Palliative care dentistry

The importance of dental care is often overlooked due to the omission of the dentist as a member of the palliative care team. However, many terminal patients exhibit oral difficulties that affect their quality of life. Palliative care dentists must exhibit empathy and compassion, and must be excellent communicators Dentists can play an important role in alleviating both the physical and psychological pain of dying. This paper describes the role of dentistry in palliative care.     

Depending on care: recognition of vulnerability and the social contribution of care provision

People who are paid to provide basic care for others are frequently undervalued, exploited and expected to reach often unrealistic standards of care. I argue that appropriate social recognition, support and fair pay for people who provide care for those who are disabled, frail and aged, or suffering ill health that impedes their capacity to negotiate daily activities without support, depends on a reconsideration of the paradigm of the citizen or and moral agent. I argue that by drawing on the ideas of human vulnerability and dependency as central to our personhood, a more realistic conception of selves, citizens and persons can be developed that better recognises the inevitability of human dependency and the social value of care work. I also indicate the significance of this vulnerability-focussed view for ethical evaluation of the emotional aspects of care relationships.     

The origin of parental care in relation to male and female life history

The evolution of maternal, paternal, and bi‐parental care has been the focus of a great deal of research. Males and females vary in basic life‐history characteristics (e.g., stage‐specific mortality, maturation) in ways that are unrelated to parental investment. Surprisingly, few studies have examined the effect of this variation in male and female life history on the evolution of care. Here, we use a theoretical approach to determine the sex‐specific life‐history characteristics that give rise to the origin of paternal, maternal, or bi‐parental care from an ancestral state of no care. Females initially invest more into each egg than males. Despite this inherent difference between the sexes, paternal, maternal, and bi‐parental care are equally likely when males and females are otherwise similar. Thus, sex differences in initial zygotic investment do not explain the origin of one pattern of care over another. However, sex differences in adult mortality, egg maturation rate, and juvenile survival affect the pattern of care that will be most likely to evolve. Maternal care is more likely if female adult mortality is high, whereas paternal care is more likely if male adult mortality is high. These findings suggest that basic life‐history differences between the sexes can alone explain the origin of maternal, paternal, and bi‐parental care. As a result, the influence of life‐history characteristics should be considered as a baseline scenario in studies examining the origin of care.     

Sex differences in life history drive evolutionary transitions among maternal,paternal, and bi‐parental care

Evolutionary transitions among maternal, paternal, and bi‐parental care have been common in many animal groups. We use a mathematical model to examine the effect of male and female life‐history characteristics (stage‐specific maturation and mortality) on evolutionary transitions among maternal, paternal, and bi‐parental care. When males and females are relatively similar – that is, when females initially invest relatively little into eggs and both sexes have similar mortality and maturation – transitions among different patterns of care are unlikely to be strongly favored. As males and females become more different, transitions are more likely. If females initially invest heavily into eggs and this reduces their expected future reproductive success, transitions to increased maternal care (paternal → maternal, paternal → bi‐parental, bi‐parental → maternal) are favored. This effect of anisogamy (i.e., the fact that females initially invest more into each individual zygote than males) might help explain the predominance of maternal care in nature and differs from previous work that found no effect of anisogamy on the origin of different sex‐specific patterns of care from an ancestral state of no care. When male mortality is high or male egg maturation rate is low, males have reduced future reproductive potential and transitions to increased paternal care (maternal → paternal, bi‐parental → paternal, maternal → bi‐parental) are favored. Offspring need (i.e., low offspring survival in the absence of care) also plays a role in transitions to paternal care. In general, basic life‐history differences between the sexes can drive evolutionary transitions among different sex‐specific patterns of care. The finding that simple life‐history differences can alone lead to transitions among maternal and paternal care suggests that the effect of inter‐sexual life‐history differences should be considered as a baseline scenario when attempting to understand how other factors (mate availability, sex differences in the costs of competing for mates) influence the evolution of parental care.     

Collaborative Care for Depression in Primary Care: How Psychiatry Could “Troubleshoot” Current Treatments and Practices

The bulk of mental health services for people with depression are provided in primary care settings. Primary care providers prescribe 79 percent of antidepressant medications and see 60 percent of people being treated for depression in the United States, and they do that with little support from specialist services. Depression is not effectively managed in the primary care setting. Collaborative care based on a team approach, a population health perspective, and measurement-based care has been proven to treat depression more effectively than care as usual in a variety of settings and for different populations, and it increases people’s access to medications and behavioral therapies. Psychiatry has the responsibility of supporting the primary care sector in delivering mental health services by disseminating collaborative care approaches under recent initiatives and opportunities made possible by the Affordable Care Act (ACA).     

Variation in the parental care systems of mammals and the impact on zoo breeding programs

The identity of mammalian caregivers, the types of care each may provide to young, and the developmental, ecological, and social factors that influence the amount and distribution of care are discussed. Care is distinguished from use and abuse in terms of the impact on the survival of young. Some effects of the failure to allow for adequate maternal care are described, and various management strategies to promote adequate and appropriate care behaviors are identified. © 1994 Wiley-Liss, Inc.     

北京某三级甲等医院ICU 患者家属满意度调查研究

目的:了解ICU患者家属对现有医疗护理服务质量的满意程度,为今后医疗护理服务质量的改善提供科学的依据。方法:采用Wasser的"危重患者家属满意度量表"中文版对符合入选标准的危重患者家属进行问卷调查。运用SPSS17.0进行统计分析。结果:共145名ICU患者家属完成问卷,其中男性83名,女性62名。危重患者家属满意度量表总得分很高(91±9),五个因子得分从高到低依次是舒适(5±0.50)、病情保证(4.75±0.625)、获得支持(4.67±0.50)、获取信息(4.40±0.60)和接近患者(4.33±0.67);其中满意度最高的一项"护士护理病人的质量情况",满意率高达100%;满意度最低的一项是"探视时间的弹性"。结论:ICU患者家属对现有医疗护理服务质量具有较高的满意度;更好的提高ICU患者家属满意度,改善医疗护理质量,需加强医务人员与家属的沟通,增进医护间的合作。     

Depression remission after six months of collaborative care management: role of initial severity of depression in outcome

Aim The impact of initial severity of depression on the rate of remission has not been well studied. The hypothesis for this study was that increased depression severity would have an inverse relationship on clinical remission at six months while in collaborative care management.Participants The study cohort was 1128 primary care patients from a south-eastern Minnesota practice and was a longitudinal retrospective chart review analysis.Results Clinical remission at six months was less likely in the severe depression group at 29.6% compared with 36.9% in the moderately severe group and 45.6% in the moderate depression group (P < 0.001). Multivariate analysis of a sub-group demonstrated that increased initial anxiety symptoms (odds ratio [OR] 0.9645, 95% confidence interval [CI] 0.9345–0.9954, P = 0.0248) and an abnormal screening for bipolar disorder (OR 0.4856, 95% CI 0.2659–0.8868, P = 0.0187) predicted not achieving remission at six months. A patient with severe depression was significantly less likely to achieve remission at six months (OR 0.6040, 95% CI 0.3803–0.9592, P = 0.0327) compared with moderate depression, but not moderately severe depression (P = 0.2324). There was no statistical difference in the adjusted means of the PHQ-9 score for those patients who were in remission at six months. However, in the unremitted patients, the six-month PHQ-9 score was significantly increased by initial depression severity when controlling for all other variables.Conclusion Multivariate analysis in our study demonstrated that patients with severe depression have a decreased OR for remission at six months compared with moderate depression. Also, there was a significant increase in the six-month PHQ-9 score for those unremitted patients in the severe vs. moderate depression groups.     

Utilisation of dental services in a university hospital palliative and long-term care unit in Geneva

Objectives: Dental care plays an important role in the multidisciplinary approach, which is used in palliative and long‐term care to address the complex needs of terminally ill patients. The aim of this study was to assess the utilisation of dental services in a University Hospital Palliative and Long‐term Care Unit. Material and method: Over an observation period of 13 months, structured questionnaires were filled in after each dental appointment. The survey covered three main topics: the initiation and incentive from the dental consultation, particular difficulties because of the patient’s health or the hospital’s organisation as well as the accomplished treatment. Results: Two hundred and seventy‐five questionnaires from a total of 102 patients were available for analysis. The patients’ median age was 83 years (SD 10.3, range 49–101 years), 63 were female, 39 male. A majority of first appointments were initiated by a physician (n = 49 of 102), mainly because of pain (n = 62 of 275). 10.5% of the appointments were cancelled on the same day. Only one‐fifth of the patients were able to reach the practice on foot. Six used a walking stick and 54 relied on a wheelchair. Eighteen patients needed to be seen in their bed. The most frequently performed procedures were extractions and removal of denture sore spots (n = 67 of 275) followed by the manufacturing of new dentures (n = 38 of 275). In more than 17% of the appointments, no particular treatment was performed. Conclusion: The utilisation of dental services in terminally ill and severely compromised elderly patients shown justifies a dental service in a palliative care or geriatric hospital setting. The particular dental work profile requires a practitioner with empathy and professional experience.     

英国健康服务整合进展及对中国的启示

通过万方、知网、PUMED和谷歌学术搜索,查阅获取近年来有关英国健康服务整合的文献和政策文件,分析了健康服务整合的内涵,归纳总结了英国健康服务整合实践的政策历程,目前的整合实践模式,并归纳分析了英国健康服务整合的应对策略,最后结合中国实际,提出对健康和社会保健相关职能部门进行整合,对中央和地方的责权利进行合理划分,从而落实健康服务的整合供给,通过信息化和多媒体,建立以患者为中心的健康保健提供的激励约束机制,建立现代化的健康和社会保健服务的人才保障机制。     

Obesity and the Use of Health Care Services

Objective: This study investigated differences in the use of health care services and associated costs between obese and nonobese patients. Research Methods and Procedures: New adult patients (N = 509) were randomly assigned to primary care physicians at a university medical center. Their use of medical services and related charges was monitored for 1 year. Data collected included sociodemographics, self‐reported health status using the Medical Outcomes Study Short Form‐36, evaluation for depression using the Beck Depression Index, and measured height and weight to calculate BMI. Results: Obese patients included a significantly higher percentage of women and had higher mean age, lower mean education, lower mean health status, and higher mean Beck Depression Index scores. Obese patients had a significantly higher mean number of visits to both primary care (p = 0.0005) and specialty care clinics (p = 0.0006), and a higher mean number of diagnostic services (p < 0.0001). Obese patients also had significantly higher primary care (p = 0.0058), specialty clinic (p = 0.0062), emergency department (p = 0.0484), hospitalization (p = 0.0485), diagnostic services (p = 0.0021), and total charges (p = 0.0033). Controlling for health status, depression, age, education, income, and sex, obesity was significantly related to the use of primary care (p = 0.0364) and diagnostic services (p = 0.0075). There was no statistically significant relationship between obesity and medical expenditures in any of the five categories or for total charges. Discussion: Obesity is a chronic condition requiring long‐term management, with an emphasis on prevention. If this critical health issue is not appropriately addressed, the prevalence of obesity and obesity‐related diseases will continue to grow, resulting in escalating use of health care services.     

Eficiencia del apoyo de Geriatría Transversal en el manejo de pacientes mayores de 80 años ingresados en el Servicio de Cirugía General. Resultados en la liberación de estancias y el coste asociado

ObjectiveTo determine the efficiency of «Cross-speciality Geriatrics» program in patients older than 80 years admitted to the Colorectal Pathology Unit of a General Surgery Department.Material and methodsA «before-after» study was conducted. The initial period (usual treatment for General Surgery) included patients admitted from 1^st January to 31^st August 2018, and the subsequent period (with support from geriatrics) from 1^st January to 31^st December 2019. Two types of patients were studied: Type 1, who were admitted to the Emergency Department, and Type 2, programmed admissions for colorectal cancer intervention. The Geriatrics intervention consisted of daily monitoring in the ward, collaboration in clinical management, and discharge planning. Furthermore, in Type 2 patients, a previous visit was made in the clinic, which included the detection and approach of frailty and pre-habilitation for surgery.ResultsA total of 175 patients were included, of whom 53 were treated by General Surgery and 122 with the co-management of geriatrics. The mean age was 84.9 years (SD 4.8). In the period with the Cross-speciality Geriatrics program, the mean stay was reduced by 10.6 days (39%), and 8.5 days (44%) in types 1 and 2, respectively (P < .01). This led to a decrease in bed occupancy (3.3 beds/day) and a cost reduction (1,215,970 € / year).ConclusionsThe support of Cross-speciality Geriatrics in patients older than 80 years admitted to General Surgery is an efficient care model. These data support its implementation in hospitals where this care line has not yet been developed     

When should cuckolded males care for extra-pair offspring?

In socially monogamous species with bi-parental care, males suffer reduced reproductive success if their mate engages in extra-pair copulations (EPCs). One might therefore expect that males should refuse to care for a brood if they can detect that an EPC has occurred. Here, we use a game-theory model to study male brood care in the face of EPCs in a cooperatively breeding species in which offspring help to raise their (half-) siblings in their parents' next breeding attempt. We show that under certain conditions males are selected to care even for broods completely unrelated to themselves. This counterintuitive result arises through a form of pseudo-reciprocity, whereby surviving extra-pair offspring, when helping to rear their younger half-siblings, can more than compensate for the cost incurred by the male that raised them. We argue that similar effects may not be limited to cooperative breeders, but may arise in various contexts in which cooperation between (half-) siblings occurs.     

Patient's weight 6 months after depression treatment is not affected by either clinical remission or enrolment in collaborative care management

Objective The primary aim of this study was to determine whether enrolment in collaborative care management (CCM) for treatment of major depression would have a significant impact on 6-month changes in weight compared with patients treated by their primary care provider with usual care. The secondary aim was to determine whether clinical remission would also affect 6-month weight changes.Design A retrospective chart review study included 1550 patients who had been diagnosed with major depression or dysthymia and who had a Patient Health Questionnaire (PHQ-9) score of ≥ 10 with follow-up data (PHQ-9 score and weight) at 6 months.Subjects The study sample consisted of adult patients (aged ≥ 18 years) from primary care practices, representing all body mass index (BMI) categories. The exclusion criteria were a diagnosis of bipolar disorder, recent obstetric delivery or recent gastric bypass procedure.Measurements Weight was measured at index and 6 months, with BMI calculated from electronic medical record data. Patient assessment data (including PHQ-9 score and clinical diagnosis) and demographic variables (age, gender, marital status and clinical location) were also collected.Results With regression modelling, neither enrolment in CCM (P = 0.306) nor clinical remission (P = 0.828) was associated with a significant weight gain.Conclusion After 6 months, enrolment in CCM had no significant impact on weight gain or weight loss among patients treated for depression, nor was improvement to clinical remission a factor in the patient''s weight after 6 months. Incorporating a weight loss management intervention within the model may be warranted if concomitant weight reduction is desired.     

Adult male replacement and subsequent infant care by male and siblings in socially monogamous owl monkeys (<Emphasis Type="Italic">Aotus azarai</Emphasis>)

Owl monkeys (Aotus azarai) are small, territorial, socially monogamous primates that show intense infant care by the adult male in the group. It has been hypothesized that male care may be adaptive because it increases offspring survival and/or reduces the metabolic costs to the female of raising the offspring. Alternatively, males may provide care even when they are not related to the infants to increase future reproductive opportunities. We describe changes in infant care patterns that took place after the eviction of the resident male by a solitary male in an owl monkey population in the Argentinean Chaco. The resident male and mother provided all infant care during the first month of life of the infant, until the male was evicted. During the three-day male replacement event, care of the infant was shared among the mother, a four-year-old sister, and a one-year-old brother. The new male began contributing to infant care soon after entering the group, carrying, and interacting socially with the infant in much the same way as any male regularly does. However, despite receiving biparental care from both the original and new resident males, the infant disappeared at the age of four months and was presumed dead. These are the first reports of care by sibling and by non-putative fathers in wild owl monkeys. Given the significant amount of time that new pairs of owl monkeys spend before reproducing, it is possible that male care in owl monkeys functions as mating effort as much as or more than parenting effort.