Should I stay or should I go – Factors associated with hospitalization risk among older persons in Sweden

An increasingly older population will most likely lead to greater demands on the health care system, as older age is associated with an increased risk of having acute and chronic conditions. The number of diseases or disabilities is not the only marker of the amount of health care utilized, as persons may seek hospitalization without a disease and/or illness that requires hospital healthcare. Hospitalization may pose a severe risk to older persons, as exposure to the hospital environment may lead to increased risks of iatrogenic disorders, confusion, falls and nosocomial infections, i.e., disorders that may involve unnecessary suffering and lead to serious consequences. Aims: The overall aim of this thesis was to describe and explore individual trajectories of cognitive development in relation to hospitalization and risk factors for hospitalization among older persons living in different accommodations in Sweden and to explore older persons' reasons for being transferred to a hospital. Methods: The study designs were longitudinal, prospective and descriptive, and both quantitative and qualitative methods were used. Specifically, latent growth curve modelling was used to assess the association of cognitive development with hospitalization. The Cox proportional hazards regression model was used to analyse factors associated with hospitalization risk overtime. In addition, an explorative descriptive design was used to explore how home health care patients experienced and perceived their decision to seek hospital care. Results: The most common reasons for hospitalization were cardiovascular diseases, which caused more than one-quarter of first hospitalizations among the persons living in ordinary housing and nursing home residents (NHRs). The persons who had been hospitalized had a lower mean level of cognitive performance in general cognition, verbal, spatial/fluid, memory and processing speed abilities compared to those who had not been hospitalized. Significantly steeper declines in general cognition, spatial/fluid and processing speed abilities were observed among the persons who had been hospitalized. Cox proportional hazards regression analysis showed that the number of diseases, number of drugs used, having experienced a fall and being assessed as malnourished according to the Mini Nutritional Assessment scale were related to an increased hospitalization risk among the NHRs. Among the older persons living in ordinary housing, the risk factors for hospitalization were related to marital status, i.e., unmarried persons and widows/widowers had a decreased hospitalization risk. In addition, among social factors, receipt of support from relatives was related to an increased hospitalization risk, while receipt of support from friends was related to a decreased risk. The number of illnesses was not associated with the hospitalization risk for older persons in any age group or for those of either sex, when controlling for other variables. The older persons who received home health care described different reasons for their decisions to seek hospital care. The underlying theme of the home health care patients’ perceptions of their transfer to a hospital involved trust in hospitals. This trust was shared by the home health care patients, their relatives and the home health care staff, according to the patients. Conclusions: This thesis revealed that middle-aged and older persons who had been hospitalized exhibited a steeper decline in cognition. Specifically, spatial/fluid, processing speed, and general cognitive abilities were affected. The steeper decline in cognition among those who had been hospitalized remained even after controlling for comorbidities. The most common causes of hospitalization among the older persons living in ordinary housing and in nursing homes were cardiovascular diseases, tumours and falls. Not only health-related factors, such as the number of diseases, number of drugs used, and being assessed as malnourished, but also social factors and marital status were related to the hospitalization risk among the older persons living in ordinary housing and in nursing homes. Some risk factors associated with hospitalization differed not only between the men and women but also among the different age groups. The information provided in this thesis could be applied in care settings by professionals who interact with older persons before they decide to seek hospital care. To meet the needs of an older population, health care systems need to offer the proper health care at the most appropriate level, and they need to increase integration and coordination among health care delivered by different care services.

Cancer and fertility preservation: International recommendations from an expert meeting

In the last years, thanks to the improvement in the prognosis of cancer patients, a growing attention has been given to the fertility issues. International guidelines on fertility preservation in cancer patients recommend that physicians discuss, as early as possible, with all patients of reproductive age their risk of infertility from the disease and/or treatment and their interest in having children after cancer, and help with informed fertility preservation decisions. As recommended by the American Society of Clinical Oncology and the European Society for Medical Oncology, sperm cryopreservation and embryo/oocyte cryopreservation are standard strategies for fertility preservations in male and female patients, respectively; other strategies (e.g. pharmacological protection of the gonads and gonadal tissue cryopreservation) are considered experimental techniques. However, since then, new data have become available, and several issues in this field are still controversial and should be addressed by both patients and their treating physicians. In April 2015, physicians with expertise in the field of fertility preservation in cancer patients from several European countries were invited in Genova (Italy) to participate in a workshop on the topic of "cancer and fertility preservation". A total of ten controversial issues were discussed at the conference. Experts were asked to present an up-to-date review of the literature published on these topics and the presentation of own unpublished data was encouraged. On the basis of the data presented, as well as the expertise of the invited speakers, a total of ten recommendations were discussed and prepared with the aim to help physicians in counseling their young patients interested in fertility preservation. Although there is a great interest in this field, due to the lack of large prospective cohort studies and randomized trials on these topics, the level of evidence is not higher than 3 for most of the recommendations highlighting the need of further research efforts in many areas of this field. The participation to the ongoing registries and prospective studies is crucial to acquire more robust information in order to provide evidence-based recommendations.

The past, present and projected scenarios in the Lake Albert and Albert Nile fisheries: implications for sustainable management

Lake Albert is one of the largest lakes in Uganda that still supports a multi-species fishery which as a result of variable adult sizes of the species, causes management challenges especially in relation to gear mesh size enforcement. Prior to the 1980s, commercial species were 17 large sized fishes especially Citharinus citharinus, Distichodus niloticus and Lates spp. that were confimed to inshore habitats of the lake and were thus rapidly over fished. Frame and catch assessment surveys conducted in this study revealed a >80% dominance of small size fish species (Neobola bredoi and Brycinus nurse) and a 40 -60% decrease in the contribution of the large commercial species. Sustainability of small size fish species is uncertain due to seasonal fluctuations and low beach value. At about 150,000 tons of fish recorded from Lake Albert and Albert Nile, the beach value was estimated at 55.3 million USD. Despite the noted decline in catches of the large sized fishes their contribution was more than 50% of total beach value. Therefore, management measures should couple value addition for the small sized species and maintain effort regulation targeting recovery of the large previously important commercial species.

Study of feeding competition between invasion ctenophore (M. leidyi) and anchovy (C. engrauliformis) in the Southern Caspian Sea (Mazandran Coast)

Mnemiopsis leidyi one species of phylum Ctenophora, is a native species in America. It has most likely moved across the Atlantic in the ballast water of cargo ships to the Black sea in 1982, and then to the Caspian Sea thought the Volga-Don Channel, in Nov 1999. The population of M. leidyi rows rapidly and by end of 2000, the entire sea was teeming with them. This survey was arranged In order to study the relationship between the invasion of M. leidyi and sharp decline in main stocks pelagic fish such as Kilka. Dietary analysis was conducted on Anchovy Killka (Clupeonella engrauliformis) and M. leidyi from August 2001 to October 2002 in two stations, located at the costal water near Babolsar (52.38° E ,36.42° N ) and Noshahar (51.33° E,36.39° N) in the Caspian Sea province of Mazandaran, Iran. M. leidyi was caught by plankton net, at three vertical strata of both station at surface 5 in, 10m, and 15 m the Kilka was caught by fisheries boat at Babolasar fishery harbour. Samples of M. leidyi were not fixed in its common fixative, we used 96% Ethanol In order to study of M. leidyi digestion system some alive samples, directly, were studied by the fluorescence microscope which was connected to a computer prepared specially for this process. In many cases, the light was directly reflected on the sample and microscopic image was prepared in dark background. We found that there were some common organisms in diet of both species. The Schoener index analysis reflected these similarities, as values more than critical level of overlap (>89 in Babolsar samples and >84 in Noshahar samples) were found. Results from this study suggests that M. leidyi and Anchovy have a similar feeding niche and computation between them is one of the reasons to decline in anchovy stocks. Economical effects of M. leidyi s invasion in research area were studied by data on kilka caught before and after introducing M. leidyi.

Status of the beach management units development in Uganda

Fisheries plays a significant and important part in the economy of the country contributing to foreign exchange, food security and employment creation. Lake Victoria contributes over 50% of the total annual fish catch. The purpose of fisheries management is to ensure conservation, protection, proper use, economic efficiency and equitable distribution of the fisheries resources both for the present and future generations through sustainable utilization. The earliest fisheries were mainly at the subsistence level. Fishing gear consisted of locally made basket traps, hooks and seine nets of papyrus. Fishing effort begun to increase with the introduction of more efficient flax gillnets in 1905. Fisheries management in Uganda started in 1914. Before then, the fishery was under some form of traditional management based on the do and don'ts. History shows that the Baganda had strong spiritual beliefs in respect of "god Mukasa" (god of the Lake) and these indirectly contributed to sustainable management of the lake. If a fisherman neglected to comply witt'l any of the ceremonies related to fishing he was expected to encounter a bad omen (Rev. Roscoe, 1965) However, with the introduction of the nylon gill nets, which could catch more fish, traditional management regime broke down. By 1955 the indigenous fish species like Oreochromis variabilis and Oreochromis esculentus had greatly declined in catches. Decline in catches led to introduction of poor fishing methods because of competition for fish. Government in an attempt to regulate the fishing irldustry enacted the first Fisheries Ordinance in 1951 and recruited Fisheries Officers to enforce them. The government put in place minimum net mesh-sizes and Fisheries Officers arrested fishermen without explaining the reason. This led to continued poor fishing practices. The development of government centred management systems led to increased alienation of resource users and to wilful disregard of specific regulations. The realisation of the problems faced by the central management system led to the recognition that user groups need to be actively involved in fisheries management if the systems are to be consistent with sustainable fisheries and be legitimate. Community participation in fisheries management under the Comanagement approach has been adopted in Lake Victoria including other water bodies.

Dynamics of a large submersed plant bed in upper Chesapeake Bay

A large SAV bed in upper Chesapeake Bay has experienced several abrupt shifts over the past half-century, beginning with near-complete loss after a record-breaking flood in 1972, followed by an unexpected, rapid resurgence in the early 2000’s, then partial decline in 2011 following another major flood event. Together, these trends and events provide a unique opportunity to study a recovering SAV ecosystem from several different perspectives. First, I analyzed and synthesized existing time series datasets to make inferences about what factors prompted the recovery. Next, I analyzed existing datasets, together with field samples and a simple hydrodynamic model to investigate mechanisms of SAV bed loss and resilience to storm events. Finally, I conducted field deployments and experiments to explore how the bed affects internal physical and biogeochemical processes and what implications those effects have for the dynamics of the system. I found that modest reductions in nutrient loading, coupled with several consecutive dry years likely facilitated the SAV resurgence. Furthermore, positive feedback processes may have played a role in the sudden nature of the recovery because they could have reinforced the state of the bed before and after the abrupt shift. I also found that scour and poor water clarity associated with sediment deposition during the 2011 flood event were mechanisms of plant loss. However, interactions between the bed, water flow, and waves served as mechanisms of resilience because these processes created favorable growing conditions (i.e., clear water, low flow velocities) in the inner core of the bed. Finally, I found that that interactions between physical and biogeochemical processes led to low nutrient concentrations inside the bed relative to outside the bed, which created conditions that precluded algal growth and reinforced vascular plant dominance. This work demonstrates that positive feedbacks play a central role in SAV resilience to both chronic eutrophication as well as acute storm events. Furthermore, I show that analysis of long-term ecological monitoring data, together with field measurements and experiments, can be an effective approach for understanding the mechanisms underlying ecosystem dynamics.

Ecological drivers of a vector borne pathogen: distribution and abundance of Borrelia burgdorferi sensu lato and its vector Ixodes ricinus in Scotland

Vector-borne disease emergence in recent decades has been associated with different environmental drivers including changes in habitat, hosts and climate. Lyme borreliosis is among the most important vector-borne diseases in the Northern hemisphere and is an emerging disease in Scotland. Transmitted by Ixodid tick vectors between large numbers of wild vertebrate host species, Lyme borreliosis is caused by bacteria from the Borrelia burgdorferi sensu lato species group. Ecological studies can inform how environmental factors such as host abundance and community composition, habitat and landscape heterogeneity contribute to spatial and temporal variation in risk from B. burgdorferi s.l. In this thesis a range of approaches were used to investigate the effects of vertebrate host communities and individual host species as drivers of B. burgdorferi s.l. dynamics and its tick vector Ixodes ricinus. Host species differ in reservoir competence for B. burgdorferi s.l. and as hosts for ticks. Deer are incompetent transmission hosts for B. burgdorferi s.l. but are significant hosts of all life-stages of I. ricinus. Rodents and birds are important transmission hosts of B. burgdorferi s.l. and common hosts of immature life-stages of I. ricinus. In this thesis, surveys of woodland sites revealed variable effects of deer density on B. burgdorferi prevalence, from no effect (Chapter 2) to a possible ‘dilution’ effect resulting in lower prevalence at higher deer densities (Chapter 3). An invasive species in Scotland, the grey squirrel (Sciurus carolinensis), was found to host diverse genotypes of B. burgdorferi s.l. and may act as a spill-over host for strains maintained by native host species (Chapter 4). Habitat fragmentation may alter the dynamics of B. burgdorferi s.l. via effects on the host community and host movements. In this thesis, there was lack of persistence of the rodent associated genospecies of B. burgdorferi s.l. within a naturally fragmented landscape (Chapter 3). Rodent host biology, particularly population cycles and dispersal ability are likely to affect pathogen persistence and recolonization in fragmented habitats. Heterogeneity in disease dynamics can occur spatially and temporally due to differences in the host community, habitat and climatic factors. Higher numbers of I. ricinus nymphs, and a higher probability of detecting a nymph infected with B. burgdorferi s.l., were found in areas with warmer climates estimated by growing degree days (Chapter 2). The ground vegetation type associated with the highest number of I. ricinus nymphs varied between studies in this thesis (Chapter 2 & 3) and does not appear to be a reliable predictor across large areas. B. burgdorferi s.l. prevalence and genospecies composition was highly variable for the same sites sampled in subsequent years (Chapter 2). This suggests that dynamic variables such as reservoir host densities and deer should be measured as well as more static habitat and climatic factors to understand the drivers of B. burgdorferi s.l. infection in ticks. Heterogeneity in parasite loads amongst hosts is a common finding which has implications for disease ecology and management. Using a 17-year data set for tick infestations in a wild bird community in Scotland, different effects of age and sex on tick burdens were found among four species of passerine bird (Chapter 5). There were also different rates of decline in tick burdens among bird species in response to a long term decrease in questing tick pressure over the study. Species specific patterns may be driven by differences in behaviour and immunity and highlight the importance of comparative approaches. Combining whole genome sequencing (WGS) and population genetics approaches offers a novel approach to identify ecological drivers of pathogen populations. An initial analysis of WGS from B. burgdorferi s.s. isolates sampled 16 years apart suggests that there is a signal of measurable evolution (Chapter 6). This suggests demographic analyses may be applied to understand ecological and evolutionary processes of these bacteria. This work shows how host communities, habitat and climatic factors can affect the local transmission dynamics of B. burgdorferi s.l. and the potential risk of infection to humans. Spatial and temporal heterogeneity in pathogen dynamics poses challenges for the prediction of risk. New tools such as WGS of the pathogen (Chapter 6) and blood meal analysis techniques will add power to future studies on the ecology and evolution of B. burgdorferi s.l.

CAST OFF: MARITIME LABOR IN AMERICA FROM 1935 TO 1955

Many studies have observed the precipitous decline in American shipping following the Second World War. Most focus on changes in maritime policy and the upsurge of flags of convenience. Yet this interpretation relegates mariners to a footnote. This thesis argues that America abandoned its seamen years before it abandoned its merchant marine, and that the labor story is an integral and largely overlooked dimension of the industry’s broader decline. It explores how the status and makeup of American seamen underwent monumental shifts from 1935 to 1955. Increased nationalization, improved conditions, and a patriotic cause boosted the standing of the industry, but federal and union intervention also changed the composition of the workforce and even eroded seamen’s status. These greater controls on mariners negatively affected the industry and this work contends that labor played a role in the transformation, and even decline, of the overall American Merchant Marine.

Rangeland profitability in the northern Gulf region of Queensland: understanding beef business complexity and the subsequent impact on land resource management and environmental outcomes

The farm-gate value of extensive beef production from the northern Gulf region of Queensland, Australia, is ~$150 million annually. Poor profitability and declining equity are common issues for most beef businesses in the region. The beef industry relies primarily on native pasture systems and studies continue to report a decline in the condition and productivity of important land types in the region. Governments and Natural Resource Management groups are investing significant resources to restore landscape health and productivity. Fundamental community expectations also include broader environmental outcomes such as reducing beef industry greenhouse gas emissions. Whole-of-business analysis results are presented from 18 extensive beef businesses (producers) to highlight the complex social and economic drivers of management decisions that impact on the natural resource and environment. Business analysis activities also focussed on improving enterprise performance. Profitability, herd performance and greenhouse emission benchmarks are documented and discussed.

Carbon losses in terrestrial hydrological pathways in sugarcane cropping systems of Australia

Climate change and carbon (C) sequestration are a major focus of research in the twenty-first century. Globally, soils store about 300 times the amount of C that is released per annum through the burning of fossil fuels (Schulze and Freibauer 2005). Land clearing and introduction of agricultural systems have led to rapid declines in soil C reserves. The recent introduction of conservation agricultural practices has not led to a reversing of the decline in soil C content, although it has minimized the rate of decline (Baker et al. 2007; Hulugalle and Scott 2008). Lal (2003) estimated the quantum of C pools in the atmosphere, terrestrial ecosystems, and oceans and reported a “missing C” component in the world C budget. Though not proven yet, this could be linked to C losses through runoff and soil erosion (Lal 2005) and a lack of C accounting in inland water bodies (Cole et al. 2007). Land management practices to minimize the microbial respiration and soil organic C (SOC) decline such as minimum tillage or no tillage were extensively studied in the past, and the soil erosion and runoff studies monitoring those management systems focused on other nutrients such as nitrogen (N) and phosphorus (P).

Indirect child mortality estimation technique to identify trends of under-five mortality in Ethiopia.

Background: In sub-Saharan African countries, the chance of a child dying before the age of five years is high. The problem is similar in Ethiopia, but it shows a decrease over years. Methods: The 2000; 2005 and 2011 Ethiopian Demographic and Health Survey results were used for this work. The purpose of the study is to detect the pattern of under-five child mortality overtime. Indirect child mortality estimation technique is adapted to examine the under-five child mortality trend in Ethiopia. Results: From the result, it was possible to see the trend of under-five child mortality in Ethiopia. The under-five child mortality shows a decline in Ethiopia. Conclusion: From the study, it can be seen that there is a positive correlation between mother and child survival which is almost certain in any population. Therefore, this study shows the trend of under-five mortality in Ethiopia and decline over time.

A systematic review of trends and patterns of congenital heart disease in children in Nigeria from 1964-2015.

Background: Congenital heart diseases cause significant childhood morbidity and mortality. Several restricted studies have been conducted on the epidemiology in Nigeria. No truly nationwide data on patterns of congenital heart disease exists. Objectives: To determine the patterns of congenital heart disease in children in Nigeria and examine trends in the occurrence of individual defects across 5 decades. Method: We searched PubMed database, Google scholar, TRIP database, World Health Organisation libraries and reference lists of selected articles for studies on patterns of congenital heart disease among children in Nigeria between 1964 and 2015. Two researchers reviewed the papers independently and extracted the data. Seventeen studies were selected that included 2,953 children with congenital heart disease. Results: The commonest congenital heart diseases in Nigeria are ventricular septal defect (40.6%), patent ductus arteriosus (18.4%), atrial septal defect (11.3%) and tetralogy of Fallot (11.8%). There has been a 6% increase in the burden of VSD in every decade for the 5 decades studied and a decline in the occurrence of pulmonary stenosis. Studies conducted in Northern Nigeria demonstrated higher proportions of atrial septal defects than patent ductus arteriosus. Conclusions: Ventricular septal defects are the commonest congenital heart diseases in Nigeria with a rising burden.

EFFECTS OF AGING ON MIDBRAIN AND CORTICAL SPEECH-IN-NOISE PROCESSING

Older adults frequently report that they can hear what they have been told but cannot understand the meaning. This is particularly true in noisy conditions, where the additional challenge of suppressing irrelevant noise (i.e. a competing talker) adds another layer of difficulty to their speech understanding. Hearing aids improve speech perception in quiet, but their success in noisy environments has been modest, suggesting that peripheral hearing loss may not be the only factor in the older adult’s perceptual difficulties. Recent animal studies have shown that auditory synapses and cells undergo significant age-related changes that could impact the integrity of temporal processing in the central auditory system. Psychoacoustic studies carried out in humans have also shown that hearing loss can explain the decline in older adults’ performance in quiet compared to younger adults, but these psychoacoustic measurements are not accurate in describing auditory deficits in noisy conditions. These results would suggest that temporal auditory processing deficits could play an important role in explaining the reduced ability of older adults to process speech in noisy environments. The goals of this dissertation were to understand how age affects neural auditory mechanisms and at which level in the auditory system these changes are particularly relevant for explaining speech-in-noise problems. Specifically, we used non-invasive neuroimaging techniques to tap into the midbrain and the cortex in order to analyze how auditory stimuli are processed in younger (our standard) and older adults. We will also attempt to investigate a possible interaction between processing carried out in the midbrain and cortex.

Factors affecting vaccine handling and storage practices among immunization service providers in Ibadan, Oyo State, Nigeria.

Background: Improper handling has been identified as one of the major reasons for the decline in vaccine potency at the time of administration. Loss of potency becomes evident when immunised individuals contract the diseases the vaccines were meant to prevent. Objective: Assessing the factors associated with vaccine handling and storage practices. Methods: This was a cross-sectional study. Three-stage sampling was used to recruit 380 vaccine handlers from 273 health facilities from 11 Local Government areas in Ibadan. Data was analysed using SPSS version 16 Results: Seventy-three percent were aware of vaccine handling and storage guidelines with 68.4% having ever read such guidelines. Only 15.3% read a guideline less than 1 month prior to the study. About 65.0% had received training on vaccine management. Incorrect handling practices reported included storing injections with vaccines (13.7%) and maintaining vaccine temperature using ice blocks (7.6%). About 43.0% had good knowledge of vaccine management, while 66.1% had good vaccine management practices. Respondents who had good knowledge of vaccine handling and storage [OR=10.0, 95%CI (5.28 – 18.94), p < 0.001] and had received formal training on vaccine management [OR=5.3, 95%CI (2.50 – 11.14), p< 0.001] were more likely to have good vaccine handling and storage practices. Conclusion: Regular training is recommended to enhance vaccine handling and storage practices.

Ontogeny and nutritional programming of the hepatic growth hormone-insulin-like growth factor-prolactin axis in the sheep

The liver is an important metabolic and endocrine organ in the fetus but the extent to which its hormone receptor (R) sensitivity is developmentally regulated in early life is not fully established. We, therefore, examined developmental changes in mRNA abundance for the growth hormone (GH) and prolactin (PRL) receptors (R) plus insulin-like growth factor (IGF)-I and –II and their receptors. Fetal and postnatal sheep were sampled at either 80, or 140 days gestation, 1, 30 days or six months of age. The effect of maternal nutrient restriction between early to mid (i.e. 28 to 80 days gestation, the time of early liver growth) gestation on gene expression was also examined in the fetus and juvenile offspring. Gene expression for the GHR, PRLR and IGF-IR increased through gestation peaking at birth, whereas IGF-I was maximal near to term. In contrast, IGF-II mRNA decreased between mid and late gestation to increase after birth whereas IGF-IIR remained unchanged. A substantial decline in mRNA abundance for GHR, PRLR and IGF-IR then occurred up to six months. Maternal nutrient restriction reduced GHR and IGF-IIR mRNA abundance in the fetus, but caused a precocious increase in the PRLR. Gene expression for IGF-I and –II were increased in juvenile offspring born to nutrient restricted mothers. In conclusion, there are marked differences in the developmental ontogeny and nutritional programming of specific hormones and their receptors involved in hepatic growth and development in the fetus. These could contribute to changes in liver function during adult life.