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The coronavirus disease 2019 pandemic caused substantial changes to healthcare delivery and antibiotic prescribing beginning in March 2020. To assess pandemic impact on Clostridioides difficile infection (CDI) rates, we described patients and trends in facility-level incidence, testing rates, and percent positivity during 2019–2020 in a large cohort of US hospitals.
We estimated and compared rates of community-onset CDI (CO-CDI) per 10,000 discharges, hospital-onset CDI (HO-CDI) per 10,000 patient days, and C. difficile testing rates per 10,000 discharges in 2019 and 2020. We calculated percent positivity as the number of inpatients diagnosed with CDI over the total number of discharges with a test for C. difficile. We used an interrupted time series (ITS) design with negative binomial and logistic regression models to describe level and trend changes in rates and percent positivity before and after March 2020.
In pairwise comparisons, overall CO-CDI rates decreased from 20.0 to 15.8 between 2019 and 2020 (P < .0001). HO-CDI rates did not change. Using ITS, we detected decreasing monthly trends in CO-CDI (−1% per month, P = .0036) and HO-CDI incidence (−1% per month, P < .0001) during the baseline period, prior to the COVID-19 pandemic declaration. We detected no change in monthly trends for CO-CDI or HO-CDI incidence or percent positivity after March 2020 compared with the baseline period.
While there was a slight downward trajectory in CDI trends prior to March 2020, no significant change in CDI trends occurred during the COVID-19 pandemic despite changes in infection control practices, antibiotic use, and healthcare delivery.
Lithium has a narrow therapeutic index with a risk of toxicity and potential to increase morbidity and mortality, particularly in the elderly with co-morbid illness and polypharmacy. Lithium therapy and monitoring of lithium levels require precision and several guidelines have been issued including recommendations for strict control of lithium levels in the elderly population.
We evaluated the effect of implementation of a multifaceted management programme on the compliance with international practice standards for lithium monitoring in patients under the care of Psychiatry of Old Age (POA), Sligo Leitrim Mental Health Services in the North West of Ireland.
Results from a prior audit performed in February 2020 involving a cohort of 18 patients prescribed lithium under the care of POA were analysed and compared to accepted standards. The guideline used as the benchmark for compliance was the National Institute for Clinical Excellence (NICE) guidelines on the use and monitoring of lithium therapy, as published in 2014. Several deficits were found and therefore a designated Lithium Management Programme was established. A subsequent audit, performed using a simplified audit tool incorporating the NICE guidelines, delivered results which were directly compared to the initial findings and analysed to evaluate the effect of the implemented management programme.
PRELIMINARY RESULTS OF THE ONGOING STUDY:
In comparison with findings from 2020, there had been a significant improvement in most facets of lithium management and compliance to practice standards. Of particular note was the improvement of biochemical monitoring, side effect screening, polypharmacy surveillance, patient education and interdisciplinary communication.
The launch of a dedicated Lithium Management Programme with specific features aimed at identifying and addressing poor compliance with monitoring guidelines has led to improved adherence to accepted international practice standards. Our model provides a dynamic, multi-layered system which paves the way for better patient outcomes, timely access to care and furthering education for patients and staff members.
Synchrotron radiation images from runaway electrons (REs) in an ASDEX Upgrade discharge disrupted by argon injection are analysed using the synchrotron diagnostic tool Soft and coupled fluid-kinetic simulations. We show that the evolution of the runaway distribution is well described by an initial hot-tail seed population, which is accelerated to energies between 25–50 MeV during the current quench, together with an avalanche runaway tail which has an exponentially decreasing energy spectrum. We find that, although the avalanche component carries the vast majority of the current, it is the high-energy seed remnant that dominates synchrotron emission. With insights from the fluid-kinetic simulations, an analytic model for the evolution of the runaway seed component is developed and used to reconstruct the radial density profile of the RE beam. The analysis shows that the observed change of the synchrotron pattern from circular to crescent shape is caused by a rapid redistribution of the radial profile of the runaway density.
We present continuous estimates of snow and firn density, layer depth and accumulation from a multi-channel, multi-offset, ground-penetrating radar traverse. Our method uses the electromagnetic velocity, estimated from waveform travel-times measured at common-midpoints between sources and receivers. Previously, common-midpoint radar experiments on ice sheets have been limited to point observations. We completed radar velocity analysis in the upper ~2 m to estimate the surface and average snow density of the Greenland Ice Sheet. We parameterized the Herron and Langway (1980) firn density and age model using the radar-derived snow density, radar-derived surface mass balance (2015–2017) and reanalysis-derived temperature data. We applied structure-oriented filtering to the radar image along constant age horizons and increased the depth at which horizons could be reliably interpreted. We reconstructed the historical instantaneous surface mass balance, which we averaged into annual and multidecadal products along a 78 km traverse for the period 1984–2017. We found good agreement between our physically constrained parameterization and a firn core collected from the dry snow accumulation zone, and gained insights into the spatial correlation of surface snow density.
The aim of the study was to identify dietary patterns (DP) and examine differences in anthropometric measures, blood pressure (BP), cardiorespiratory fitness and nutritional knowledge of 6- and 10-year-old children at baseline and following a nutrition and physical activity intervention, with respect to DP and treatment group. This is a longitudinal study. Food diary, nutritional knowledge questionnaire and 550-m walk/run test measured dietary intake, nutritional knowledge and cardiorespiratory fitness, respectively. BP, weight, height and waist circumference were also measured and BMI and waist-to-height ratio (WHtR) were derived. All measurements were performed at baseline and following intervention. Two primary schools (one intervention, one control) in Cork, Ireland, were selected. Participants were 6- (n 39, age 5·9 (sd 0·6) years) and 10- (n 49, age 9·8 (sd 0·5) years)-year-olds. Two DP were identified, using k-means cluster analysis, for both 6- (unhealthy and nutrient-dense) and 10-year-olds (processed and Western diet) at baseline. DP derived post-intervention were (1) plant-based and (2) processed foods for 6-year-olds and (1) nutrient-dense and (2) unhealthy for 10-year-olds. There was no statistically significant difference in DP for 6- and 10-year-olds at baseline and post-intervention (P > 0·05). Following the intervention, a multivariate ANOVA showed there were no statistically significant differences in nutritional knowledge, BMI, WHtR, cardiorespiratory fitness and BP based on DP and intervention/control group for both age groups (P > 0·05). Three out of four dietary patterns identified for 6- and 10-year-olds were unfavourable. While no statistically significant evidence of intervention impact was found on DP, a positive trend was emerging among 10-year-olds.
Amino acid bioavailability is critical for muscle protein synthesis (MPS) and preservation of skeletal muscle mass (SMM). Ageing is associated with reduced responsiveness of MPS to essential amino acids (EAA). Further, the older adult population experiences anabolic resistance, leading to increased frailty, functional decline and depleted muscle mass preservation, which facilitates the need for increased protein intake to increase their SMM. This review focuses on the role of proteins in muscle mass preservation and examines the contribution of EAA and protein intake patterns to MPS. Leucine is the most widely studied amino acid for its role as a potent stimulator of MPS, though due to inadequate data little is yet known about the role of other EAA. Reaching a conclusion on the best pattern of protein intake has proven difficult due to conflicting studies. A mixture of animal and plant proteins can contribute to increased MPS and potentially attenuate muscle wasting conditions; however, there is limited research on the biological impact of protein blends in older adults. While there is some evidence to suggest that liquid protein foods with higher than the RDA of protein may be the best strategy for achieving high MPS rates in older adults, clinical trials are warranted to confirm an association between food form and SMM preservation. Further research is warranted before adequate recommendations and strategies for optimising SMM in the elderly population can be proposed.
Delirium is associated with poor outcomes and high mortality. Current research shows conflicting results regarding mortality rates in patients with delirium.
The aim was to examine the hazard risk associated with delirium in elderly medically ill patients at 1 year follow-up, controlling for baseline risk factors and interaction effects.
This was a prospective, observational, longitudinal study carried out in the medical wards of Sligo Regional Hospital. All acute medical admissions of patients 70 years old and over were approached. Each patient was assessed twice weekly for 2 weeks or until discharge. The following scales were used: CAM, DRS-98R, MoCA, Barthel Index, APACHE II. Primary outcome was time of death during 1 year. Cox proportional hazards were estimated and compared across patients who had delirium during hospitalisation and those who did not.
Two hundred patients agreed to take part in the study. The mean age of the studied sample was 81.13 (SD = 6.45; minimum 70 and maximum 100 years old) with 100 (50%) females. One hundred fifty four (77%) patients never developed delirium during hospitalization. Thirty four (17%) had delirium at admission and 12 (6%) developed prevalence delirium while inpatients. A total of 55 (27.5%) patients died during the one year follow-up. Significant risk factors for 1 year mortality were length of hospital staying, severity of illness (APACHE II), and cognition (MoCA).
Delirium was not found as an independent risk factor for 1 year mortality after controlling for other confounder variables.
Forensic Mental Health provision in secure healthcare is complex. the availability of a short and quantifiable, yet comprehensive instrument for summarising patient progress encompassing multi-professional clinical input would facilitate clinical decision-making.
To develop and validate a Progress Rating Scale (PRS) for use in secure healthcare to assess patient course in treatment.
PRS items will reflect multi-professional clinical input. Measurement will be valid and reliable.
Development was undertaken at the Personality Disorder Service, Arnold Lodge Regional Secure Unit. Thematic analysis of 5 randomly selected archived treatment reviews resulted in a preliminary list of items. This scale was then piloted and refined via independent rating of further anonymised reports.
Validation and further development
To assess content validity, 3 independent raters applied the scale on archived treatment reviews of 12 randomly selected patients. Following examination of single-rating intra-class correlations (ICCs), items were revised to achieve greater content validity.
The domains of the scale were: Engagement, Behaviour, Mental State, Interactions with Peers and Staff, Insight, Supportive relationship, Employment, Leave, Violence/risk, Psychometric score and Final outcome (upon discharge). Initial inter-rater agreement ranged from fair to substantial (ICCs: 0.37–0.82). Following revisions, agreement improved ranging from moderate to substantial (ICCs: 0.63–0.92), the latter applying to most items.
A scale for evaluating patient progress was developed based on multi-professional clinical input. the scale was refined to improve content validity. Internal consistency and factorial structure are under scrutiny and results will be available at the conference.
Autism spectrum disorder (ASD) affects 20–30% of adults with intellectual disability. This group are vulnerable to challenging behaviour and mental health problems.
To explore the extent to which ASD affects challenging behaviour among specialist mental health service users with intellectual disability.
To identify predictors of challenging behaviour among adults who have intellectual disability.
A cross-sectional study of 92 participants from a specialist mental health service for adults with intellectual disability in the UK. The presence/absence of ASD was confirmed using the Autism Diagnostic Observation Schedule. Challenging behaviour was assessed using the Developmental Behaviour Checklist (DBC).
Participants with ASD (N=48) had higher total DBC scores than those without ASD (N=44; mean=54.2 vs. 29.2). ASD, severity of intellectual disability, age, presence of psychiatric disorder and total number of needs were entered as independent variables into a linear regression. The model accounted for 51% of the variance and was statistically significant (F(5,91)=18.1, p<0.001). Presence of ASD and total number of needs were the only significant predictors of challenging behaviour. Presence of ASD had the highest standardised coefficient (β=0.56).
Participants with ASD had significantly higher levels of challenging behaviour than those without ASD. Challenging behaviour was also independently associated with total number of needs. Understanding which service users with intellectual disability have higher levels of challenging behaviour than others despite receiving psychiatric treatment, and the extent to which having ASD is a contributing factor, should inform the development of more effective services and lead to improved outcomes.
Clozapine is licensed for treatment-resistant schizophrenia and when clozapine is not able to be used, less evidence based practices may be required. Full remission may require combinations or high doses of psychotropic medications having greater potential for interactions and side effects. If this is not successful, symptoms may persist and long-term disability may occur.
To explore safety and efficacy of a rechallenge of clozapine in a patient with treatment resistant schizoaffective disorder, who previously developed pericardial effusion. Collateral history reported best improvement with clozapine compared to other medications.
To improve level of functioning and reduce need for less evidence based choices of medication.
Initial consultation with clozapine monitoring service over prospects of rechallenge. Full medication history and review. Consultation with a cardiologist regarding validity of local monitoring strategy. Obtain consent from the patient and his family. Titrate clozapine slowly. Once clozapine initiated, measure temperature, blood pressure, pulse rate and monitoring of symptoms of pericarditis including chest pain, cough and dyspnoea daily. ECG and echocardiography at baseline and 2 and 4 weeks after initiation of the rechallenge. ECGs monthly thereafter, with a further echocardiogram at 3 months. Weekly troponin and CRP for three months to monitor developing myocarditis and pericarditis.
Successful rechallenge of clozapine with significant reduction in psychopathology, improvement in functioning and no adverse events reported. Reduction of risk enabled transfer to open ward conditions.
There is increasing evidence of successful rechallenges of clozapine however, further research is necessary to aid such clinical decisions.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Outcome measurements in mental health services is beneficial in allowing healthcare providers in determining the effectiveness of their treatment plan. Health of the Nation Outcome Scale (HoNOS) and Global Assessment of Functioning (GAF) are two well-established instruments to measure patients’ outcome.
Aims and objectives
To measure the correlation of these two scales, and the feasibility of HoNOS.
Prospective longitudinal study of psychiatric outpatients attending a clinic in Sligo. Patients were assessed using HoNOS and GAF by trained doctors during the consultation. Feedback from doctors using HoNOS during the research was taken as a measure for feasibility.
Total of 441 HoNOS and 237 GAF completed on 280 patients (53.2% female, mean age 46.23; SD = 14.89). The correlation between HoNOS and GAF was (r = –0.696, P < 0.001). In reassessment, we found significant reduction in HoNOS score when comparing the first assessment with the second (t = 4.590, df = 110, P < 0.01) and the third (t = 2.876, df = 37, P < 0.01). Using a linear mixed-effects model, it was found that patients with diagnosis of schizophrenia, mood affective disorder, neurotic disorder, personality disorder and younger in age are more likely to improve during the follow-up compared to those with organic mental disorders, alcohol related problems and older age.
HoNOS is a feasible scale and can be potentially used as an outcome measurement in the mental health services. Can help in deciding better management plan for patient and improvement of the service. HoNOs can also be used for comparison of outcomes between services in national and international level.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Both MMSE and MoCA are two widely used cognitive screening test. Comparison of the two tests has been done in specific populations (Parkinson) but not in general elderly psychiatric populations. In research, equating methodologies has been used to compare results among studies that use different scales, which measure the same construct.
To explore their level of agreement within a particular clinical setting.
(a) To find MoCA and MMSE agreement. (b) To derive a conversion formula between the two scales and test it in a random population of similar setting.
Prospective study of consecutive community dwelling older patients who attend outpatient clinic or day hospital. Both tests were administered from the same researcher the same day in random order.
The total sample (n = 135) was randomly divided in two. One from where the equating rule derived (n = 70) and a second (n = 65) in which the derived conversion was tested. Agreement of the two scales (Pearson's r) was 0.86 (P < 0.001), and Lin's Concordance Correlation Coefficient (CCC) was 0.57 (95% CI 0.45–0.66). In the second sample, we convert the MoCA scores to MMSE scores according to equating rule from the first sample and after we examined the agreement between the converted MMSE scores and the originals. The Pearson's r was 0.89 (n = 65, P < 0.001) and the CCC 0.88 (95% CI 0.82–0.92).
Although the two scales overlap considerably, the agreement is modest. The conversion rule derived showed promising accuracy in this population but need further testing in other populations.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Fetal growth restriction (FGR) is defined as failure of the fetus to achieve its genetically determined growth potential due to an underlying pathological process . FGR affects approximately 10% of all pregnancies and is a major determinant of perinatal and childhood mortality and morbidity, as well as chronic disease in adulthood [2–4]. A challenge in studying FGR is the lack of a gold standard definition and clear diagnostic criteria. Small for gestational age (SGA) is often used interchangeably with FGR but fails to differentiate between the constitutionally small but healthy fetus and the pathologically growth-restricted fetus. SGA is typically defined as a baby <10th centile, but 40% of these babies are physiologically small and healthy, therefore fetal size alone cannot be used to differentiate SGA from FGR. Assessment of functional parameters has been proposed to improve diagnostic accuracy but may still miss the larger baby (>10th centile) that is also in fact growth restricted. The importance of accurately diagnosing FGR is that it identifies the potential risk of fetal demise or perinatal complications, which may be averted via appropriate monitoring and optimized delivery.
The world's population is getting older. By 2050 it is projected that 22% of the global population will be over 60 years of age. Aging is characterized by a decline in physiological functions and an increase in malnutrition and associated disease. Oxidative stress is associated with several age-related conditions, including cardiovascular disease, obesity, neurodegenerative disease and cancer. The negative effects of reactive oxygen species (ROS) are neutralized by antioxidants, which can be endogenously synthesised or consumed through the diet. Cheese is a nutritious dairy food and previous research has highlighted the antioxidant potential of some cheese types. Physiological changes associated with age can impact digestion processes, thus the ability to efficiently release bioactive compounds, including antioxidants, may be impaired with age. Cheese products varying by milk source, texture and fat content were subjected to simulated gastrointestinal in vitro digestion (SGID) using a modified model to account for physiological changes associated with aging. The antioxidant potential of undigested and digested cheese (n = 11) was determined in vitro using DPPH radical scavenging, ferric reducing antioxidant power (FRAP) and total phenolic content (TPC) assays. Cellular antioxidant potential was also investigated using the reduced glutathione assay (GSH) in the human macrophage cell line (U937). Experiments were carried out in triplicate. Statistical analysis by T-test demonstrated that digestion significantly increased (P < 0.05) FRAP and TPC of all cheese products analysed. Of the eleven cheese products investigated, goats’ cheese displayed a significant increase (P < 0.05) in radical scavenging properties (89.8% inhibition). Low fat white cheddar had significantly higher (P < 0.05) GSH levels compared to full fat white cheddar (0.16 ± 0.01, 0.11 ± 0.01 μmol GSH/mg protein, respectively). Findings from this study suggest that despite physiological changes associated with age, cheese digestates retain, and in some cases, possess higher antioxidant potential than undigested samples. Cheese demonstrates potential as a functional food for the elderly by neutralizing the negative effects associated with age-related oxidative stress.
Destruction of tropical rainforests reduces many unprotected habitats to small fragments of remnant forests within agricultural matrices. To date, these remnant forest fragments have been largely disregarded as wildlife habitat, and little is known about mammalian use of these areas in Sumatra. Here, we conducted camera trap surveys (2285 trap-nights) within Bukit Barisan Selatan National Park and five surrounding remnant forest fragments during 2010–2013 and used species composition metrics to compare use. We found 28 mammal species in the protected forest and 21 in the fragments. The fragments harboured a subset of species found in the protected forest and several species not observed in the protected forest. Critically endangered species such as Sunda pangolin (Manis javanica) and Sumatran tiger (Panthera tigris sumatrae) were found in the forest fragments, along with species of conservation concern such as marbled cat (Pardofelis marmorata) and Asiatic golden cat (Pardofelis temminckii). The biodiversity found within the fragments suggests that these small patches of remnant forest may have conservation value to certain mammal species and indicates the importance of further research into the role these habitats may play in landscape-level, multispecies conservation planning.
To assess the effectiveness of a nutrition and physical activity (PA) intervention on dietary intake (DI), nutritional knowledge (NK), blood pressure (BP), anthropometric measures and cardiorespiratory fitness (CRF) of schoolchildren.
Longitudinal study. DI, NK, BMI, waist-to-height ratio (WHtR), BP and CRF were all measured/calculated prior to (October 2014) and at the end of (June 2016) intervention delivery.
Two primary schools (one intervention and one control), Cork, Ireland.
Six-year-olds (n 49; mean age = 6·09 (sd 0·33) years) and 10-year-olds (n 52; mean age = 9·90 (sd 0·37) years).
There was a large and a moderate statistically significant difference between the change in systolic (P = 0·005, effect size (ES) = 0·165) and diastolic BP (P = 0·023, ES = 0·116), respectively, for 10-year-olds in the intervention and control groups. There was also a large statistically significant difference between the change in WHtR (P = 0·0005, ES = 0·386) and a moderate statistically significant difference between the change in NK (P = 0·027, ES = 0·107) for 10-year-olds in the intervention and control groups. There was a large statistically significant difference between the change in percentage of energy from protein in 10-year-old females (P = 0·021, ES = 0·276) in the intervention and control groups.
Project Spraoi is Ireland’s first ever school-based intervention that has been evaluated and proven effective in improving DI, NK, WHtR and BP in older primary-school children in one intervention school.