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The National Institute for Health and Care Excellence (NICE) informs us that the first-line treatments for behavioural and psychological symptoms of dementia (BPSD) are non-pharmacological. Although psychotropics used to be the main strategy in the management of behaviours that challenge, there has been an increase in the use of biopsychosocial formulations since 2010, and there are now over a dozen to choose from. However, many are overly focused on obtaining information about the agitation, and less specific about providing details of the actions required to manage the behaviours. The NICE guidelines too fail to provide specific guidance on which non-pharmacological approaches to use. This article argues for giving equal weight to both the collection of meaningful information and the development of ‘informed actions’, because it is the actions that lead to change. The article outlines a management programme providing a framework for the assessment, formulation and treatment of agitation in dementia. The work draws on theory, evidence-based practice and practice-based evidence to provide a model with sufficient structure and flexibility to be useful for clinicians across a range of settings and professional groups.
An early economic evaluation to inform the translation into clinical practice of a spectroscopic liquid biopsy for the detection of brain cancer. Two specific aims are (1) to update an existing economic model with results from a prospective study of diagnostic accuracy and (2) to explore the potential of brain tumor-type predictions to affect patient outcomes and healthcare costs.
A cost-effectiveness analysis from a UK NHS perspective of the use of spectroscopic liquid biopsy in primary and secondary care settings, as well as a cost–consequence analysis of the addition of tumor-type predictions was conducted. Decision tree models were constructed to represent simplified diagnostic pathways. Test diagnostic accuracy parameters were based on a prospective validation study. Four price points (GBP 50-200, EUR 57-228) for the test were considered.
In both settings, the use of liquid biopsy produced QALY gains. In primary care, at test costs below GBP 100 (EUR 114), testing was cost saving. At GBP 100 (EUR 114) per test, the ICER was GBP 13,279 (EUR 15,145), whereas at GBP 200 (EUR 228), the ICER was GBP 78,300 (EUR 89,301). In secondary care, the ICER ranged from GBP 11,360 (EUR 12,956) to GBP 43,870 (EUR 50,034) across the range of test costs.
The results demonstrate the potential for the technology to be cost-effective in both primary and secondary care settings. Additional studies of test use in routine primary care practice are needed to resolve the remaining issues of uncertainty—prevalence in this patient population and referral behavior.
To assess variability in antimicrobial use and associations with infection testing in pediatric ventilator-associated events (VAEs).
Descriptive retrospective cohort with nested case-control study.
Pediatric intensive care units (PICUs), cardiac intensive care units (CICUs), and neonatal intensive care units (NICUs) in 6 US hospitals.
Children≤18 years ventilated for≥1 calendar day.
We identified patients with pediatric ventilator-associated conditions (VACs), pediatric VACs with antimicrobial use for≥4 days (AVACs), and possible ventilator-associated pneumonia (PVAP, defined as pediatric AVAC with a positive respiratory diagnostic test) according to previously proposed criteria.
Among 9,025 ventilated children, we identified 192 VAC cases, 43 in CICUs, 70 in PICUs, and 79 in NICUs. AVAC criteria were met in 79 VAC cases (41%) (58% CICU; 51% PICU; and 23% NICU), and varied by hospital (CICU, 20–67%; PICU, 0–70%; and NICU, 0–43%). Type and duration of AVAC antimicrobials varied by ICU type. AVAC cases in CICUs and PICUs received broad-spectrum antimicrobials more often than those in NICUs. Among AVAC cases, 39% had respiratory infection diagnostic testing performed; PVAP was identified in 15 VAC cases. Also, among AVAC cases, 73% had no associated positive respiratory or nonrespiratory diagnostic test.
Antimicrobial use is common in pediatric VAC, with variability in spectrum and duration of antimicrobials within hospitals and across ICU types, while PVAP is uncommon. Prolonged antimicrobial use despite low rates of PVAP or positive laboratory testing for infection suggests that AVAC may provide a lever for antimicrobial stewardship programs to improve utilization.
Sepsis – syndrome of infection complicated by organ dysfunction – is responsible for over 750 000 hospitalisations and 200 000 deaths in the USA annually. Despite potential nutritional benefits, the association of diet and sepsis is unknown. Therefore, we sought to determine the association between adherence to a Mediterranean-style diet (Med-style diet) and long-term risk of sepsis in the REasons for Geographic Differences in Stroke (REGARDS) cohort. We analysed data from REGARDS, a population-based cohort of 30 239 community-dwelling adults age ≥45 years. We determined dietary patterns from a baseline FFQ. We defined Med-style diet as a high consumption of fruit, vegetables, legumes, fish, cereal and low consumption of meat, dairy products, fat and alcohol categorising participants into Med-style diet tertiles (low: 0–3, moderate: 4–5, high: 6–9). We defined sepsis events as hospital admission for serious infection and at least two systematic inflammatory response syndrome criteria. We used Cox proportional hazard models to determine the association between Med-style diet tertiles and first sepsis events, adjusting for socio-demographics, lifestyle factors, and co-morbidities. We included 21 256 participants with complete dietary data. Dietary patterns were: low Med-style diet 32·0 %, moderate Med-style diet 42·1 % and high Med-style diet 26·0 %. There were 1109 (5·2 %) first sepsis events. High Med-style diet was independently associated with sepsis risk; low Med-style diet referent, moderate Med-style diet adjusted hazard ratio (HR) 0·93 (95 % CI 0·81, 1·08), high Med-style diet adjusted HR=0·74 (95 % CI 0·61, 0·88). High Med-style diet adherence is associated with lower risk of sepsis. Dietary modification may potentially provide an option for reducing sepsis risk.
This study examined electrophysiological correlates of sentence comprehension of native-accented and foreign-accented speech in a second language (L2), for sentences produced in a foreign accent different from that associated with the listeners' L1. Bilingual speaker-listeners process different accents in their L2 conversations, but the effects on real-time L2 sentence comprehension are unknown. Dutch–English bilinguals listened to native American-English accented sentences and foreign (and for them unfamiliarly-accented) Chinese-English accented sentences while EEG was recorded. Behavioral sentence comprehension was highly accurate for both native-accented and foreign-accented sentences. ERPs showed different patterns for L2 grammar and semantic processing of native- and foreign-accented speech. For grammar, only native-accented speech elicited an Nref. For semantics, both native- and foreign-accented speech elicited an N400 effect, but with a delayed onset across both accent conditions. These findings suggest that the way listeners comprehend native- and foreign-accented sentences in their L2 depends on their familiarity with the accent.
Fomesafen provides effective control of glyphosate-resistant Palmer amaranth in cotton. However, cotton seedlings can be injured when fomesafen is applied PRE. Therefore, greenhouse and field experiments were conducted at Athens, GA, and at six locations in Alabama and Georgia in 2013 and 2016 to evaluate cotton growth and yield response to fomesafen applied PRE at 70, 140, 280, 560, 1,120, or 2,240 g ai ha−1, and in combination with pendimethalin, diuron, acetochlor, and fluridone at 1×label rates. Greenhouse bioassays indicated that fomesafen reduced cotton height and dry weight with increasing rate in Cecil sandy loam and Tifton loamy sand but not in Greenville sandy clay loam––possibly as a result of this soil’s higher organic matter (OM) and clay content. Fomesafen applied at 2,240 g ai ha−1 reduced cotton stand by as much as 83% compared to the nontreated check (NTC) at all field locations except Alabama’s Macon and Baldwin counties, and 1,120 g ai ha−1 reduced cotton stand only at Pulaski County, GA, by 52%. Cotton height was reduced by the two highest rates of fomesafen at all locations except Clarke County, GA, and Baldwin County, AL. Injury data indicated more visual injury followed increasing fomesafen rates, and high-rate treatments produced more injury in sandier soils. Cotton yield was unaffected by herbicide treatments at any location, except for the 1,120 g ai ha−1 rate at Pulaski County (49% yield loss compared to NTC), 2,240 g ai ha−1 at Pulaski County (72% yield loss), and Tift County (29% yield loss). These data indicated cotton yield should not be negatively affected by fomesafen applied PRE alone within label rates or in combination with pendimethalin, diuron, acetochlor, and fluridone at 1×label rates, although some visual injury, or stand or height reduction may occur early in the growing season.
This study examined the qualitative differences between the types of strengths identified by satisfied versus distressed couples seeking a Marriage Checkup. We hypothesised that distressed couples would nominate less intimate strengths, while satisfied couples would nominate more intimate strengths. We found that distressed partners were significantly more likely to nominate items from a Parallel Support category, whereas satisfied women, but not men, were significantly more likely to nominate items from an Intimate/Affectionate category. These findings suggest that an indicator of developing couple distress is the point where couples begin to focus their attention on less emotionally vulnerable relationship aspects.
This qualitative study investigates how the Electronic Patient-Reported Outcome (ePRO) mobile application and portal system, designed to capture patient-reported measures to support self-management, affected primary care provider workflows.
The Canadian health system is facing an ageing population that is living with chronic disease. Disruptive innovations like mobile health technologies can help to support health system transformation needed to better meet the multifaceted needs of the complex care patient. However, there are challenges with implementing these technologies in primary care settings, in particular the effect on primary care provider workflows.
Over a six-week period interdisciplinary primary care providers (n=6) and their complex care patients (n=12), used the ePRO mobile application and portal to collaboratively goal-set, manage care plans, and support self-management using patient-reported measures. Secondary thematic analysis of focus groups, training sessions, and issue tracker reports captured user experiences at a Toronto area Family Health Team from October 2014 to January 2015.
Key issues raised by providers included: liability concerns associated with remote monitoring, increased documentation activities due to a lack of interoperability between the app and the electronic patient record, increased provider anxiety with regard to the potential for the app to disrupt and infringe upon appointment time, and increased demands for patient engagement. Primary care providers reported the app helped to focus care plans and to begin a collaborative conversation on goal-setting. However, throughout our investigation we found a high level of provider resistance evidenced by consistent attempts to shift the app towards fitting with existing workflows rather than adapting much of their behaviour. As health systems seek innovative and disruptive models to better serve this complex patient population, provider change resistance will need to be addressed. New models and technologies cannot be disruptive in an environment that is resisting change.
Regulatory impact analyses (RIAs) weigh the benefits of regulations against the burdens they impose and are invaluable tools for informing decision makers. We offer 10 tips for nonspecialist policymakers and interested stakeholders who will be reading RIAs as consumers.
1. Core problem: Determine whether the RIA identifies the core problem (compelling public need) the regulation is intended to address.
2. Alternatives: Look for an objective, policy-neutral evaluation of the relative merits of reasonable alternatives.
3. Baseline: Check whether the RIA presents a reasonable “counterfactual” against which benefits and costs are measured.
4. Increments: Evaluate whether totals and averages obscure relevant distinctions and trade-offs.
5. Uncertainty: Recognize that all estimates involve uncertainty, and ask what effect key assumptions, data, and models have on those estimates.
6. Transparency: Look for transparency and objectivity of analytical inputs.
7. Benefits: Examine how projected benefits relate to stated objectives.
8. Costs: Understand what costs are included.
9. Distribution: Consider how benefits and costs are distributed.
10. Symmetrical treatment: Ensure that benefits and costs are presented symmetrically.
Adult ventilator-associated event (VAE) definitions include ventilator-associated conditions (VAC) and subcategories for infection-related ventilator-associated complications (IVAC) and possible ventilator-associated pneumonia (PVAP). We explored these definitions for children.
Pediatric, cardiac, or neonatal intensive care units (ICUs) in 6 US hospitals
Patients ≤18 years old ventilated for ≥1 day
We identified patients with pediatric VAC based on previously proposed criteria. We applied adult temperature, white blood cell count, antibiotic, and culture criteria for IVAC and PVAP to these patients. We matched pediatric VAC patients with controls and evaluated associations with adverse outcomes using Cox proportional hazards models.
In total, 233 pediatric VACs (12,167 ventilation episodes) were identified. In the cardiac ICU (CICU), 62.5% of VACs met adult IVAC criteria; in the pediatric ICU (PICU), 54.2% of VACs met adult IVAC criteria; and in the neonatal ICU (NICU), 20.2% of VACs met adult IVAC criteria. Most patients had abnormal white blood cell counts and temperatures; we therefore recommend simplifying surveillance by focusing on “pediatric VAC with antimicrobial use” (pediatric AVAC). Pediatric AVAC with a positive respiratory diagnostic test (“pediatric PVAP”) occurred in 8.9% of VACs in the CICU, 13.3% of VACs in the PICU, and 4.3% of VACs in the NICU. Hospital mortality was increased, and hospital and ICU length of stay and duration of ventilation were prolonged among all pediatric VAE subsets compared with controls.
We propose pediatric AVAC for surveillance related to antimicrobial use, with pediatric PVAP as a subset of AVAC. Studies on generalizability and responsiveness of these metrics to quality improvement initiatives are needed, as are studies to determine whether lower pediatric VAE rates are associated with improvements in other outcomes.
We establish links between countable algebraically closed graphs and the endomorphisms of the countable universal graph R. As a consequence we show that, for any countable graph Γ, there are uncountably many maximal subgroups of the endomorphism monoid of R isomorphic to the automorphism group of Γ. Further structural information about End R is established including that Aut Γ arises in uncountably many ways as a Schützenberger group. Similar results are proved for the countable universal directed graph and the countable universal bipartite graph.
The collective response of electrons in an ultrathin foil target irradiated by an ultraintense (
) laser pulse is investigated experimentally and via 3D particle-in-cell simulations. It is shown that if the target is sufficiently thin that the laser induces significant radiation pressure, but not thin enough to become relativistically transparent to the laser light, the resulting relativistic electron beam is elliptical, with the major axis of the ellipse directed along the laser polarization axis. When the target thickness is decreased such that it becomes relativistically transparent early in the interaction with the laser pulse, diffraction of the transmitted laser light occurs through a so called ‘relativistic plasma aperture’, inducing structure in the spatial-intensity profile of the beam of energetic electrons. It is shown that the electron beam profile can be modified by variation of the target thickness and degree of ellipticity in the laser polarization.
The literature on the λ Boo stars has grown to become somewhat heterogenous, as different authors have applied different criteria across the UV, optical, and infrared regions to determine the membership status of λ Boo candidates. We aim to clear up the confusion by consulting the literature on 212 objects that have been considered as λ Boo candidates, and subsequently evaluating the evidence in favour of their admission to the λ Boo class. We obtained new spectra of ~ 90 of these candidates and classified them on the MK system to aid in the membership evaluations. The re-evaluation of the 212 objects resulted in 64 members and 103 non-members of the λ Boo class, with a further 45 stars for which membership status is unclear. We suggest observations for each of the stars in the latter category that will allow them to be confidently included or rejected from the class. Our reclassification facilitates homogenous analysis on group members, and represents the largest collection of confirmed λ Boo stars known.
Luminescence dating provides a direct age estimate of the time of last exposure of quartz or feldspar minerals to light or heat and has been successfully applied to deposits, rock surfaces, and fired materials in a number of archaeological and geological settings. Sampling strategies are diverse and can be customized depending on local circumstances, although all sediment samples need to include a light-safe sample and material for dose-rate determination. The accuracy and precision of luminescence dating results are directly related to the type and quality of the material sampled and sample collection methods in the field. Selection of target material for dating should include considerations of adequacy of resetting of the luminescence signal (optical and thermal bleaching), the ability to characterize the radioactive environment surrounding the sample (dose rate), and the lack of evidence for post-depositional mixing (bioturbation in soils and sediment). Sample strategies for collection of samples from sedimentary settings and fired materials are discussed. This paper should be used as a guide for luminescence sampling and is meant to provide essential background information on how to properly collect samples and on the types of materials suitable for luminescence dating.
Habitat loss, the primary driver for loss of biodiversity worldwide, is of special concern for species that have a small area of occurrence, such as those restricted to islands. The Forest Thrush Turdus lherminieri is a ‘Vulnerable’ (VU) species endemic to four islands in the Caribbean, and its population has declined dramatically over the past 15 years. Because this decline is poorly understood, we studied its habitat associations on Montserrat. We conducted three repeat point count surveys and measured forest structure and habitat at each of 88 randomly placed locations in the largest forest area remaining on the island. We related Forest Thrush abundance to habitat using binomial mixture models that account for imperfect detection. Detection probability was a function of survey time, survey date, location of the survey point, and wind. Local habitat structure had the greatest influence on Forest Thrush abundance, with birds being more abundant at mid-elevations under closed canopies. We conclude that the Forest Thrush prefers mature mesic and wet forests on Montserrat. Assuming similar habitat selection in the rest of its range, the species’s long-term future depends on good protection of these natural forests on all four islands where it occurs.
Patients may present to Emergency Departments (ED) in shock for various reasons. Emergency medicine physicians may require the use of vasopressors or inotropes to manage these patients. The Critical Care Practice Committee of the Canadian Association of Emergency Physicians (C4) conducted an intensive literature search and guideline development process to help create an evidence based approach for use of these agents in the stabilization of shock.