fatty acid concentrations (600 g.kg-1 bio-oil) were recorded in N2 atmosphere compared to oil prepared in a CO2 atmosphere (500 g.kg-1 bio-oil). The oil yield increased to a maximum at 320°C, after which there were no significant changes. Highest bio-oil yields (425 g.kg-1 dry microalgae) were obtained in ethanol as solvent. FTIR spectroscopy and ultimate analysis showed that proteins present in the feedstock were degraded by breakage of peptide linkages, and nitrogen present in the oils is peptide fragments from protein degradation. The carbon content of all produced oils was high, but the hydrogen content was low, leading to low hydrogen/carbon ratios. Energy consumption and energy efficiency calculations showed that liquefaction in both reaction atmospheres results in a net energy gain, and a CO2 atmosphere is best for high energy efficiency.

Governments and social benefit organizations are expected to consider evidence in decision-making. In development and sustainability, evidence spans disciplines and methodological traditions and is often inconclusive. Graphical models are widely promoted to organize interdisciplinary evidence and improve decision-making by considering mediating variables. However, the reproducibility, objectivity and benefits for decision-making of graphical models have not been studied. We evaluate these considerations in the setting of energy services in the developing world, a contemporary development and sustainability imperative. We develop a database of relevant causal relations (313 concepts, 1337 relationships) asserted in the literature (561 peer-reviewed articles). We demonstrate that high-level relationships of interest to practitioners feature less consistent evidence than the causal relationships that underpin them, supporting increased use of problem decomposition through graphical modeling approaches. However, adding such detail increases complexity exponentially, introducing a hazard of overparameterization if evidence is not available to match the level of mechanistic detail. Published (Publication status)

Spectroscopic studies of aluminum monofluoride (AlF) have revealed its highly favorable properties for direct laser cooling. All $Q$ lines of the strong A$^1\Pi$ $\leftarrow$ X$^1\Sigma^+$ transition around 227~nm are rotationally closed and thereby suitable for the main cooling cycle. The same holds for the narrow, spin-forbidden a$^3\Pi$ $\leftarrow$ X$^1\Sigma^+$ transition around 367 nm which has a recoil limit in the micro Kelvin range. We here report on the spectroscopic characterization of the lowest rotational levels in the a$^3\Pi$ state of AlF for $v=0-8$ using a jet-cooled, pulsed molecular beam. An accidental AC Stark shift is observed on the a$^3\Pi_0, v=4$ $\leftarrow$ X$^1\Sigma^+, v=4$ band. By using time-delayed ionization for state-selective detection of the molecules in the metastable a$^3\Pi$ state at different points along the molecular beam, the radiative lifetime of the a$^3\Pi_1, v=0, J=1$ level is experimentally determined as $\tau=1.89 \pm 0.15$~ms. A laser/radio-frequency multiple resonance ionization scheme is employed to determine the hyperfine splittings in the a$^3\Pi_1, v=5$ level. The experimentally derived hyperfine parameters are compared to the outcome of quantum chemistry calculations. A spectral line with a width of 1.27 kHz is recorded between hyperfine levels in the a$^3\Pi, v=0$ state. These measurements benchmark the electronic potential of the a$^3\Pi$ state and yield accurate values for the photon scattering rate and for the elements of the Franck-Condon matrix of the a$^3\Pi$ $-$ X$^1\Sigma^+$ system., Comment: 16 pages, 9 figures

Background Access to an Emergency Medical Communication Centre is essential for the population in emergency situations. Handling inbound calls without delay requires managing activity, process and outcome measures of the Emergency Medical Communication Centre to improve the workforce management and the level of service. France is facing political decisions on the evolution of the organisation of Emergency Medical Communication Centres to improve accessibility for the population. First, we aim to describe the variation in activity between Emergency Medical Communication Centres, and second, to explore the correlation between process measures and outcome measures. Methods Using telephone activity data extraction, we conducted an observational multicentre study of six French Emergency Medical Communication Centres from 1 July 2016 to 30 June 2017. We described the activity (number of incoming calls, call rate per 1000 inhabitants), process measure (agent occupation rate), and outcome measure (number of calls answered within 20 s) by hourly range and estimated the correlation between them according to the structural equation methods. Results A total of 52,542 h of activity were analysed, during which 2,544,254 calls were received. The annual Emergency Medical Communication Centre call rate was 285.5 [95% CI: 285.2–285.8] per 1000 inhabitants. The average hourly number of calls ranged from 29 to 61 and the call-handled rate from 75 to 98%. There are variations in activity between Emergency Medical Communication Centres. The mean agent occupation rate was correlated with the quality of service at 20 s (coefficient at − 0.54). The number of incoming calls per agent was correlated with the mean occupation rate (coefficient at 0.67). Correlation coefficients varied according to the centres and existed between different process measures. Conclusions The activity dynamics of the six Emergency Medical Communication Centres are not identical. This variability, illustrating the particularity of each centre, must be accurately assessed and should be taken into account in managerial considerations. The call taker occupation rate is the leverage in the workforce management to improve the population accessibility.

Pour faire face a l'attentat terroriste multisite du 13 novembre 2015, une regulation medicale zonale des huit Samu de la region Ile-de-France a ete mise en place au Samu de Paris. Elle a permis, en utilisant une strategie de sectorisation des moyens Smur et des ressources hospitalieres, la medicalisation des sites, la regulation et le transport par des equipes medicales de la majorite des victimes en urgence absolue. Des moyens Smur et des hopitaux ont pu etre gardes en reserve pour faire face a une aggravation de la situation (notamment sur le site du Bataclan) et a d'eventuelles autres attaques. L'analyse de cette experience montre de nombreux points forts mais aussi des pistes d'amelioration utiles pour tous ceux qui seraient confrontes a un tel evenement.

The Sources of Discomfort Scale (SODS) assesses discomfort manifestations based on source of discomfort, thus making it both distinct from and complementary to pain assessments for persons with dementia. Sources were categorized as pertaining to physical discomfort, to body position, and to environmental sources. Body position sources of discomfort were related to poor functional status and to pain. The SODS scores were not related to cognitive functioning, and sources of discomfort other than those pertaining to body position were not correlated with pain. This paper demonstrates a direct and enhanced method to detect the manifestations of discomfort separately from pain indicators in a population with advanced dementia. The determination of the source of discomfort has direct implications for intervention.

OBJECTIVE: X-linked adrenoleukodystrophy (ALD) is a neurodegenerative disorder due to mutations in the peroxisomal very long-chain fatty acyl-CoA transporter, ABCD1, with limited therapeutic options. ALD may manifest in a slowly progressive adrenomyeloneuropathy (AMN) phenotype, or switch to rapid inflammatory demyelinating cerebral disease (cALD), in which microglia have been shown to play a pathophysiological role. The aim of this study was to determine the role of patient phenotype in the immune response of ex vivo monophagocytic cells to stimulation, and to evaluate the efficacy of polyamidoamine dendrimer conjugated to the antioxidant precursor N-acetyl-cysteine (NAC) in modulating this immune response. METHODS: Human monophagocytic cells were derived from fresh whole blood, from healthy (n = 4), heterozygote carrier (n = 4), AMN (n = 7), and cALD (n = 4) patients. Cells were exposed to very long-chain fatty acids (VLCFAs; C24:0 and C26:0) and treated with dendrimer-NAC (D-NAC). RESULTS: Ex vivo exposure to VLCFAs significantly increased tumor necrosis factor α (TNFα) and glutamate secretion from cALD patient macrophages. Additionally, a significant reduction in total intracellular glutathione was observed in cALD patient cells. D-NAC treatment dose-dependently reduced TNFα and glutamate secretion and replenished total intracellular glutathione levels in cALD patient macrophages, more efficiently than NAC. Similarly, D-NAC treatment decreased glutamate secretion in AMN patient cells. INTERPRETATION: ALD phenotypes display unique inflammatory profiles in response to VLCFA stimulation, and therefore ex vivo monophagocytic cells may provide a novel test bed for therapeutic agents. Based on our findings, D-NAC may be a viable therapeutic strategy for the treatment of cALD.

Poster presented during Brain 2017 in Berlin, Germany (01.-04.04.2017)

Objective Behavioral symptoms are common in persons with dementia, and nonpharmacological interventions are recommended as the first line of therapy. We describe barriers to conducting nonpharmacological interventions for behavioral symptoms. Design A descriptive study of barriers to intervention delivery in a controlled trial. Settings The study was conducted in six nursing homes in Maryland. Participants Participants were 89 agitated nursing home residents with dementia. Intervention Personalized interventions were developed using the Treatment Routes for Exploring Agitation decision tree protocol. Trained research assistants prepared and delivered the interventions. Feasibility of the interventions was determined. Measurements Barriers to Intervention Delivery Assessment, activities of daily living, cognitive functioning, depressed affect, pain, observed agitation, and observed affect. Results Barriers were observed for the categories of resident barriers (specifically, unwillingness to participate; resident attributes, such as unresponsive), barriers related to resident unavailability (resident asleep or eating), and external barriers (staff-related barriers, family-related barriers, environmental barriers, and system process variables). Interventions pertaining to food/drink and to 1-on-1 socializing were found to have the fewest barriers, whereas higher numbers of barriers occurred with puzzles/board games and arts and crafts activities. Moreover, when successful interventions were presented to participants after the feasibility period, we noted fewer barriers, presumably because barrier identification had been used to better tailor interventions to each participant and to the environment. Conclusion Knowledge of barriers provides a tool by which to tailor interventions so as to anticipate or circumvent barriers, thereby maximizing intervention delivery.

Background Engagement refers to the act of being occupied or involved with an external stimulus. In dementia, engagement is the antithesis of apathy. Objective The Comprehensive Process Model of Engagement was examined, in which environmental, personal, and stimulus characteristics impact the level of engagement. Methods Participants were 193 residents of 7 Maryland nursing with a diagnosis of dementia. Stimulus engagement was assessed via the Observational Measure of Engagement, measuring duration, attention, and attitude to the stimulus. Twenty-five stimuli were presented, which were categorized as live human social stimuli, simulated social stimuli, inanimate social stimuli, a reading stimulus, manipulative stimuli, a music stimulus, task and work-related stimuli, and two different self-identity stimuli. Results All stimuli elicited significantly greater engagement in comparison to the control stimulus. In the multivariate model, music significantly increased engagement duration, whereas all other stimuli significantly increased duration, attention, and attitude. Significant environmental variables in the multivariate model that increased engagement were: use of the long introduction with modeling (relative to minimal introduction), any level of sound (especially moderate sound), and the presence of between 2 and 24 people in the room. Significant personal attributes included Mini-Mental State Examination scores, activities of daily living performance and clarity of speech, which were positively associated with higher engagement scores. Conclusions Results are consistent with the Comprehensive Process Model of Engagement. Personal attributes, environmental factors, and stimulus characteristics all contribute to the level and nature of engagement, with a secondary finding being that exposure to any stimulus elicits engagement in persons with dementia.

Author(s): Cleary, Robert K; Kassir, Andrew; Johnson, Craig S; Bastawrous, Amir L; Soliman, Mark K; Marx, Daryl S; Giordano, Luca; Reidy, Tobi J; Parra-Davila, Eduardo; Obias, Vincent J; Carmichael, Joseph C; Pollock, Darren; Pigazzi, Alessio | Abstract: BackgroundThe primary objective of this study was to retrospectively compare short-term outcomes of intracorporeal versus extracorporeal anastomosis for minimally invasive laparoscopic and robotic-assisted right colectomies for benign and malignant disease. Recent studies suggest potential short-term outcomes advantages for the intracorporeal anastomosis technique.MethodsThis is a multicenter retrospective propensity score-matched comparison of intracorporeal and extracorporeal anastomosis techniques for laparoscopic and robotic-assisted right colectomy between January 11, 2010, and July 21, 2016.ResultsAfter propensity score-matching, there were a total of 1029 minimal invasive surgery cases for analysis-379 right colectomies (335 robotic-assisted and 44 laparoscopic) done with an intracorporeal anastomosis and 650 right colectomies (253 robotic-assisted and 397 laparoscopic) done with an extracorporeal anastomosis. There were no significant differences in any preoperative patient characteristics between groups. The minimally invasive intracorporeal anastomosis group had significantly longer operative times (pl0.0001), lower conversion to open rate (p = 0.01), shorter hospital length of stay (p = 0.02) and lower complication rate from after discharge to 30-days (p = 0.04) than the extracorporeal anastomosis group.ConclusionsThis comparison shows several clinical outcomes advantages for the intracorporeal anastomosis technique in minimally invasive right colectomy. These data may guide future refinements in minimally invasive training techniques and help surgeons choose among different minimally invasive options.

A quantitative metrology technique is required to provide quality control necessary for production-worthy through-silicon-via (TSV) etch. This paper reports on backside infrared interferometric wafer thickness sensing for highly repeatable, nondestructive, and high-throughput determination of TSV depth, unlimited by aspect ratio (AR). Selected etch depth measurements for 1-18 μm critical dimension TSVs with AR up to 28:1 are demonstrated with 3 sigma measurement repeatability of less than 50 nm. On the 5 μm×25 μm TSV etch process baseline on 300 mm wafers, lot-to-lot, run-to-run, and within wafer etch depth variations have been quantified in a production-worthy fashion. This technique has found no appreciable depth differences between dense and isolated TSVs within run, and has identified improvements in run-to-run variability when using oxide conditioning wafers.

Objectives The objective of this paper was to assess the relative impact of different types of stimuli on agitated behaviors of nursing home residents with dementia.

We examined engagement with stimuli in 193 nursing home residents with dementia. We hypothesized that activities and stimuli based on a person's past and current preferences would result in more engagement than other activities/stimuli.The expanded version of the self-identity questionnaire [Cohen-Mansfield, J., Golander, H.Arheim, G. (2000)] was used to determine participants' past/present interests (as reported by relatives) in the following areas: art, music, babies, pets, reading, television, and office work. We utilized the observational measurement of engagement (Cohen-Mansfield, J., Dakheel-Ali, M.,Marx, M.S. (2009).Analysis revealed that residents with current interests in music, art, and pets were more engaged by stimuli that reflect these interests than residents without these interests.Our findings demonstrate the utility of determining a person's preferences for stimuli in order to predict responsiveness. Lack of prediction for some stimuli may reflect differences between past preferences and activities that are feasible in the present.

Objective To examine the impact of personal attributes on engagement in persons with dementia. Methods Participants were 193 residents of seven Maryland nursing homes. All participants had a diagnosis of dementia. Cognitive functioning was assessed via the Mini-Mental State Examination, and engagement was assessed via the Observational Measure of Engagement. Data pertaining to activities of daily living were obtained from the Minimum Data Set. Results Women had longer mean engagement duration than men, and significant results were not seen with the other demographic variables. Significant, positive correlations were found between higher cognitive functioning and longer engagement duration, more attention, a more positive attitude, and a higher refusal rate. There was a positive and significant correlation between the comorbidity index and engagement duration, and between the number of medications and attention. All functional status variables yielded significance in a positive direction. Participants with poor hearing had a higher refusal rate. Cognitive status was the most consistent and potent predictor of engagement in this population. Conclusion Despite a higher refusal rate among those with higher cognitive levels, their overall engagement with stimuli is higher. Caregivers should anticipate higher refusal rates in those with poor hearing, and therefore compensatory methods should be used in presenting stimuli in this population. The potent role of cognitive and functional status on engagement of persons with dementia underscores the importance of tailoring activities to nursing home residents' needs, interests, and limitations. Copyright © 2009 John Wiley & Sons, Ltd.

Nursing home residents with dementia often lack the skills needed for successful communication, with the result being that social interactions become limited. In fact, Cohen-Mansfield et al1 found that nursing home residents with dementia were alone during 22% of their waking hours. One way to promote social interactions in the nursing home is through animal-assisted therapy (AAT),2,3 which involves interaction with a trained animal facilitated by a human handler. Outcomes of AAT include providing relaxation and pleasure or providing rehabilitation.3 Animal-assisted therapy is well suited for nursing home residents with dementia as it provides social interaction that is not dependent on the resident’s level of cognitive functioning; that is, a dog will provide companionship regardless of a resident’s state of awareness. A dog is a nonjudgmental listener and would not react negatively to hearing repetitions of the same phrase or story. The literature contains many anecdotal reports of positive results from AAT in persons with dementia as well as some published findings from controlled studies. When comparing a group of 7 persons in a closed psychiatric ward (6 with dementia, 1 with schizophrenia) with matched controls, Walsh et al4 found that the presence of a visiting dog resulted in fewer loud or aggressive outbursts (such that the noise level on the unit was lower) as well as a reduction in heart rate (suggestive of a calming effect) in the experimental group. The study participants reverted to their former behaviors after the dog was removed. In an experimental, within-participant repeated-measures design, Churchill et al5 studied persons with dementia who manifested increased agitated behavior in the evening hours (“sundown syndrome”). Study participants were observed during 2 conditions—dog with researcher and researcher alone (control condition). Analysis revealed that the frequency and duration of socialization behaviors (eg, leans, smiles, looks toward, tactile contact, and verbalization) increased and agitation decreased in the presence of the dog relative to the control condition. The authors reported that interaction with the dog was linked with less confusion and served to stimulate reminiscence and memories, distracting the participant from agitation during the sundowning hours. Other investigators have corroborated the findings of Churchill et al5 in other samples of nursing home residents with dementia, reporting increases in socialization and decreases in agitation as a result of AAT.6–10 Additionally, AAT has been reported to improve apathetic state11 and improve emotional well-being12 in nursing home residents with dementia. A link between study participants’ past interest in or ownership of animals and positive outcomes has been reported.8, 13 As it is not always practical to bring live animals to nursing homes, some researchers have focused on robotic animals or plush animals (also called stuffed animals) for their residents. In 2004, Libin and Cohen-Mansfield14 compared an enhanced robotic cat (NeCoRo) to a plush cat in a study of 9 agitated nursing home residents with dementia. Statistically significant decreases in agitation (relative to baseline) were seen with the plush cat, and a similar trend was seen with the robotic cat. In addition, statistically significant increases in interest and pleasure were found with the robotic cat, and while test statistics for the plush cat were not significant, the authors reported a trend in the same direction. Tamura et al15 compared a metal robotic dog (AIBO) with a plush motor-driven toy dog in a group of 13 persons with severe dementia in a geriatric health care facility. Statistical analyses were not provided for this study; however, results suggest that the study participants responded to both dogs with social behaviors (eg, talking, watching, clapping, touching, and caring for the dog), with more of these behaviors being directed at the plush motor-driven toy dog. In addition, fewer interventions on the part of the occupational therapist were observed with the plush motor-driven toy dog than with the metal robotic dog. Recently, in a group of nursing residents with neither cognitive impairment nor a diagnosis of Alzheimer’s disease, AIBO was compared with a live dog and results showed that AAT with either led to similar improvements in loneliness relative to a control group.16 Banks et al16 noted that some residents and staff were initially reluctant to interact with AIBO but that this resistance dissipated with exposure. The present study focused on dogs and was conducted to provide further empirical evaluation of AAT in a group of 56 nursing home residents with dementia. Filan and Llewellyn-Jones,3 in a literature review of AAT for persons with dementia, noted that the AAT studies in nursing homes to date have been limited by small sample sizes (ranging from 7 to 28 persons; 1 study included 62 persons). We included a standard poodle as well as 2 miniature schnauzers (one was 11 pounds and the other was 25 pounds) in our study because it is conceivable that residents may have a preference for a dog on the basis of size. As some residents may be afraid or allergic to dogs, we also included a variety of dog-related stimuli—a plush dog, pictures of dogs to color with markers, a robotic dog, and a puppy video—and evaluated the engaging value of these stimuli. In addition, we looked at the influence of a past preference for dogs on our response measures. Indeed, it has been shown that interventions based on past identity roles result in greater interest, pleasure, and involvement than the typical structured activities for residents with dementia.17

The Unmet Needs Model states that problem behaviors of people with dementia result from unmet needs stemming from a decreased ability to communicate those needs and to provide for oneself. The purpose of this study is to describe the unmet needs of persons with dementia exhibiting behavior problems. Eighty-nine residents with dementia from six Maryland nursing homes were assessed by research assistants and nursing assistants for their unmet needs using multiple assessment tools. Three unmet needs per resident were identified on average, with informants rating boredom/sensory deprivation, loneliness/need for social interaction, and need for meaningful activity as the most prevalent needs. Discomfort was associated with higher levels of verbally agitated behaviors (e.g., complaining). Based on results and independent ratings of pain, the authors estimate notable under-detection of discomfort and pain by both types of informants. The study demonstrates methodologies for uncovering unmet needs among persons with dementia and highlights the importance of developing programs that address those unmet needs, especially social and activity needs of nursing home residents. The detection of pain, and possibly that of discomfort, may require a different methodology.

Background and aims: Two different models of exercise behavior in an older population have been previously published (Schuster et al., 1995 and Resnick et al., 2000). We aimed to validate the models with data from a different sample, and to examine whether any of these models explained a greater proportion of the variance in exercise behavior in this population. Methods: Participants were 324 community-dwelling persons aged 74–85 years who completed a mailed questionnaire. The questionnaire included questions about demographics, current exercise habits, health, activities of daily living, depressed affect, living arrangement, attitudes about exercise, self-efficacy, barriers to exercise, and enjoyment of exercise. Results: While our data explained some of the variance of the two previously published models of exercise behavior, the percentage of variance explained was less impressive than that reported by those authors. A path analysis of demographic and psychological constructs, which have been used in both models, demonstrated that physical health, mental health, gender, and past enjoyment of exercise affect self-efficacy, attitudes/outcome expectancy, and reported barriers to exercise. These psychological constructs in turn affect exercise habits. Conclusions: The relatively low percentage of variance explained by the models may imply that other factors contribute to exercise behavior in older adults, that the constructs are very sensitive to measurement differences, or that these factors are not as important as previously thought. Our results are consistent with the models of both Schuster et al. and Resnick et al., but suggest that a combined model may better represent the data. Future investigations of exercise behavior in older persons should examine this possibility.

Background Recent guidelines recommend assessing medical inpatients for bleeding risk prior to providing chemical prophylaxis for VTE. The International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) bleeding risk score (BRS) was derived from a well-defined population of medical inpatients but it has not been validated externally. We sought to externally validate the IMPROVE BRS. Methods We prospectively collected characteristics on admission and VTE prophylaxis data each hospital day for all patients admitted for a medical illness to the Walter Reed Army Medical Center over an 18-month period. We calculated the IMPROVE BRS for each patient using admission data and reviewed medical records to identify bleeding events. Results From September 2009 through March 2011, 1,668 inpatients met the IMPROVE inclusion criteria. Bleeding events occurred during 45 separate admissions (2.7%); 31 events (1.9%) were major and 14 (0.8%) were nonmajor but clinically relevant. Two hundred fifty-six patients (20.7%) had an IMPROVE BRS ≥ 7.0. Kaplan-Meier curves showed a higher cumulative incidence of major ( P = .02) and clinically important (major plus clinically relevant nonmajor) ( P = .06) bleeding within 14 days in patients with an IMPROVE BRS ≥ 7.0. An IMPROVE BRS ≥ 7.0 was associated with major bleeding in Cox-regression analysis adjusted for administration of chemical prophylaxis (OR, 2.6; 95% CI, 1.1-5.9; P = .03); there was a trend toward a significant association with clinically important bleeding (OR, 1.9; 95% CI, 0.9-3.7; P = .07). Conclusions The IMPROVE BRS calculated at admission predicts major bleeding in medical inpatients. This model may help assess the relative risks of bleeding and VTE before chemoprophylaxis is administered.

Two representational abilities, expressive and receptive language and symbolic play, were assessed in multiple formats in hearing and deaf 2-year-old children of hearing and deaf mothers. Based on maternal report, hearing children of hearing and deaf mothers produced more words than deaf children of hearing mothers, hearing children of hearing mothers more words than deaf children of deaf mothers, and deaf children of deaf mothers more words than deaf children of hearing mothers. Based on experimenter assessments, hearing children in both groups produced and comprehended more words than deaf children in both groups. By contrast, no differences emerged among these groups in child solitary symbolic play or in child-initiated or mother-initiated child collaborative symbolic play; all groups also increased equivalently in symbolic play between solitary and collaborative play. Representational language and symbolic play were unrelated in hearing children of hearing mothers and in deaf children of deaf mothers, but the 2 abilities were associated in children in the 2 child/mother mismatched hearing status groups. These findings are placed in the context of a proposed developing modularity of verbal and nonverbal symbol systems, and the implications of hearing status in communicative exchanges between children and their mothers in diverse hearing and deaf dyads are explored.

To explore how well medical schools prepare students to address end-of-life issues with their patients.In 1997, the authors surveyed 226 fourth-year students at Georgetown University School of Medicine and Mayo Medical School, assessing relevant knowledge, experiences, and attitudes, and the students' sense of preparedness to address end-of-life issues.Seventy-two percent (162) of the eligible students responded. Almost all (99%) recognized the importance of advance directives and anticipated discussing end-of-life issues with patients in their practices (84%). However, only 41% thought their education regarding end-of-life issues had been adequate, only 27% had ever discussed end-of-life issues with a patient themselves, and only 35% thought they had had adequate exposure and education regarding advance directives. Eighty percent favored more education about end-of-life issues. Educational exposure to end-of-life issues and to role models, ability to correctly define an advance directive, number of end-of-life discussions witnessed, and age all were associated the students' sense of preparedness to discuss advance directives with patients.Most of the students felt unprepared to discuss end-of-life issues with their patients, but wanted to learn more. The factors associated with a sense of preparedness suggest several possible, easily made, educational interventions, but further research is required to understand the scope of the problem and to implement curricular modifications.

OBJECTIVE: To examine the long-term effects of an innovative curriculum on medical house officers' (HOs') knowledge, confidence, and attitudes regarding medical ethics. DESIGN: Long term cohort study. The two-year curriculum, implemented by a single physician ethicist with assistance from other faculty, was fully integrated into the programme. It consisted of monthly sessions: ethics morning report alternating with didactic conferences. The content included topics such as ethics vocabulary and principles, withdrawing life support, informed consent, and justice. Identical content was offered simultaneously at the largest affiliated community hospital. SETTING: A multi-hospital university training programme from July, 1992 to June, 1994. PARTICIPANTS: Thirty-nine HOs responded in 92. Thirty HOs from the same cohort responded in 94 (response rates = 83% v 71%; P = 0.19). RESULTS: The curriculum was well received, with 96% of HOs finding the sessions stimulating. Previously validated scales of knowledge and confidence were administered at baseline and at follow-up. The average knowledge score improved 14% (P < 0.001). Confidence also improved, rising from 3.3 to 3.8 on a 5-point Likert scale (P < 0.001). These findings were independent of age, gender, religion, and prior education. The only attitudinal change was an increase in the proportion of residents who thought that ethics should be a required part of residency training (57% v 80%, P = 0.05). CONCLUSION: This curriculum appears practical, popular, and effective. It should be readily transferable to other institutions.

Objective This study compares different nonpharmacological interventions for persons with behavioral symptoms and dementia on frequency of use and perceived efficacy in terms of change in behavior and interest. Methods Participants were 89 nursing home residents from six Maryland nursing homes with a mean age of 85.9 years (SD: 8.6 years). Research assistants presented interventions tailored to the participants' needs and preferences in a pre-intervention trial phase and in an intervention phase. The impact of each intervention on behavioral symptoms and on the person's interest was rated immediately after the intervention by a research assistant. Results The most utilized interventions in both trial and treatment phases were the social intervention of one-on-one interaction, simulated social interventions such as a lifelike doll and respite video, the theme intervention of magazine, and the sensory stimulation intervention of music. In contrast, the least utilized interventions in both phases were sewing, fabric book, and flower arrangement. Interventions with the highest impact on behavioral symptoms included one-on-one social interaction, hand massage, music, video, care, and folding towels. Other high impact interventions included walking, going outside, flower arranging, food or drink, sewing, group activity, book presentation, ball toss, coloring or painting, walking, and family video. Conclusions The results provide initial directions for choosing specific interventions for persons with dementia and also demonstrate a methodology for increasing knowledge through ongoing monitoring of practice.

OBJECTIVES: To study the accuracy of reviewing ward notes (chart review) as a measure of the quality of care rendered to patients with "Do Not Resuscitate" (DNR) orders. DESIGN: We reviewed the charts of 19 consecutive, competent inpatients with DNR orders for evidence that the staff addressed a broad range of patient care needs called Concurrent Care Concerns (CCCs), such as withholding treatments other than resuscitation itself, and attention to patient comfort needs. We then interviewed the patient, consultant physician, house officer, and primary nurse and compared the ward notes with the understandings of these staff members. SETTING: The medical service of an urban university medical centre. RESULTS: The average number of documented CCCs addressed per DNR order was 1.1. The ward notes generally agreed with the perceptions of patients, house officers, and nurses (% agreement with notes = 79%, 77%, and 82%; kappa = 0.43, 0.40, 0.50). Consultant physicians' understandings were poorly reflected in the ward notes (% agreement = 59%; kappa = 0.18). They overestimated attention to CCCs compared with the notes (P < 0.0001) and with other observers (P < 0.0001). CONCLUSION: Chart review for attention to CCCs accurately reflects the understandings of patients, house officers, and nurses, but consultant physicians report more attention to CCCs than is recorded in the ward notes or understood by other observers. Better communication regarding end-of-life care plans should be encouraged.

A prospective study of vision-related outcomes of cataract surgery as well as cognitive functioning, activities of daily living (ADL) functioning, and depressed affect was conducted with 19 nursing home residents scheduled for cataract surgery. Also studied were 22 candidates for cataract surgery who decided against it. Comparison of both groups at baseline revealed that residents who chose cataract surgery were less cognitively and ADL impaired. Analysis after cataract surgery showed that visual acuity improved significantly at 4 months and was maintained at 1 year after surgery.

Liquid-liquid equilibrium data were measured for the 1-propanol-NaCl−H2O system at 25°C. Liquid-liquid equilibrium in aqueous biphasic salt systems containing salts and alcohols or polymers was modelled using an expression for the excess Gibbs energy of the solution. The model is based on modified forms of the nonprimitive Mean Spherical Approximation, the Bromley equation, and the Flory-Huggins theory and requires three and five adjustable parameters for ternary and quaternary systems, respectively. The model accurately correlated binary water-polymer or water-alcohol vapor-liquid equilibrium data and liquidliquid equilibrium data for seven ternary and three quaternary aqueous biphasic salt systems.

We examined the impact of environmental, person, and stimulus characteristics on pleasure in persons with dementia. Study participants were 193 residents of 7 Maryland nursing homes who were presented with 25 stimuli from these categories: live human social stimuli, live pet social stimuli, simulated social stimuli, inanimate social stimuli, a reading stimulus, manipulative stimuli, a music stimulus, task and work-related stimuli, and two different self-identity stimuli. Systematic observations of pleasure in the natural environment were conducted using Lawton's Modified Behavior Stream. Analysis showed that pleasure is related to stimulus category, personal attributes and environmental conditions. In the multivariate analyses, all types of social stimuli (live and simulated, human and nonhuman), self-identity stimuli, and music were related to significantly higher levels of pleasure than the control condition. Females and persons with higher ADL and communication functional status exhibited more pleasure. Pleasure was most likely to occur in environments with moderate noise levels. These results demonstrate that these nursing home residents are indeed capable of showing pleasure. Caregivers of nursing home residents with dementia should incorporate social, self-identity, and music stimuli into their residents' care plans so that eliciting pleasure from each resident becomes the norm rather than a random occurrence.

International audience; We examined whether antidepressants alter expression of psychopathic personality traits in patients with major depressive disorder (MDD). Data were collected from a double-blind, placebo-controlled 8-week trial evaluating the efficacy of sertraline (50-200 mg/day) combined with either tri-iodothyronine (T3) or matching placebo in adult outpatients with major depressive disorder. Administration of sertraline was open-label; T3/placebo was double-blind. At the baseline and week 8 visits, patients completed the short form of the Psychopathic Personality Inventory (PPI), a well-validated self-report measure assessing two major factors of psychopathy: Fearless Dominance (PPI-1) and Self-Centered Impulsivity (PPI-2). Change in PPI scores were assessed using paired t-tests for all participants who completed a baseline and postrandomization PPI. Ninety patients (84 completers and six who terminated the trial early) were eligible for the analysis. Both PPI factors changed significantly from baseline to endpoint, but in opposing directions. The mean score on PPI-1 increased significantly during treatment; this change was weakly correlated with change in depression scores. In contrast, the mean score on PPI-2 decreased significantly, but these changes were not correlated with changes in depression scores. Independent of their effects on depression, antidepressants increase adaptive traits traditionally observed in psychopathic individuals, such as social charm and interpersonal and physical boldness. Antidepressants reduce other, more maladaptive, traits associated with psychopathy, including dysregulated impulsivity and externalization.

The present study examined the impact of different attributes of social stimuli using the stimulus attributes aspect of the Comprehensive Process Model of Engagement (Cohen-Mansfield et al., (2009a) Am J Geriatr Psychiatry. 17:299–307). Participants were 193 residents of 7 Maryland nursing homes with a diagnosis of dementia. Stimuli were chosen to represent different levels of the following social attributes: social versus not social, realistic versus not realistic, animated versus nonanimated, human versus nonhuman, and alive versus not alive. Participants had significantly longer engagement, were significantly more attentive, and displayed a significantly more positive attitude with social stimuli than with nonsocial stimuli. Longer durations and higher ratings of attention and attitude were seen with realistic and animated stimuli as compared to their counterparts. Human and live stimuli resulted in significantly more engagement than their counterparts. Giving any social stimulus to the residents is preferable to providing none, and the social attributes of stimuli should be maximized.

We examined the impact of setting characteristics and presentation effects on engagement with stimuli in a group of 193 nursing home residents with dementia (recruited from a total of seven nursing homes). Engagement was assessed through systematic observations using the Observational Measurement of Engagement (OME), and data pertaining to setting characteristics (background noise, light, and number of persons in proximity) were recorded via the environmental portion of the Agitation Behavior Mapping Inventory (ABMI; Cohen-Mansfield, Werner, & Marx, (1989). An observational study of agitation in agitated nursing home residents. International Psychogeriatrics, 1, 153–165). Results revealed that study participants were engaged more often with moderate levels of sound and in the presence of a small group of people (from four to nine people). As to the presentation effects, multiple presentations of the same stimulus were found to be appropriate for the severely impaired as well as the moderately cognitively impaired. Moreover, modeling of the appropriate behavior significantly increased engagement, with the severely cognitively impaired residents receiving the greatest benefit from modeling. These findings have direct implications for the way in which caregivers could structure the environment in the nursing home and how they could present stimuli to residents in order to optimize engagement in persons with dementia.

Objectives To determine which stimuli are 1) most engaging 2) most often refused by nursing home residents with dementia, and 3) most appropriate for persons who are more difficult to engage with stimuli. Methods Participants were 193 residents of seven Maryland nursing homes. All participants had a diagnosis of dementia. Stimulus engagement was assessed by the Observational Measure of Engagement. Results The most engaging stimuli were one-on-one socializing with a research assistant, a real baby, personalized stimuli based on the person's self-identity, a lifelike doll, a respite video, and envelopes to stamp. Refusal of stimuli was higher among those with higher levels of cognitive function and related to the stimulus' social appropriateness. Women showed more attention and had more positive attitudes for live social stimuli, simulated social stimuli, and artistic tasks than did men. Persons with comparatively higher levels of cognitive functioning were more likely to be engaged in manipulative and work tasks, whereas those with low levels of cognitive functioning spent relatively more time responding to social stimuli. The most effective stimuli did not differ for those most likely to be engaged and those least likely to be engaged. Conclusion Nursing homes should consider both having engagement stimuli readily available to residents with dementia, and implementing a socialization schedule so that residents receive one-on-one interaction. Understanding the relationship among type of stimulus, cognitive function, and acceptance, attention, and attitude toward the stimuli can enable caregivers to maximize the desired benefit for persons with dementia.

W.F.J. Steenkamp en/and H.J.J. Reynders (Hoofredakteurs/Chief Edi-tors. Ekonomiese en Bedryfswoordeboek: Engels–Afrikaans/Dictionary of Eco-nomics and Business: English–Afrikaans. Tweede, hersiene en vermeerder-de uitgawe/Second, revised and enlarged edition. 2004, xii + 1199 pp. ISBN 1868900312. Kaapstad/Cape Town: Pharos Woordeboeke/Dic-tionaries. Prys/Price: R400.

To examine how presentation of different stimuli impacts affect in nursing home residents with dementia.Participants were 193 residents aged 60 to 101 years from 7 Maryland nursing homes who had a diagnosis of dementia (derived from the medical chart or obtained from the attending physician). Cognitive functioning was assessed via the Mini-Mental State Examination (MMSE), and data pertaining to activities of daily living were obtained through the Minimum Data Set. Affect was assessed using observations of the 5 moods from Lawton's Modified Behavior Stream. Baseline observations of affect were performed for comparisons. During the study, each participant was presented with 25 predetermined engagement stimuli in random order over a period of 3 weeks. Stimuli were categorized as live social, simulated social, manipulative, work/task-related, music, reading, or individualized to the participant's self-identity. The dates of data collection were 2005-2007.Differences between stimulus categories were significant for pleasure (F(6,144) = 25.137, P.001) and interest (F(6,144) = 18.792, P.001) but not for negative affect. Pleasure and interest were highest for the live social category, followed by self-identity and simulated social stimuli for pleasure, and for manipulative stimuli in terms of the effect on interest. The lowest levels of pleasure and interest were observed for music. Participants with higher cognitive function had significantly higher pleasure (F(1,97) = 6.27, P.05). Although the general trend of the impact of the different categories was similar for different levels of cognitive function, there were significant differences in pleasure in response to specific stimuli (interaction effect: F(6,92) = 2.31, P.05). Overall, social stimuli have the highest impact on affect in persons with dementia.The findings of the present study are important, as affect is a major indicator of quality of life and this study is the first to systematically examine the impact of specific types of stimuli on affect. As live social stimuli are not always readily available, particularly in busy nursing home environments, simulated social stimuli can serve as an effective substitute, and other stimuli should have a role in the activity tool kit in the nursing home. The relative ranking of stimuli was different for interest and pleasure. The findings demonstrate the differential effect of presentation of different types of stimuli on the affect of persons with dementia, and that, while the impact is greater on persons with higher levels of cognitive function, there is a different effect of varying stimuli even in persons with MMSE scores of 3 or lower. Future research should attempt to ascertain a person's degree of interest in stimuli prior to developing an intervention.

Purpose The aim of this article is to delineate the underlying premises of the concept of engagement in persons with dementia and present a new theoretical framework of engagement. Setting/Subjects The sample included 193 residents of seven Maryland nursing homes. All participants had a diagnosis of dementia. Methodology The authors describe a model of factors that affect engagement of persons with dementia. Moreover, the authors present the psychometric qualities of an assessment designed to capture the dimensions of engagement (Observational Measurement of Engagement). Finally, the authors detail plans for future research and data analyses that are currently underway. Discussion This article lays the foundation for a new theoretical framework concerning the mechanisms of interactions between persons with cognitive impairment and environmental stimuli. Additionally, the study examines what factors are associated with interest and negative and positive feelings in engagement.