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To investigate resident-level, provider-type, nursing home (NH), and regional factors associated with feeding tube (FT) placement in advanced dementia. Retrospective cohort study. NH residents in Texas with dementia diagnosis and severe cognitive impairment (N = 20,582). This study used 2011-2016 Texas Medicare data to identify NH residents with a stay of at least 120 days who had a diagnosis of dementia on Long Term Care Minimum Data Set (MDS) evaluation and severe cognitive impairment on clinical score. Multivariable repeated measures analyses were conducted to identify associations between FT placement and resident-level, provider-type, NH, and regional factors. The prevalence of FT placement in advanced dementia in Texas between 2011 and 2016 ranged from 12.5% to 16.1% with a nonlinear trend. At the resident level, the prevalence of FT decreased with age [age > 85 years, prevalence ratio (PR) 0.60, 95% confidence interval (CI) 0.52-0.69] and increased among residents who are black (2.74, 95% CI 2.48-3.03) or Hispanic (PR 1.91, 95% CI 1.71-2.13). Residents cared for by a nurse practitioner or physician assistant were less likely to have an FT (PR 0.90, 95% CI 0.85-0.96). No facility characteristics were associated with prevalence of FT placement in advanced dementia. There were regional differences in FT placement with the highest use areas on the Texas-Mexico border and in South and East Texas (Harlingen border area, PR 4.26, 95% CI 3.69-4.86; San Antonio border area, PR 3.93, 95% CI 3.04-4.93; Houston, PR 2.17, 95% CI 1.87-2.50), and in metro areas (PR 1.36, 95% CI 1.22-1.50). Regional, race, and ethnic variations in prevalence of FT use among NH residents suggest opportunities for clinicians and policy makers to improve the quality of end-of-life care by especially considering other palliative care measures for minorities living in border towns. [ABSTRACT FROM AUTHOR]

Subtropical estuaries worldwide face increased pressure on their ecosystem health and services due to increasing human population growth and associated land use/land cover changes, expansion of ports, and climate change. We investigated freshwater inflows (river discharge) and the physico-chemical characteristics of Galveston Bay (Texas, USA) as mechanisms driving variability in phytoplankton biomass and community composition between February 2008 and December 2009. Results of multivariate analyses (hierarchical cluster analysis, PERMANOVA, Mantel test, and nMDS ordination coupled to environmental vector fitting) revealed that temporal and spatial differences in phytoplankton community structure correlate to differences in hydrographic and water quality parameters. Spatially, phytoplankton biomass and community composition responded to nutrient loading from the San Jacinto River in the northwest region of the bay (consistent with nutrient limitation) while hydraulic displacement (and perhaps other processes) resulted in overall lower biomass in the Trinity River delta (northeast region). The influence of inflows on phytoplankton diminished along a north to south gradient in the bay. Temporally, temperature and variables associated with freshwater inflow (discharge volume, salinity, inorganic nitrogen and phosphorus concentrations) were major influences on phytoplankton dynamics. Dissolved inorganic nitrogen: phosphorus (DIN:DIP) ratios suggest that phytoplankton communities will be predominately nitrogen limited. Diatoms dominated during periods of moderate to high freshwater inflows in winter/spring and were more abundant in the upper bay while cyanobacteria dominated during summer/fall when inflow was low. Given the differential influences of freshwater inflow on the phytoplankton communities of Galveston Bay, alterations upstream (magnitude, timing, frequency) will likely have a profound effect on downstream ecological processes and corresponding ecosystem services.