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Warming of the Arctic due to climate change means the Arctic Ocean is now free from ice for longer, as sea ice melts earlier and refreezes later. Yet, it remains unclear how this extended ice-free period will impact carbon dioxide (CO2) fluxes due to scarcity of surface ocean CO2 measurements. Baseline measurements are urgently needed to understand spatial and temporal air–sea CO2 flux variability in the changing Arctic Ocean. There is also uncertainty as to whether the previous basin-wide surveys are representative of the many smaller bays and inlets that make up the Canadian Arctic Archipelago (CAA). By using a research vessel that is based in the remote Inuit community of Ikaluqtuutiak (Cambridge Bay, Nunavut), we have been able to reliably survey pCO2 shortly after ice melt and access previously unsampled bays and inlets in the nearby region. Here we present 4 years of consecutive summertime pCO2 measurements collected in the Kitikmeot Sea in the southern CAA. Overall, we found that this region is a sink for atmospheric CO2 in August (average of all calculated fluxes over the four cruises was −4.64 mmol m−2 d−1), but the magnitude of this sink varies substantially between years and locations (average calculated fluxes of +3.58, −2.96, −16.79 and −0.57 mmol m−2 d−1 during the 2016, 2017, 2018 and 2019 cruises, respectively). Surface ocean pCO2 varied by up to 156 µatm between years, highlighting the importance of repeat observations in this region, as this high interannual variability would not have been captured by sparse and infrequent measurements. We find that the surface ocean pCO2 value at the time of ice melt is extremely important in constraining the magnitude of the air–sea CO2 flux throughout the ice-free season. However, further constraining the air–sea CO2 flux in the Kitikmeot Sea will require a better understanding of how pCO2 changes outside of the summer season. Surface ocean pCO2 measurements made in small bays and inlets of the Kitikmeot Sea were ∼ 20–40 µatm lower than in the main channels. Surface ocean pCO2 measurements made close in time to ice breakup (i.e. within 2 weeks) were ∼ 50 µatm lower than measurements made > 4 weeks after breakup. As previous basin-wide surveys of the CAA have focused on the deep shipping channels and rarely measure close to the ice breakup date, we hypothesize that there may be an observational bias in previous studies, leading to an underestimate of the CO2 sink in the CAA. These high-resolution measurements constitute an important new baseline for gaining a better understanding of the role this region plays in the uptake of atmospheric CO2.

Surface ocean carbon dioxide (CO2) measurements are used to compute the oceanic air–sea CO2 flux. The CO2 flux component from rivers and estuaries is uncertain due to the high spatial and seasonal heterogeneity of CO2 in coastal waters. Existing high-quality CO2 instrumentation predominantly utilises showerhead and percolating style equilibrators optimised for open-ocean observations. The intervals between measurements made with such instrumentation make it difficult to resolve the fine-scale spatial variability of surface water CO2 at timescales relevant to the high frequency variability in estuarine and coastal environments. Here we present a novel dataset with unprecedented frequency and spatial resolution transects made at the Western Channel Observatory in the south-west of the UK from June to September 2016, using a fast-response seawater CO2 system. Novel observations were made along the estuarine–coastal continuum at different stages of the tide and reveal distinct spatial patterns in the surface water CO2 fugacity (fCO2) at different stages of the tidal cycle. Changes in salinity and fCO2 were closely correlated at all stages of the tidal cycle and suggest that the mixing of oceanic and riverine endmembers partially determines the variations in fCO2. The correlation between salinity and fCO2 was different in Cawsand Bay, which could be due to enhanced gas exchange or to enhanced biological activity in the region. The observations demonstrate the complex dynamics determining spatial and temporal patterns of salinity and fCO2 in the region. Spatial variations in observed surface salinity were used to validate the output of a regional high-resolution hydrodynamic model. The model enables a novel estimate of the air–sea CO2 flux in the estuarine–coastal zone. Air–sea CO2 flux variability in the estuarine–coastal boundary region is influenced by the state of the tide because of strong CO2 outgassing from the river plume. The observations and model output demonstrate that undersampling the complex tidal and mixing processes characteristic of estuarine and coastal environment biases quantification of air–sea CO2 fluxes in coastal waters. The results provide a mechanism to support critical national and regional policy implementation by reducing uncertainty in carbon budgets.

We describe a case of myocarditis associated with a brown recluse spider bite in a 31-year-old man. Cardiac magnetic resonance revealed late gadolinium enhancement in the lateral wall and inferior wall. There was also regional elevation of the myocardial T2 and extracellular volume indicative of myocardial edema. (Level of Difficulty: Intermediate.), Graphical abstract

The Kitikmeot Sea is a semi-enclosed, east–west waterway in the southern Canadian Arctic Archipelago (CAA). In the present work, the ice conditions, stratification, and circulation of the Kitikmeot...

The carbonate chemistry of sea ice is known to play a role in global carbon cycles, but its importance is uncertain in part due to disparities in reported results. Variability in physical and biological drivers is usually invoked to explain differences between studies. In the Canadian Arctic Archipelago, “invisible polynyas” – areas of strong currents, thin ice, and potentially high biological productivity – are examples of extreme spatial variability. We used an invisible polynya as a natural laboratory to study the effects of inferred initial ice formation conditions, ice growth rate, and algal biomass on the distribution of carbonate species by collecting enough cores to perform a statistical comparison between sites located within, and just outside of, a polynya near Iqaluktuttiaq (Cambridge Bay, Nunavut, Canada). At both sites, the uppermost 10 cm ice horizon showed evidence of CO2 off-gassing, while carbonate distributions in the middle and bottommost 10 cm horizons largely followed the salinity distribution. In the polynya, the upper ice horizon had significantly higher bulk total inorganic carbon (TIC), total alkalinity (TA), and salinity potentially due to freeze-up conditions that favoured frazil ice production. The middle ice horizons were statistically indistinguishable between sites, suggesting that ice growth rate is not an important factor for the carbonate distribution under mid-winter conditions. The thicker (non-polynya) site experienced higher algal biomass, TIC, and TA in the bottom horizon. Carbonate chemistry in the bottom horizon could largely be explained by the salinity distribution, with the strong currents at the polynya site potentially playing a role in desalinization; biology appeared to exert only a minor control, with some evidence that the ice algae community was net heterotrophic. We did see evidence of calcium carbonate precipitation but with little impact on the TIC:TA ratio and little difference between sites. Because differences were constrained to relatively thin layers at the top and bottom, vertically averaged values of TIC, TA, and especially the TIC:TA ratio were not meaningfully different between sites. This provides some justification for using a single bulk value for each parameter when modelling sea ice effects on ocean chemistry at coarse resolution. Exactly what value to use (particularly for the TIC:TA ratio) likely varies by region but could potentially be approximated from knowledge of the source seawater and sea ice salinity. Further insights await a rigorous intercomparison of existing data.

Importance Early-onset atrial fibrillation (AF) can be the initial manifestation of a more serious underlying inherited cardiomyopathy or arrhythmia syndrome. Objective To examine the results of genetic testing for early-onset AF. Design, Setting, and Participants This prospective, observational cohort study enrolled participants from an academic medical center who had AF diagnosed before 66 years of age and underwent whole genome sequencing through the National Heart, Lung, and Blood Institute’s Trans-Omics for Precision Medicine program. Participants were enrolled from November 23, 1999, to June 2, 2015. Data analysis was performed from October 24, 2020, to March 11, 2021. Exposures Rare variants identified in a panel of 145 genes that are included on cardiomyopathy and arrhythmia panels used by commercial clinical genetic testing laboratories. Main Outcomes and Measures Sequencing data were analyzed using an automated process followed by manual review by a panel of independent, blinded reviewers. The primary outcome was classification of rare variants using American College of Medical Genetics and Genomics criteria: benign, likely benign, variant of undetermined significance, likely pathogenic, or pathogenic. Disease-associated variants were defined as pathogenic/likely pathogenic variants in genes associated with autosomal dominant or X-linked dominant disorders. Results Among 1293 participants (934 [72.2%] male; median [interquartile range] age at enrollment, 56 [48-61] years; median [interquartile range] age at AF diagnosis, 50 [41-56] years), genetic testing identified 131 participants (10.1%) with a disease-associated variant, 812 (62.8%) with a variant of undetermined significance, 92 (7.1%) as heterozygous carriers for an autosomal recessive disorder, and 258 (20.0%) with no suspicious variant. The likelihood of a disease-associated variant was highest in participants with AF diagnosed before the age of 30 years (20 of 119 [16.8%; 95% CI, 10.0%-23.6%]) and lowest after the age of 60 years (8 of 112 [7.1%; 95% CI, 2.4%-11.9%]). Disease-associated variants were more often associated with inherited cardiomyopathy syndromes compared with inherited arrhythmias. The most common genes wereTTN(n = 38),MYH7(n = 18),MYH6(n = 10),LMNA(n = 9), andKCNQ1(n = 8). Conclusions and Relevance In this cohort study, genetic testing identified a disease-associated variant in 10% of patients with early-onset AF (the percentage was higher if diagnosed before the age of 30 years and lower if diagnosed after the age of 60 years). Most pathogenic/likely pathogenic variants are in genes associated with cardiomyopathy. These results support the use of genetic testing in early-onset AF.

Surface ocean CO2 measurements are used to compute the oceanic air–sea CO2 flux. The CO2 flux component from rivers and estuaries is uncertain. Estuarine and coastal water carbon dioxide (CO2) observations are relatively few compared to observations in the open ocean. The contribution of these regions to the global air–sea CO2 flux remains uncertain due to systematic under-sampling. Existing high-quality CO2 instrumentation predominantly utilise showerhead and percolating style equilibrators optimised for open ocean observations. The intervals between measurements made with such instrumentation make it difficult to resolve the fine-scale spatial variability of surface water CO2 at timescales relevant to the high frequency variability in estuarine and coastal environments. Here we present a novel dataset with unprecedented frequency and spatial resolution transects made at the Western Channel Observatory in the south west of the UK from June to September 2016, using a fast response seawater CO2 system. Novel observations were made along the estuarine–coastal continuum at different stages of the tide and reveal distinct spatial patterns in the surface water CO2 fugacity (fCO2) at different stages of the tidal cycle. Changes in salinity and fCO2 were closely correlated at all stages of the tidal cycle and suggest that the mixing of oceanic and riverine end members determines the variations in fCO2. The observations demonstrate the complex dynamics determining spatial and temporal patterns of salinity and fCO2 in the region. Spatial variations in observed surface salinity were used to validate the output of a regional high resolution hydrodynamic model. The model enables a novel estimate of the air–sea CO2 flux in the estuarine–coastal zone. Air–sea CO2 flux variability in the estuarine–coastal boundary region is dominated by the state of the tide because of strong CO2 outgassing from the river plume. The observations and model output demonstrate that undersampling the complex tidal and mixing processes characteristic of estuarine and coastal environment bias quantification of air-sea CO2 fluxes in coastal waters. The results provide a mechanism to support critical national and regional policy implementation by reducing uncertainty in carbon budgets.

Remoteness and tough conditions have made the Arctic Ocean historically difficult to access; until recently this has resulted in an undersampling of trace gas and gas exchange measurements. The seasonal cycle of sea ice completely transforms the air sea interface and the dynamics of gas exchange. To make estimates of gas exchange in the presence of sea ice, sea ice fraction is frequently used to scale open water gas transfer parametrisations. It remains unclear whether this scaling is appropriate for all sea ice regions. Ship based eddy covariance measurements were made in Hudson Bay during the summer of 2018 from the icebreaker CCGS Amundsen. We will present fluxes of carbon dioxide (CO2), heat and momentum and will show how they change around the Hudson Bay polynya under varying sea ice conditions. We will explore how these fluxes change with wind speed and sea ice fraction. As freshwater stratification was encountered during the cruise, we will compare our measurements with other recent eddy covariance flux measurements made from icebreakers and also will compare our turbulent CO2 fluxes with bulk fluxes calculated using underway and surface bottle pCO2 data.

This paper describes a near-surface ocean profiler, which has been designed to precisely measure vertical gradients in the top 10 m of the ocean. Variations in the depth of seawater collection are minimized when using the profiler compared to conventional CTD/rosette deployments. The profiler consists of a remotely operated winch mounted on a tethered yet free-floating buoy, which is used to raise and lower a small frame housing sensors and inlet tubing. Seawater at the inlet depth is pumped back to the ship for analysis. The profiler can be used to make continuous vertical profiles or to target a series of discrete depths. The profiler has been successfully deployed during wind speeds up to 10 m s−1 and significant wave heights up to 2 m. We demonstrate the potential of the profiler by presenting measured vertical profiles of the trace gases carbon dioxide and dimethylsulfide. Trace gas measurements use an efficient microporous membrane equilibrator to minimize the system response time. The example profiles show vertical gradients in the upper 5 m for temperature, carbon dioxide and dimethylsulfide of 0.15 °C, 4 µatm and 0.4 nM respectively.

The sacroiliac joint (SIJ) is often overlooked as a cause of pain, partially because it is not well visualized on standard imaging and partially because other structures may refer pain to it. This chapter reviews the anatomy of the SIJ as well as the diagnosis and differential diagnosis of SI joint dysfunction and pain, including a multitude of physical exam maneuvers such as the FABER, Gaenslen, extension, Gillet’s, sacroiliac shear, thigh thrust, compression, and distraction tests. In addition, it discusses the evidence-based approach to treat sacroiliac pain, with a focus on both conservative and nonconservative approaches such as image-guided steroid injections and radiofrequency denervation procedures and outcomes.

Strong evidence for a pan-Arctic expansion of upright shrubs comes from analysis of satellite imagery, historical photographs, vegetation plots, and growth rings. However, there are still uncertainties related to local-scale patterns of shrub growth, resulting interactions among vegetation functional groups, and the relative roles of disturbance and climate as drivers of observed change. Here, we present evidence that widespread and rapid shrub expansion and lichen declines over a 15,000 km2 area of the western Canadian Arctic have been driven by regional increases in temperature. Using 30 m resolution Landsat satellite imagery and high resolution repeat color-infrared aerial photographs, we show that 85% of the land surface has a positive 1985–2011 trend (P 0.03 NDVI/decade) occurred consistently across all landscape positions and most vegetation types. Comparison of 208, 1:2,000 scale vertical air photo pairs from 1980 and 2013 clearly shows that this greening was driven by increased canopy cover of erect dwarf and tall shrubs, with declines in terricolous lichen cover. Disturbances caused by wildfires, exploratory gas wells, and drained lakes all produced strong, yet localized increases in NDVI due to shrub growth. Our analysis also shows that a 4°C winter temperature increase over the past 30 years, leading to warmer soils and enhanced nutrient mineralization provides the best explanation for observed vegetation change. These observations thus provide early corroboration for modeling studies predicting large-scale vegetation shifts in low-Arctic ecosystems from climate change.

This paper describes a Near Surface Ocean Profiler, which has been designed to precisely measure vertical gradients in the top 10 m of the ocean. Variations in the depth of seawater collection are minimised when using the profiler compared to conventional CTD/rosette deployments. The profiler consists of a remotely operated winch mounted on a tethered yet free floating buoy, which is used to raise and lower a small frame housing sensors and inlet tubing. Seawater at the inlet depth is pumped back to the ship for analysis. The profiler can be used to make continuous vertical profiles or to target a series of discrete depths. The profiler has been successfully deployed during wind speeds up to 10 m s−1 and significant wave heights up to 2 m. We demonstrate the potential of the profiler by presenting measured vertical profiles of the trace gases carbon dioxide and dimethylsulfide. Trace gas measurements use an efficient microporous membrane equilibrator to minimise the system response time. The example profiles show vertical gradients in the upper 5 m for temperature, carbon dioxide and dimethylsulfide of 0.15 °C, 4 μatm and 0.4 nM respectively.

We employed an auto-ethnography approach to explore the affective dimension of life review sessions with community-dwelling older military veterans with minor cognitive impairment (MCI) and early dementia. Using researchers’ analytic memos, we identified facilitators’ interactional strategies that fostered the participant’s sense of personal identity, dignity and social self-worth. Interaction among participant, caregiver, and facilitators evoked a range of emotional responses, offering a window into the affective world of MCI and early dementia. Positive emotional responses outnumbered negative emotional responses by a ratio of two-to-one in the life review sessions; however, negative emotions were more revelatory of current struggles with declines in health and function. Facilitators utilized two interactional strategies, in particular, to foster personhood and social value of participants: focusing on the participant and creating an empathic connection with the participant. Further work is needed to understand the role of emotions in research interactions and to examine the psychosocial mechanisms through which positive affect functions in promoting identity, personhood and social value among persons with MCI and early dementia.

OBJECTIVES: To understand the potential roles of various patient and provider factors in the underuse of pneumococcal vaccination in Medicare-eligible older African Americans. DESIGN: The Cardiovascular Health Study. SETTING: Four U.S. states. PARTICIPANTS: Seven hundred ninety-five pairs of community-dwelling Medicare-eligible African-American and white adults aged 65 and older, balanced according to age and sex. MEASUREMENTS: Data on self-reported race, receipt of pneumococcal vaccination, and other important sociodemographic and clinical variables were collected at baseline. RESULTS: Participants had a mean age ± standard deviation of 73 ± 6; 63% were female. Pneumococcal vaccination rates were 22% for African Americans and 28% for whites (unadjusted odds ratios (OR) for African Americans=0.75; 95% confidence interval (CI)=0.60�0.94; P=.01). This association remained significant despite adjustment for sociodemographic and clinical confounders, including education, income, chronic obstructive pulmonary disease, and prior pneumonia (OR=0.74, 95% CI=0.56�0.97; P=.03), but the association was no longer significant after additional adjustment for the receipt of influenza vaccination (OR=0.79, 95% CI=0.59�1.06; P=.12). Receipt of influenza vaccination was associated with higher odds of receiving pneumococcal vaccination (unadjusted OR=6.43, 95% CI=5.00�8.28; P

To determine the demographic and clinical predictors of in-hospital mortality among hospitalized nursing home (NH) residents.Retrospective analysis of the public-use copies of the 2005-2006 National Hospital Discharge Survey (NHDS) datasets.Non-federal acute-care, short-stay hospitals in all 50 states and the District of Columbia.Participants were 1904 and 1752 NH residents, 45 years or older, hospitalized in 2005 and 2006, respectively.In-hospital mortality.A multivariable logistic regression model was developed to determine independent predictors of in-hospital mortality using the 2005 dataset. The model was then applied to the 2006 dataset to determine the generalizability of the predictors.Significant independent predictors of in-hospital mortality in 2005 included age 85 years or older (adjusted odds ratio [OR], 2.53; 95% confidence interval [CI], 1.21-5.30; P=.013), acute respiratory failure (adjusted OR, 5.67; 95% CI, 3.51-9.17; P.0001), septicemia (adjusted OR, 4.63; 95% CI, 3.08-6.96; P.0001), and acute renal failure (adjusted OR, 2.11; 95% CI, 1.30-3.41; P=.002). The following baseline characteristics also predicted in-hospital mortality in 2006: age 85 years or older (adjusted OR, 2.45; 95% CI, 1.31-4.59; P=.005), acute respiratory failure (adjusted OR, 7.11; 95% CI, 4.46-11.33; P.0001), septicemia (adjusted OR, 3.91; 95% CI, 2.64-5.80; P.0001), and acute renal failure (adjusted OR, 2.75; 95% CI, 1.82-4.15; P.0001). Chronic morbidities were not associated with in-hospital mortality.Among hospitalized NH residents, age 85 years or older and several acute conditions, but not chronic morbidities, predicted in-hospital mortality. Elderly NH residents at risk of developing these acute conditions may benefit from palliative care.

BACKGROUND: Stopping driving has significant negative consequences for older adults, but there is no simple, reliable screening tool to predict driving cessation. We sought to determine if self-rated health (SRH) was an independent predictor of driving cessation among older adults. METHODS: Data on SRH (poor, fair, good, very good, or excellent), medical diagnoses, physical performance, visual acuity, driving status, and other relevant covariates were collected from 649 community-dwelling older Alabama drivers during in-home interviews. Using multivariable logistic regression analyses, we estimated the association of SRH with driving cessation 2 years later. RESULTS: Participants had a mean age of 74 years; 43% were women, 41% African American, and 48% rural. Overall, 36% reported poor to fair SRH at baseline, and 11% had stopped driving after 2 years. Compared to 8% of drivers with good to excellent SRH, 17% with poor to fair health stopped driving (adjusted odds ratio [OR], 1.93; 95% confidence interval [CI], 1.09-3.41; p=.025). Lower Short Physical Performance Battery (SPPB) scores (adjusted OR, 0.86; 95% CI, 0.78-0.95; p=.001) and older age (adjusted OR, 1.06 per year; 95% CI, 1.01-1.11; p=.010) were also associated with driving cessation. Receiver operating characteristics curves documented similar predictive discrimination (c statistics) for SRH (0.72), the SPPB (0.70), and a count of comorbidities based on the Charlson Comorbidity Index (0.73). CONCLUSIONS: Poor to fair SRH predicted incident driving cessation after 2 years in a cohort of older adults. SRH can be easily obtained during clinic visits to identify at-risk drivers. Language: en

OBJECTIVES: To define racial similarities and differences in mobility among community-dwelling older adults and to identify predictors of mobility change. DESIGN: Prospective, observational, cohort study. PARTICIPANTS: Nine hundred and five community-dwelling older adults. MEASURES: Baseline in-home assessments were conducted to assess life-space mobility, sociodemographic variables, disease status, geriatric syndromes, neuropsychological factors, and health behaviors. Disease reports were verified by review of medications, physician questionnaires, or hospital discharge summaries. Telephone interviews defined follow-up life-space mobility at 18 months of follow-up. RESULTS: African Americans had lower baseline life-space (LS-C) than whites (mean 57.0 ± standard deviation [SD] 24.5 vs. 72.7 ± SD 22.6; P

The appropriate roles for generalists and cardiologists in the care of patients with heart failure (HF) are unknown. The objective of this retrospective cohort study was to determine whether consultation between generalists and cardiologists was associated with better quality and outcomes of HF care.We studied left ventricular function evaluation (LVFE) and angiotensin-converting enzyme inhibitor (ACEI) use and 90-day readmission and 90-day mortality rates in patients with HF who were hospitalized. Patient care was categorized into cardiologist (solo), generalist (solo), or consultative cares. The processes and outcomes of care were compared by care category using logistic regression analyses fit with generalized linear mixed models to adjust for hospital-related clustering.Of the 1075 patients studied, 13% received cardiologist care, 55% received generalist care, and 32% received consultative care. More patients who received consultative care (75%) received LVFE than patients who received generalist care (36%) and cardiologist care (53%; P.001). Fewer patients who received solo care (54% each) received ACEI compared with 71% of patients who received consultative care (P.001). After multivariable adjustment, consultative care was associated with higher odds of LVFE than generalist care (adjusted odds ratio [OR], 6.06; 95% CI, 3.97-9.26) or cardiologist care (adjusted OR, 2.96; 95% CI, 1.70-5.13) care. Consultation was also associated with higher odds of ACEI use compared with generalist (adjusted OR, 2.42; 95% CI, 1.42-4.12) or cardiologist (adjusted OR, 2.32; 95% CI, 1.14-4.72) care. Compared with patients who received generalist care, patients who received consultative care had lower odds of 90-day readmission (adjusted OR, 0.54; 95% CI, 0.34-0.86).Collaboration between generalists and cardiologists, rather than solo care by either, was associated with better HF processes and outcomes of care.

In this retrospective follow-up study, the authors examined the association between race and the receipt of cardiology care in 1062 Medicare beneficiaries 65 years of age and older who were hospitalized with heart failure. The primary outcome measure was receipt of care from a cardiologist (via admission or consultation). Using logistic regression analyses, crude and adjusted odds ratios (OR) and 95% confidence intervals (95%CI) of receipt of cardiology care were estimated for nonwhite versus white patients. Two hundred (19%) patients were nonwhites and 483 (46%) patients received care from cardiologists. Proportion of patients receiving cardiology care was lower among nonwhite patients (35% versus 48% among whites; P = 0.001), and nonwhite race was associated with a lower odds of receiving cardiology care (crude OR = 0.57; 95%CI = 0.42-0.79). After adjustment for various patient characteristics and process-of-care variables, the magnitude and precision of the association between nonwhite race and a lower odds of receiving care from a cardiologist remained unchanged (adjusted OR = 0.43; 95% CI = 0.30-0.62). These findings suggest that nonwhite elderly hospitalized heart failure patients are less likely to be cared for by cardiologists.

Purpose To describe a pilot initiative sponsored by the Veterans Health Administration (VHA) to improve the health and community tenure of frail older veterans living in rural counties 50-100 miles from two host VHA medical centers. Design and methods Veterans aged 75 and older who scored at risk of repeated hospital admission on the PRA-Plus telephone questionnaire were targeted and visited by evaluators who administered a comprehensive health questionnaire prior to being assessed at home by the Coordination and Advocacy for Rural Elders (CARE) program clinical teams. Guided by current state-of-the-art practices, the nurse-social worker teams performed in-home standardized assessments using the MDS-HC, developed patient-specific care plans, and mobilized family, community, and VHA resources to implement plans. Results On average, eight problems were identified for each patient, most commonly falls risk, social needs, pain, and needs related to IADL disability. As a result of initial assessment, two thirds of CARE participants received referral/linkage to formal services, more than half to medical providers. Implications Through CARE, the VHA is learning more about the unmet needs of older rural veterans. Further development and evaluation should guide the VHA toward providing efficient, effective community-based services to all frail older veterans.

Objectives: To evaluate the association between chronic medical conditions, functional, cognitive, and visual impairments and driving difficulty and habits among older drivers. Design: Cross-sectional study. Setting: Mobile County, Alabama. Participants: A total of 901 residents of Mobile County, Alabama aged 65 or older who possessed a driver's license in 1996. Measurements: Information on demographic characteristics, functional limitations, chronic medical conditions, driving habits, and visual and cognitive function were collected via telephone. The three dependent variables in this study were difficulty with driving, defined as any reported difficulty in ≥3 driving situations (e.g. at night), low annual estimated mileage, defined as driving less than 3000 miles in 1996, and low number of days (≤3) driven per week. Results: A history of falls, kidney disease or stroke was associated with difficulty driving. Older drivers with a history of kidney disease were more likely to report a low annual mileage than subjects without kidney disease. Low annual mileage was also associated with cognitive impairment. In general, older drivers with a functional impairment were more likely to drive less than 4 days per week. Older drivers with a history of cataracts or high blood pressure were more likely to report a low number of days driven per week, while subjects with visual impairment were at increased risk of experiencing difficulty driving as well as low number of days driven per week. Conclusions: The results underscore the need to further understand the factors negatively affecting driving independence and mobility in older drivers, as well as the importance of improved communication between older adults and health care professionals regarding driving.

In this preliminary, intrasubject study (N = 8), we examined the effects of communication skills training and the use of memory books by Nursing Assistants (NAs) on the social ecology of a nursing home. Through inservice and on-the-job training, NAs were taught to use communication skills and memory books during their interactions with residents with mild to moderate cognitive impairment (Mini Mental Status Examination, M = 16.25), but relatively intact communication abilities. An abbreviated staff motivational system called Behavioral Supervision (Burgio and Burgio, 1990. Int. J. Aging Hum. Deve. 30: 287–302.) was attempted to encourage performance of these skills on the nursing units. Results showed that, regardless of sporadic implementation of the intervention by nursing staff, the intervention improved communication between staff and residents during care routines, increased the amount of time other residents and visitors spent talking with target residents, and increased the rate of positive statements made by the target residents and others in their immediate environment. Results are discussed in terms of limitations of the staff motivational system and modifications made to the system in a larger ongoing intervention trial.

Older drivers have elevated crash rates and are more likely to be injured or die if they have a crash. Medical conditions and medications have been hypothesized as determinants of crash involvement. This population-based case-control study sought to identify medical conditions and medications associated with risk of at-fault crashes among older drivers. A total of 901 drivers aged 65 years and older were selected in 1996 from Alabama Department of Public Safety driving records: 244 at-fault drivers involved in crashes; 182 not at-fault drivers involved in crashes; and 475 drivers not involved in crashes were enrolled. Information on demographic factors, chronic medical conditions, medications, driving habits, visual function, and cognitive status was collected. Older drivers with heart disease (odds ratio (OR) = 1.5, 95% confidence interval (CI): 1.0, 2.2) or stroke (OR = 1.9, 95% CI: 0.9, 3.9) were more likely to be involved in at-fault automobile crashes. Arthritis was also associated with an increased risk among females (OR =1.8, 95% CI: 1.1, 2.9). Use of nonsteroidal antiinflammatory drugs (OR = 1.7, 95% CI 1.0, 2.6), angiotensin converting enzyme inhibitors (OR = 1.6, 95 CI: 1.0, 2.7), and anticoagulants (OR = 2.6, 95% CI: 1.0, 73) was associated with an increased risk of at-fault involvement in crashes. Benzodiazepine use (OR = 5.2, 95% CI: 0.9, 30.0) was also associated with an increased risk. Calcium channel blockers (OR = 0.5, 95% CI: 0.2, 0.9) and vasodilators (OR = 0.3, 95% CI: 0.1, 1.0) were associated with a reduced risk of crash involvement. The identification of medical conditions and medications associated with risk of crashes is important for enhancing the safety and mobility of older drivers.

OBJECTIVE: The aim of this study was to estimate the association between diabetes and its complications and at-fault automobile crashes among older drivers. RESEARCH DESIGN AND METHODS: This was a population-based case-control study. Case subjects were drivers aged > or = 65 years who had been involved in a crash during 1996 in which they were at fault. Two control groups were selected: 1) crash-involved not-at-fault subjects and 2) non-crash-involved subjects. Telephone interviewers collected information on demographic characteristics, driving habits, diabetes sequelae and treatment, other chronic medical conditions, and visual function. RESULTS: Overall, there was no association between diabetes and at-fault crash involvement. The adjusted odds ratio (OR) for diabetes was 1.1 (CI 0.7-1.9) when case subjects were compared with either control group. However, the adjusted OR for diabetes was 2.5 (0.9-7.2) among subjects who had been involved in a crash in the 4 years preceding 1996, while it was only 0.9 (0.5-1.7) among those who had not. There was no evidence of an association between treatment modalities and at-fault crash involvement. Case subjects were, although not significantly (P = 0.25), more likely (OR 2.4) to report neuropathy compared with both control groups, and retinopathy was not associated with increased crash risk. CONCLUSIONS: This study provides no evidence that older drivers with diabetes are at increased risk for automobile crashes. There remains the possibility that those with diabetes who have more severe disease or have had multiple crashes are at increased risk.

BACKGROUND Acute gastroenteritis is a cause of considerable morbidity and mortality in the elderly population. A prospective assessment of acute diarrhea in three community-based long-stay homes is described. METHODS A cohort study of acute gastroenteritis was performed in three community-based nursing homes, involving 572 residents over an 8-month period. Diarrhea cases were enrolled on the basis of the acute onset of loose stools of > or = 24 hours, as well as one of the following: a rectal temperature of > or = 100 degrees F, dehydration, positive occult blood, > or = 48 hours duration, or as a part of any outbreak. Stool cultures for Clostridium difficile were performed on all NH 1 patients. RESULTS Fifty-three gastroenteritis cases were ascertained, consistent with incidence rates of 14.6, 36.4, and 6.7 cases/100 patient years in NH 1, NH 2, and NH 3, respectively. Requiring a Foley catheter (OR = 2.57; 95% CI, 0.93, 7.09) increased diarrhea risk. Six Clostridium difficile enteritis cases and an episode attributable to Aeromonas/Pleisomonas species were diagnosed. One C. difficile diarrhea case was imported from hospital to NH 1. Ten of 12 fecal excretors resided in close geographic clusters in NH 1, where a majority of the latter were mobile and incontinent of stool. CONCLUSIONS Acute gastroenteritis was a common disease in the study nursing homes, for which specific risk factors were identified. A predominant role for Clostridium difficile in the taxonomy of nursing home diarrhea was suggested.

Dementia, delirium and depression are the 3 most prevalent mental disorders in the elderly. While dementia and depression are prevalent in the community, hospitals and nursing homes, delirium is seen most often in acute care hospitals. Much of the management of these syndromes is undertaken by primary care physicians rather than psychiatrists. Therefore, it is imperative that generalist physicians be adept at recognising, evaluating and managing patients with these syndromes. Because no diagnostic tests are pathognomonic of these syndromes, the differential diagnosis hinges on a careful clinical evaluation. The first step is to recognise which of the syndromes is present. Dementia is defined by a chronic loss of intellectual or cognitive function of sufficient severity to interfere with social or occupational function. Delirium is an acute disturbance of consciousness marked by an attention deficit and a change in cognitive function. Depression is an affective disorder evidenced by a dysphoric mood, but the most pervasive symptom is a loss of ability to enjoy usual activities. It is important to recognise that these syndromes are not mutually exclusive, as dementia frequently coexists with delirium and depression. Furthermore, physical diagnoses, such as chronic obstructive lung disease, congestive heart failure, stroke and endocrine disorders, are frequently associated with depressive symptoms. Given this, a comprehensive evaluation is mandatory. Laboratory tests are necessary to exclude concurrent metabolic, endocrine and infectious disorders, and drug effects. Imaging studies should be obtained selectively in patients with signs and symptoms, such as focal neurological findings and gait disturbances, which are suggestive of structural lesions: stroke, subdural haematoma, normal pressure hydrocephalus and brain tumours. Appropriate management involving pharmacological and nonpharmacological measures will result in significant improvement in most patients with these syndromes. Potentially offending drugs should be discontinued. In delirious patients the underlying illness must be treated concomitantly with the use of psychotropics, if necessary. Although no current medications have been shown to have a significant effect on the functional status of patients with the 2 most common causes of dementia, Alzheimer's disease and multi-infarct dementia, the management of concomitant illness in these patients may result in improved function for as long as a year. Tacrine, an anticholinesterase inhibitor, improves cognitive function slightly in selected patients with Alzheimer's disease over short periods. Finally, the treatment of depression with medications or electroconvulsive therapy (ECT) results in significant reductions in mortality and morbidity.

Heart failure (HF) patients often depend on driving for access to specialty care. We analyzed a public-use copy of the Cardiovascular Health Study (CHS) data to determine if HF is a risk factor for driving cessation and to identify other risk factors for driving cessation among those with HF.Of the 5,383 community-dwelling drivers aged ≥65 years (mean age 73 years, 55% women, 13% African American), 839 had HF: 246 had baseline prevalent HF and 593 developed incident HF before driving cessation during 9 years of follow-up. Incident driving cessation occurred at rates of 3,980 and 3,709 per 10,000 person-years of follow-up for those with and without HF, respectively (unadjusted hazard ratio [HR] associated with HF as a time-varying variable: 2.13, 95% confidence interval [CI] 1.83-2.47; P.001). This association remained unchanged after multivariable risk adjustment (HR 1.43, 95% CI 1.21-1.68; P.001). Among the 839 older drivers with HF, independent predictors for incident driving cessation were age ≥75 years (HR 1.99, 95% CI 1.44-2.73; P.001), female gender (HR 1.93, 95% CI 1.37-2.74; P.001), difficulty walking half a mile (HR 1.47 (1.04-2.08); P = .028), vision problems (HR 1.47, 95% CI 1.07-2.02; P = .018), and stroke as a time-varying covariate (HR 1.96, 95% CI 1.38-2.79; P.001).HF is an independent risk factor for incident driving cessation among community-dwelling older drivers. Several patient characteristics predicted driving cessation in older HF patients, which may be targets for interventions to prevent driving cessation among these patients.

To understand the potential roles of various patient and provider factors in the underuse of pneumococcal vaccination in Medicare-eligible older African Americans.The Cardiovascular Health Study.Four U.S. states.Seven hundred ninety-five pairs of community-dwelling Medicare-eligible African-American and white adults aged 65 and older, balanced according to age and sex.Data on self-reported race, receipt of pneumococcal vaccination, and other important sociodemographic and clinical variables were collected at baseline.Participants had a mean age ± standard deviation of 73 ± 6; 63% were female. Pneumococcal vaccination rates were 22% for African Americans and 28% for whites (unadjusted odds ratios (OR) for African Americans=0.75; 95% confidence interval (CI)=0.60-0.94; P=.01). This association remained significant despite adjustment for sociodemographic and clinical confounders, including education, income, chronic obstructive pulmonary disease, and prior pneumonia (OR=0.74, 95% CI=0.56-0.97; P=.03), but the association was no longer significant after additional adjustment for the receipt of influenza vaccination (OR=0.79, 95% CI=0.59-1.06; P=.12). Receipt of influenza vaccination was associated with higher odds of receiving pneumococcal vaccination (unadjusted OR=6.43, 95% CI=5.00-8.28; P.001), and the association between race and pneumococcal vaccination lost significance when adjusted for influenza vaccination alone (OR=0.81, 95% CI=0.63-1.03; P=.09).The strong association between receipt of influenza and pneumococcal vaccinations suggests that patient and provider attitudes toward vaccination, rather than traditional confounders such as education and income, may help explain the underuse of pneumococcal vaccination in older African Americans.

Bacterial pneumonia is among the most frequent diagnoses that bring elderly patients to the Emergency Department. The morbidity and mortality subsequent to these infections is very high among these individuals, and presenting symptoms and signs may be subtle. Gram-negative bacilli, H. influenzae, and mixed organisms more commonly cause lower respiratory tract infections in this population. The diagnosis and management of nursing home and community-acquired pneumonias are reviewed, as are important preventative strategies.

Studies of delirium in general medical populations have used criteria for delirium different from current DSM-III or DSM-IIIR criteria of the American Psychiatric Association, or have used DSM-III or DSM-IIIR criteria without operationalizing the components of these criteria. Therefore this prospective study was conducted to establish an approach to operationalizing DSM-III criteria and to determine the incidence and prevalence of delirium. Two hundred thirty-five consecutive subjects age 70 and over admitted to general medicine underwent daily standardized screening. Patients with low scores on screening tests or clinical evidence suggestive of any psychiatric disorder and controls were seen by a psychiatrist, who determined whether delirium was present by applying explicit operational definitions to each component of the DSM-III criteria for delirium. We conclude that the syndrome of delirium as defined by the American Psychiatric Association is prevalent on admission among elderly on general medical services, but the number of cases developing in the hospital is much less than often stated in the literature.

In recent years, the need for increasing the geriatrics component of residency training has been repeatedly addressed; however, there are still many programs that have been unable to meet this need. While alternative sites, such as geriatric evaluation units and nursing homes, may be the ideal sites to teach some aspects of geriatrics, this article argues that the ambulatory care program, required in all residency programs, is the appropriate setting for teaching many of the core skills needed to care for most older adults. Teaching geriatrics in the ambulatory setting, which eliminates the strategic and financial obstacles of developing non-hospital-based sites, can be accomplished with relatively modest additional resources. This article describes the methods used to integrate geriatrics into the ambulatory care component of one internal medicine residency program and the necessary faculty resources as well as the documentation, via chart audit, of the interns' compliance with recommended practice patterns in five categories. With the exception of vaccination status, interns documented 18% or less of possible pieces of information for their patients. While this assessment showed statistically significant improvement in interns' care of older patients after the program intervention, the overall level of performance was still low, underscoring the need for the integration of geriatrics principles in the ambulatory curriculum.

Ensemble methods provide a principled framework in which to build high performance classifiers and represent many types of data. As a result, these methods can be useful for making inferences about biometric and biological events. We introduce a novel ensemble method for combining multiple representations (or views). The method is a multiple view generalization of AdaBoost. Similar to AdaBoost, base classifiers are independently built from each represetation. Unlike AdaBoost, however, all data types share the same sampling distribution computed from the base classifier having the smallest error rate among input sources. As a result, the most consistent data type dominates over time, thereby significantly reducing sensitivity to noise. The method is applied to the problem of facial and gender prediction based on biometric traits. The new method outperforms several competing techniques including kernel-based data fusion, and is provably better than AdaBoost trained on any single type of data.

Innovative technologies provide the key to making pipeline operations more efficient. Thanks to recent progress in satellite-based remote sensing and image processing, it is now possible to design pipeline monitoring systems with remote sensors and context-oriented image processing software, as has been demonstrated in particular by the three-year ESA funded market development activity “PIPEMON – Geo-information services for pipeline operators: ground motion monitoring and route planning”. Business partners involved in the Project are currently undertaking pre-commercial trials with market players and potential customers, to better introduce and demonstrate Earth Observation (EO) data and services to the pipeline industry.Copyright © 2006 by ASME

In ATR applications, each feature is a convolution of an image with a filter. It is important to use most discriminant features to produce compact representations. We propose two novel subspace methods for dimension reduction to address limitations associated with Fukunaga-Koontz Transform (FKT). The first method, Scatter-FKT, assumes that target is more homogeneous, while clutter can be anything other than target and anywhere. Thus, instead of estimating a clutter covariance matrix, Scatter-FKT computes a clutter scatter matrix that measures the spread of clutter from the target mean. We choose dimensions along which the difference in variation between target and clutter is most pronounced. When the target follows a Gaussian distribution, Scatter-FKT can be viewed as a generalization of FKT. The second method, Optimal Bayesian Subspace, is derived from the optimal Bayesian classifier. It selects dimensions such that the minimum Bayes error rate can be achieved. When both target and clutter follow Gaussian distributions, OBS computes optimal subspace representations. We compare our methods against FKT using character image as well as IR data.

Correlation filters are attractive for automatic target recognition (ATR) applications due to such attributes as shift invariance, distortion tolerance and graceful degradation. Composite correlation filters are designed to handle target distortions by training on a set of images that represent the expected distortions during testing. However, if the distortion can be described algebraically, as in the case of in-plane rotation and scale, then only one training image is necessary. A recently introduced scale-tolerant correlation filter design, called the Minimum Average Correlation Energy Mellin Radial Harmonic (MACE-MRH) filter, exploits this algebraic property and allows the user to specify the scale response of the filter. These filters also minimize the average correlation energy in order to help control the sidelobes in the correlation output and produce sharper, more detectable peaks. In this paper we show that applying non-linearities in the frequency domain (leading to fractional power scale-tolerant correlation filters) can significantly improve the resulting peak sharpness, yielding larger peak-to-correlation energy values for true-class targets at various scales in a scene image. We investigate the effects of fractional power transformations on MACE-MRH filter performance by using a testbed of fifty video sequences consisting of long-wave infrared (LWIR) imagery, in which the observer moves along a flight path toward one or more ground targets of interest. Targets in the test sequences suffer large amounts of scale distortion due to the approach trajectory of the camera. MACE-MRH filter banks are trained on single targets and applied to each sequence on a frame-by-frame basis to perform target detection and recognition. Recognition results from both fractional power MACE-MRH filters and regular MACE-MRH filters are provided, showing the improvement in scale-tolerant recognition from applying fractional power non-linearities to these filters.

Robust real-time recognition of multiple targets with varying pose requires heavy computational loads, which are often too demanding to be performed online at the sensor location. Thus an important problem is the performance of ATR algorithms on highly-compressed video sequences transmitted to a remote facility. We investigate the effects of H.264 video compression on correlation-based recognition algorithms. Our primary test bed is a collection of fifty video sequences consisting of long-wave infrared (LWIR) and mid-wave infrared (MWIR) imagery of ground targets. The targets are viewed from an aerial vehicle approaching the target, which introduces large amounts of scale distortion across a single sequence. Each sequence is stored at seven different levels of compression, including the uncompressed version. We employ two different types of correlation filters to perform frame-by-frame target recognition: optimal tradeoff synthetic discriminant function (OTSDF) filters and a new scale-tolerant filter called fractional power Mellin radial harmonic (FPMRH) filters. In addition, we apply the Fisher metric to compressed target images to evaluate target class separability and to estimate recognition performance as a function of video compression rate. Targets are centered and cropped according to ground truth data prior to separability analysis. We compare our separability estimates with the actual recognition rates achieved by the best correlation filter for each sequence. Numerical results are provided for several target recognition examples.