Empirical redefinition of comprehensive health and well-being in the older adults of the United States
- Proceedings of the National Academy of Sciences of the United States of America
- Published over 3 years ago
The World Health Organization (WHO) defines health as a “state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Despite general acceptance of this comprehensive definition, there has been little rigorous scientific attempt to use it to measure and assess population health. Instead, the dominant model of health is a disease-centered Medical Model (MM), which actively ignores many relevant domains. In contrast to the MM, we approach this issue through a Comprehensive Model (CM) of health consistent with the WHO definition, giving statistically equal consideration to multiple health domains, including medical, physical, psychological, functional, and sensory measures. We apply a data-driven latent class analysis (LCA) to model 54 specific health variables from the National Social Life, Health, and Aging Project (NSHAP), a nationally representative sample of US community-dwelling older adults. We first apply the LCA to the MM, identifying five health classes differentiated primarily by having diabetes and hypertension. The CM identifies a broader range of six health classes, including two “emergent” classes completely obscured by the MM. We find that specific medical diagnoses (cancer and hypertension) and health behaviors (smoking) are far less important than mental health (loneliness), sensory function (hearing), mobility, and bone fractures in defining vulnerable health classes. Although the MM places two-thirds of the US population into “robust health” classes, the CM reveals that one-half belong to less healthy classes, independently associated with higher mortality. This reconceptualization has important implications for medical care delivery, preventive health practices, and resource allocation.
Altruism has long been taken to be the guiding principle of ethical organ donation in the UK, and has been used as justification for rejecting or allowing certain types of donation. We argue that, despite this prominent role, altruism has been poorly defined in policy and position documents, and used confusingly and inconsistently. Looking at how the term has been used over recent years allows us to define ‘organ donation altruism’, and comparing this with accounts in the philosophical literature highlights its theoretical shortcomings. The recent report from the Nuffield Council on Bioethics reaffirmed the importance of altruism in organ donation, and offered a clearer definition. This definition is, however, more permissive than that of altruism previously seen in UK policy, and as a result allows some donations that previously have been considered unacceptable. We argue that while altruistic motivation may be desirable, it is not necessary.
The global burden of cholera is largely unknown because the majority of cases are not reported. The low reporting can be attributed to limited capacity of epidemiological surveillance and laboratories, as well as social, political, and economic disincentives for reporting. We previously estimated 2.8 million cases and 91,000 deaths annually due to cholera in 51 endemic countries. A major limitation in our previous estimate was that the endemic and non-endemic countries were defined based on the countries' reported cholera cases. We overcame the limitation with the use of a spatial modelling technique in defining endemic countries, and accordingly updated the estimates of the global burden of cholera.
Diagnosis of Aortic Graft Infection: A Case Definition by the Management of Aortic Graft Infection Collaboration (MAGIC)
- European journal of vascular and endovascular surgery : the official journal of the European Society for Vascular Surgery
- Published about 3 years ago
The management of aortic graft infection (AGI) is highly complex and in the absence of a universally accepted case definition and evidence-based guidelines, clinical approaches and outcomes vary widely. The objective was to define precise criteria for diagnosing AGI.
The late Campanian-early Maastrichtian site of Lo Hueco (Cuenca, Spain) has provided a set of well-preserved crocodyliform skull and lower jaw remains, which are described here and assigned to a new basal eusuchian taxon, Lohuecosuchus megadontos gen. et sp. nov. The reevaluation of a complete skull from the synchronous site of Fox-Amphoux (Department of Var, France) allows us to define a second species of this new genus. Phylogenetic analysis places Lohuecosuchus in a clade exclusively composed by European Late Cretaceous taxa. This new clade, defined here as Allodaposuchidae, is recognized as the sister group of Hylaeochampsidae, also comprised of European Cretaceous forms. Allodaposuchidae and Hylaeochampsidae are grouped in a clade identified as the sister group of Crocodylia, the only crocodyliform lineage that reaches our days. Allodaposuchidae shows a vicariant distribution pattern in the European Late Cretaceous archipelago, with several Ibero-Armorican forms more closely related to each other than with to Romanian Allodaposuchus precedens.
During the Paris Conference in 2015, nations of the world strengthened the United Nations Framework Convention on Climate Change by agreeing to holding “the increase in the global average temperature to well below 2°C above pre-industrial levels and pursuing efforts to limit the temperature increase to 1.5°C"1. However, "pre-industrial” was not defined. Here we investigate the implications of different choices of the pre-industrial baseline on the likelihood of exceeding these two temperature thresholds. We find that for the strongest mitigation scenario RCP2.6 and a medium scenario RCP4.5 the probability of exceeding the thresholds and timing of exceedance is highly dependent on the pre-industrial baseline, for example the probability of crossing 1.5°C by the end of the century under RCP2.6, varies from 61% to 88% depending on how the baseline is defined. In contrast, in the scenario with no mitigation, RCP8.5, both thresholds will almost certainly be exceeded by the middle of the century with the definition of the pre-industrial baseline of less importance. Allowable carbon emissions for threshold stabilisation are similarly highly dependent on the pre-industrial baseline. For stabilisation at 2°C, allowable emissions decrease by as much as 40% when earlier than 19th century climates are considered as a baseline.
Epigenome-wide association studies represent one means of applying genome-wide assays to identify molecular events that could be associated with human phenotypes. The epigenome is especially intriguing as a target for study, as epigenetic regulatory processes are, by definition, heritable from parent to daughter cells and are found to have transcriptional regulatory properties. As such, the epigenome is an attractive candidate for mediating long-term responses to cellular stimuli, such as environmental effects modifying disease risk. Such epigenomic studies represent a broader category of disease -omics, which suffer from multiple problems in design and execution that severely limit their interpretability. Here we define many of the problems with current epigenomic studies and propose solutions that can be applied to allow this and other disease -omics studies to achieve their potential for generating valuable insights.
Background:Dementia is a life-limiting disease without curative treatments. Patients and families may need palliative care specific to dementia.Aim:To define optimal palliative care in dementia.Methods:Five-round Delphi study. Based on literature, a core group of 12 experts from 6 countries drafted a set of core domains with salient recommendations for each domain. We invited 89 experts from 27 countries to evaluate these in a two-round online survey with feedback. Consensus was determined according to predefined criteria. The fourth round involved decisions by the core team, and the fifth involved input from the European Association for Palliative Care.Results:A total of 64 (72%) experts from 23 countries evaluated a set of 11 domains and 57 recommendations. There was immediate and full consensus on the following eight domains, including the recommendations: person-centred care, communication and shared decision-making; optimal treatment of symptoms and providing comfort (these two identified as central to care and research); setting care goals and advance planning; continuity of care; psychosocial and spiritual support; family care and involvement; education of the health care team; and societal and ethical issues. After revision, full consensus was additionally reached for prognostication and timely recognition of dying. Recommendations on nutrition and dehydration (avoiding overly aggressive, burdensome or futile treatment) and on dementia stages in relation to care goals (applicability of palliative care) achieved moderate consensus.Conclusion:We have provided the first definition of palliative care in dementia based on evidence and consensus, a framework to provide guidance for clinical practice, policy and research.
An operational definition of musculoskeletal decline in older people is needed to allow development of interventions for prevention or treatment, as was developed for the treatment of osteoporosis. Frailty and sarcopenia are linked, but distinct, correlates of musculoskeletal aging that have many causes, including age-related changes in body composition, inflammation, and hormonal imbalance. With the emergence of a number of exciting candidate therapies to retard the loss of muscle mass with aging, the derivation of a consensual definition of sarcopenia and physical frailty becomes an urgent priority. Although several consensual definitions have been proposed, these require clinical validation. An operational definition, which might provide a threshold for treatment/trial inclusion, should incorporate a loss of muscle mass as well as evidence of a decrease in muscle strength and/or physical activity. Evidence is required for a link between improvements in the measures of muscle strength and/or physical activity and clinical outcomes to allow development of interventions to improve clinical outcomes in frail older patients.
Equilibrium climate sensitivity (ECS) remains one of the most important unknowns in climate change science. ECS is defined as the global mean warming that would occur if the atmospheric carbon dioxide (CO2) concentration were instantly doubled and the climate were then brought to equilibrium with that new level of CO2. Despite its rather idealized definition, ECS has continuing relevance for international climate change agreements, which are often framed in terms of stabilization of global warming relative to the pre-industrial climate. However, the ‘likely’ range of ECS as stated by the Intergovernmental Panel on Climate Change (IPCC) has remained at 1.5-4.5 degrees Celsius for more than 25 years. The possibility of a value of ECS towards the upper end of this range reduces the feasibility of avoiding 2 degrees Celsius of global warming, as required by the Paris Agreement. Here we present a new emergent constraint on ECS that yields a central estimate of 2.8 degrees Celsius with 66 per cent confidence limits (equivalent to the IPCC ‘likely’ range) of 2.2-3.4 degrees Celsius. Our approach is to focus on the variability of temperature about long-term historical warming, rather than on the warming trend itself. We use an ensemble of climate models to define an emergent relationship between ECS and a theoretically informed metric of global temperature variability. This metric of variability can also be calculated from observational records of global warming, which enables tighter constraints to be placed on ECS, reducing the probability of ECS being less than 1.5 degrees Celsius to less than 3 per cent, and the probability of ECS exceeding 4.5 degrees Celsius to less than 1 per cent.