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The number of people over the age of 65 attending Emergency Departments (ED) in the United Kingdom (UK) is increasing. Those who attend with a mental health related problem may be referred to liaison psychiatry for assessment. Improving responsiveness and integration of liaison psychiatry in general hospital settings is a national priority. To do this psychiatry teams must be adequately resourced and organised. However, it is unknown how trends in the number of referrals of older people to liaison psychiatry teams by EDs are changing, making this difficult.
We performed a national multi-centre retrospective service evaluation, analysing existing psychiatry referral data from EDs of people over 65. Sites were selected from a convenience sample of older peoples liaison psychiatry departments. Departments from all regions of the UK were invited to participate via the RCPsych liaison and older peoples faculty email distribution lists. From departments who returned data, we combined the date and described trends in the number and rate of referrals over a 7 year period.
Referral data from up to 28 EDs across England and Scotland over a 7 year period were analysed (n = 18828 referrals). There is a general trend towards increasing numbers of older people referred to liaison psychiatry year on year. Rates rose year on year from 1.4 referrals per 1000 ED attenders (>65 years) in 2011 to 4.5 in 2019 . There is inter and intra site variability in referral numbers per 1000 ED attendances between different departments, ranging from 0.1 - 24.3.
To plan an effective healthcare system we need to understand the population it serves, and have appropriate structures and processes within it. The overarching message of this study is clear; older peoples mental health emergencies presenting in ED are common and appear to be increasingly so. Without appropriate investment either in EDs or community mental health services, this is unlikely to improve.
The data also suggest very variable inter-departmental referral rates. It is not possible to establish why rates from one department to another are so different, or whether outcomes for the population they serve are better or worse. The data does however highlight the importance of asking further questions about why the departments are different, and what impact that has on the patients they serve.
Commonly used measures of instrumental activities of daily living (IADL) do not capture activities for a technologically advancing society. This study aimed to adapt the proxy/informant-based Amsterdam IADL Questionnaire (A-IADL-Q) for use in the UK and develop a self-report version.
An iterative mixed method cross-cultural adaptation of the A-IADL-Q and the development of a self-report version involving a three-step design: (1) interviews and focus groups with lay and professional stakeholders to assess face and content validity; (2) a questionnaire to measure item relevance to older adults in the U.K.; (3) a pilot of the adapted questionnaire in people with cognitive impairment.
Community settings in the UK.
One hundred and forty-eight participants took part across the three steps: (1) 14 dementia professionals; 8 people with subjective cognitive decline (SCD), mild cognitive impairment (MCI), or dementia due to Alzheimer’s disease; and 6 relatives of people with MCI or dementia; (2) 92 older adults without cognitive impairment; and (3) 28 people with SCD or MCI.
The cultural relevance and applicability of the A-IADL-Q scale items were assessed using a 6-point Likert scale. Cognitive and functional performance was measured using a battery of cognitive and functional measures.
Iterative modifications to the scale resulted in a 55-item adapted version appropriate for UK use (A-IADL-Q-UK). Pilot data revealed that the new and revised items performed well. Four new items correlated with the weighted average score (Kendall’s Tau −.388, −.445, −.497, −.569). An exploratory analysis of convergent validity found correlations in the expected direction with cognitive and functional measures.
The A-IADL-Q-UK provides a measurement of functional decline for use in the UK that captures culturally relevant activities. A new self-report version has been developed and is ready for testing. Further evaluation of the A-IADL-Q-UK for construct validity is now needed.
Researchers now commonly collect biospecimens for genomic analysis together with information from mobile devices and electronic health records. This rich combination of data creates new opportunities for understanding and addressing important health issues, but also intensifies challenges to privacy and confidentiality. Here, we elucidate the “web” of legal protections for precision medicine research by integrating findings from qualitative interviews with structured legal research and applying them to realistic research scenarios involving various privacy threats.
We present a detailed overview of the cosmological surveys that we aim to carry out with Phase 1 of the Square Kilometre Array (SKA1) and the science that they will enable. We highlight three main surveys: a medium-deep continuum weak lensing and low-redshift spectroscopic HI galaxy survey over 5 000 deg2; a wide and deep continuum galaxy and HI intensity mapping (IM) survey over 20 000 deg2 from
$z = 0.35$
to 3; and a deep, high-redshift HI IM survey over 100 deg2 from
$z = 3$
to 6. Taken together, these surveys will achieve an array of important scientific goals: measuring the equation of state of dark energy out to
$z \sim 3$
with percent-level precision measurements of the cosmic expansion rate; constraining possible deviations from General Relativity on cosmological scales by measuring the growth rate of structure through multiple independent methods; mapping the structure of the Universe on the largest accessible scales, thus constraining fundamental properties such as isotropy, homogeneity, and non-Gaussianity; and measuring the HI density and bias out to
$z = 6$
. These surveys will also provide highly complementary clustering and weak lensing measurements that have independent systematic uncertainties to those of optical and near-infrared (NIR) surveys like Euclid, LSST, and WFIRST leading to a multitude of synergies that can improve constraints significantly beyond what optical or radio surveys can achieve on their own. This document, the 2018 Red Book, provides reference technical specifications, cosmological parameter forecasts, and an overview of relevant systematic effects for the three key surveys and will be regularly updated by the Cosmology Science Working Group in the run up to start of operations and the Key Science Programme of SKA1.
Protein-energy malnutrition, or undernutrition, arising from a deficiency of energy and protein intake, can occur in developed countries both in hospitalised patients and in the primary care/community setting. Oral nutritional supplements (ONS) are an effective method of managing malnutrition if prescribed for patients who are malnourished or at risk of malnutrition. Pooled data of older adults at risk of malnutrition indicate that ONS combined with dietary counselling is the most effective intervention. Previous Irish research has demonstrated that management of patients ‘at risk’ of malnutrition in the primary care/community setting is sub-optimal, with low awareness of the condition and its management among non-dietetic health care professionals. Therefore, the aim of this qualitative study is to explore community nurses’ and dietitians’ experiences and opinions on the management of malnutrition and the prescription of ONS in the primary care/community setting in Ireland. Three focus groups were conducted with primary care dietitians (n = 17) and one focus group with community nurses (n = 5), one of the nurses had prescribing rights. The focus groups explored the following domains; the term malnutrition and patient population presenting as malnourished or at risk of malnutrition, barriers and facilitators in the management of malnutrition, ONS prescribing in the primary care/community setting, and future directions in the management of malnutrition and ONS prescribing. Recorded focus groups were transcribed and analysed using inductive thematic analysis. Both professional groups showed similar perspectives, and three preliminary main themes were identified; i) Malnutrition is a misunderstood term, ii) Delayed treatment of malnutrition, iii) Challenges with ONS prescription in the primary care/community setting. Both dietitians and community nurses agreed that the term malnutrition had negative connotations for patients and preferred not to use it with them. Dietitians identified the need for a multidisciplinary approach to manage patients at risk of malnutrition in the community, and community nurses agreed on their pivotal role identifying the risk of malnutrition and providing first line advice to clients. However, community nurses expressed the urgent need for training to provide first line advice to patients to improve their nutritional status to prevent malnutrition. Both groups also agreed on the need for access to more dietitians in the community, and suggested that giving dietitians prescribing rights would improve appropriate ONS prescribing. Community nurses identified a gap in their knowledge of the different ONS products, and the need to receive independent generic education on nutritional supplements.
The number of people growing older with severe mental illness (SMI) is rising, reflecting societal trends towards an ageing population. Evidence suggests that older people are less likely to seek help, be referred for and receive psychological therapy compared with younger people, but past research has focused on those with mild to moderate mental health needs.
This research aims to identify the specific barriers faced by older people with SMI.
We interviewed 53 participants (22 service users with SMI aged over 50 years, 11 carers of people with SMI, and 20 health care professionals) about their views and experiences of accessing therapy for SMI in later life.
Thematic analysis revealed five themes: organizational and resource issues; myths about therapy and attitudinal barriers; stigma; encouraging access to therapy; and meeting age-specific needs.
Barriers faced by older people with SMI are not only age-related, but also reflect specific issues associated with having a SMI over many years. Improving awareness of the benefits of psychological therapies is important not only for older people with SMI themselves, but also for their carers and staff who work with them.
Almost all living organisms on Earth utilize the same 20 amino acids to build their millions of different proteins, even though there are hundreds of amino acids naturally occurring on Earth. Although it is likely that both the prebiotic and the current environment of Earth shaped the selection of these 20 proteinogenic amino acids, environmental conditions on extraterrestrial planets and moons are known to be quite different than those on Earth. In particular, the surfaces of planets and moons such as Mars, Europa and Enceladus have a much greater flux of UV and gamma radiation impacting their surface than that of Earth. Thus, if life were to have evolved extraterrestrially, a different lexicon of amino acids may have been selected due to different environmental pressures, such as higher radiation exposure. One fundamental property an amino acid must have in order to be of use to the evolution of life is relative stability. Therefore, we studied the stability of three different proteinogenic amino acids (tyrosine, phenylalanine and tryptophan) as compared with 20 non-proteinogenic amino acids that were structurally similar to the aromatic proteinogenic amino acids, following ultraviolet (UV) light (254, 302, or 365 nm) and gamma-ray irradiation. The degree of degradation of the amino acids was quantified using an ultra-high performance liquid chromatography-mass spectrometer (UPLC-MS). The result showed that many non-proteinogenic amino acids had either equal or increased stability to certain radiation wavelengths as compared with their proteinogenic counterparts, with fluorinated phenylalanine and tryptophan derivatives, in particular, exhibiting enhanced stability as compared with proteinogenic phenylalanine and tryptophan amino acids following gamma and select UV irradiation.
Clostridium difficile spores play an important role in transmission and can survive in the environment for several months. Optimal methods for measuring environmental C. difficile are unknown. We sought to determine whether increased sample surface area improved detection of C. difficile from environmental samples.
Samples were collected from 12 patient rooms in a tertiary-care hospital in Toronto, Canada.
Samples represented small surface-area and large surface-area floor and bedrail pairs from single-bed rooms of patients with low (without prior antibiotics), medium (with prior antibiotics), and high (C. difficile infected) shedding risk. Presence of C. difficile in samples was measured using quantitative polymerase chain reaction (qPCR) with targets on the 16S rRNA and toxin B genes and using enrichment culture.
Of the 48 samples, 64·6% were positive by 16S qPCR (geometric mean, 13·8 spores); 39·6% were positive by toxin B qPCR (geometric mean, 1·9 spores); and 43·8% were positive by enrichment culture. By 16S qPCR, each 10-fold increase in sample surface area yielded 6·6 times (95% CI, 3·2–13) more spores. Floor surfaces yielded 27 times (95% CI, 4·9–181) more spores than bedrails, and rooms of C. difficile–positive patients yielded 11 times (95% CI, 0·55–164) more spores than those of patients without prior antibiotics. Toxin B qPCR and enrichment culture returned analogous findings.
Clostridium difficile spores were identified in most floor and bedrail samples, and increased surface area improved detection. Future research aiming to understand the role of environmental C. difficile in transmission should prefer samples with large surface areas.
Nutrition plays a key role in later life health and wellbeing. Older people face a high risk of nutrient deficiencies and malnutrition that can lead to sarcopenia, loss of skeletal muscle mass and strength. A recent review identified that sarcopenia was associated with functional decline, higher rate of falls, higher incidence of hospitalisations and increased mortality (Beaudart et al, 2017). Understandably severe sarcopenia is extremely disabling as it prevents independent living and places an increasing burden on care providers.
Avoiding late life malnutrition is dependent on a number of factors including physical, mental and cognitive health. However, the relative impact of each of these factors and the relationships between them are not well understood. Physical factors, such as problems with chewing, swallowing and impaired mobility, all contribute towards nutritional decline (Hickson, 2006). Mental health status also plays a part, particularly depression, which has been identified as a predictor of poor appetite in older adults (see Engel et al, 2011). Treating depression can be an effective way of increasing appetite and improving nutritional status, but it is commonly under-diagnosed and under-treated among older people (Allan et al, 2014).
There is also growing evidence of associations between diet and cognitive function. Older people with dementia or cognitive decline have a poorer nutritional status than those without (Atti et al, 2008), with increasing dementia severity related to poorer nutritional status (Riccio et al, 2007). The potential for diet to protect against cognitive decline in older people is not currently well understood as much of the epidemiological research has not been supported in trials, and more research is needed to confirm the impact of changing whole diets on cognitive measures (Smith and Blumenthal, 2016).
To explore the associations and interactions between mental and physical health and diet, new intervention and prospective cohort studies are needed (Psaltopoulou et al, 2008). Such research is challenging to complete with older adults, as both ageing itself and the accompanying cognitive and physical decline are progressive and dynamic. Existing tools for measuring diet, cognition and physical activity typically provide snapshots of the situation and cannot identify rate of decline nor readily distinguish cause and effect.
Neither the range of potential results from genomic research that might be returned to participants nor future uses of stored data and biospecimens can be fully predicted at the outset of a study. Informed consent procedures require clear explanations about how and by whom decisions are made and what principles and criteria apply. To ensure trustworthy research governance, there is also a need for empirical studies incorporating public input to evaluate and strengthen these processes.
This paper examines interactions between co-occupants of riverine niches in north-west Europe during the Late Upper Palaeolithic using both ecological and archaeological data. It is argued that consideration of both the Lateglacial record and autecology of eel, beaver and horse supports a reinterpretation of some famous but enigmatic panels of Magdalenian mobiliary art as representations of eel fishing, along with horse and beaver exploitation in disturbed riverine habitats. It is further suggested that this constitutes a humanly co-constructed niche in ecological, nutritional, and symbolic terms, which was also particularly advantageous for human well-being and social development in this time and place.
In this research we understood legacy in terms of how the projects served the community involved and delivered outcomes for them. We sought to use evaluation to understand this legacy. Within policy analysis, evaluation studies have a long history of extensive methodological and theoretical work. Over 60 years, a whole academic industry of policy evaluation has emerged. Much of the literature is dominated by epistemological debates regarding the measurement of change and causation. For instance, while methodologies such as the randomised controlled trial (RCT) dominate the mainstream, and are seen as the ‘gold standard’ among some scholars (Haynes et al, 2012) and bodies such as the UK Treasury and UK Civil Service (Government Social Research Unit, 2007; HM Treasury, 2011), there is also a broad critical literature highlighting the methodological and epistemological weaknesses of such approaches (Pawson and Tilley, 1997). As will be explored below, evaluation and evaluative approaches make us focus our attention on ontological and epistemological questions about researcher positionality, power and knowledge, how we understand social objects, and how we understand and interpret causation.
This contrasts with ways the legacy of academic research may traditionally be evaluated, for instance through the number and quality of journal papers submitted for audit exercises such as the Research Excellence Framework in the UK (see Introduction to this book and Research Excellence Framework 2012). The outputs of research co-produced with communities, such as the projects in focus discussed below, often fit uneasily within the audit regimes of contemporary academic practice (Pain et al, 2011). In evaluating the co-produced research, our research created an artificial experiment, as many evaluations do, to consider the strengths and limitations of academic-led evaluative studies, and the strengths and limitations of a study led by community partners supported by a university-employed researcher. It thus had two purposes – first, to deliver substantive evaluations of three earlier, co-produced, social ‘interventions’ and secondly, to compare different approaches to evaluation. In this chapter we do two things. First, we report on the findings of the evaluations to explore what the legacies of co-produced research are. Secondly, we use the collective reflection on doing evaluation to provide a rich account of how we might embed evaluation into community co-produced research.
Older care home residents are excluded from the sexual imaginary. Based on a consultative study involving interviews with three residents, three female spouses of residents and two focus groups of care home staff (N = 16), making an overall sample of 22 study participants, we address the neglected subject of older residents' sexuality and intimacy needs. Using thematic analysis, we highlight how residents’ and spouses’ accounts of sexuality and intimacy can reflect an ageist erotophobia occurring within conditions of panoptical control that help construct residents as post-sexual. However, not all accounts contributed to making older residents’ sexuality appear invisible or pathological. Some stories indicated recuperation of identities and the normalisation of relationships with radically changed individuals, e.g. because of a dementia. We also examine care home staff accounts of the discursive obstacles that frustrate meeting residents’ needs connected with sexuality and intimacy. Simultaneously, we explore staffs’ creative responses to dilemmas which indicate approaches to sexuality driven more by observed needs than erotophobic anxiety and governance, as well as panoptical surveillance.
New paediatric cardiology trainees are required to rapidly assimilate knowledge and gain clinical skills to which they have limited or no exposure during residency. The Pediatric Cardiology Fellowship Boot Camp (PCBC) at Boston Children’s Hospital was designed to provide incoming fellows with an intensive exposure to congenital cardiac pathology and a broad overview of major areas of paediatric cardiology practice.
The PCBC curriculum was designed by core faculty in cardiac pathology, echocardiography, electrophysiology, interventional cardiology, exercise physiology, and cardiac intensive care. Individual faculty contributed learning objectives, which were refined by fellowship directors and used to build a programme of didactics, hands-on/simulation-based activities, and self-guided learning opportunities.
A total of 16 incoming fellows participated in the 4-week boot camp, with no concurrent clinical responsibilities, over 2 years. On the basis of pre- and post-PCBC surveys, 80% of trainees strongly agreed that they felt more prepared for clinical responsibilities, and a similar percentage felt that PCBC should be offered to future incoming fellows. Fellows showed significant increase in their confidence in all specific knowledge and skills related to the learning objectives. Fellows rated hands-on learning experiences and simulation-based exercises most highly.
We describe a novel 4-week-long boot camp designed to expose incoming paediatric cardiology fellows to the broad spectrum of knowledge and skills required for the practice of paediatric cardiology. The experience increased trainee confidence and sense of preparedness to begin fellowship-related responsibilities. Given that highly interactive activities were rated most highly, boot camps in paediatric cardiology should strongly emphasise these elements.
Sexuality and intimacy in care homes for older people are overshadowed by concern with prolonging physical and/or psychological autonomy. When sexuality and intimacy have been addressed in scholarship, this can reflect a sexological focus concerned with how to continue sexual activity with reduced capacity. We review the (Anglophone) academic and practitioner literatures bearing on sexuality and intimacy in relation to older care home residents (though much of this applies to older people generally). We highlight how ageism (or ageist erotophobia), which defines older people as post-sexual, restricts opportunities for the expression of sexuality and intimacy. In doing so, we draw attention to more critical writing that recognises constraints on sexuality and intimacy and indicates solutions to some of the problems identified. We also highlight problems faced by lesbian, gay, bisexual and trans (LGB&T) residents who are doubly excluded from sexual/intimate citizenship because of ageism combined with the heterosexual assumption. Older LGB&T residents/individuals can feel obliged to deny or disguise their identity. We conclude by outlining an agenda for research based on more sociologically informed practitioner-led work.
Glass sponge reefs on the continental shelf of western Canada and south-east Alaska are considered stable deep-sea habitats that do not change significantly over time. Research cruises using a remotely operated vehicle equipped with accurate GPS positioning have allowed us to observe the same sponges at two reefs in the Strait of Georgia, British Columbia to document recruitment, growth and response to damage over time. Spermatocysts and putative embryos found in winter suggest annual, asynchronous reproduction. Juvenile sponges (2–10 cm in osculum diameter) in densities up to 1 m−2 were more concentrated near live sponges and sponge skeletons than away (Spearman rank correlations, P < 0.0001 for live cover and for skeletons), suggesting that recruitment occurs in particular regions using sponge skeletons as substrate. Most sponges showed no change in shape or size over 2–3 years, but some had died while others showed growth of 1–9 cm year−1. Deposition rates of reef-cementing sediments were 97 mm year−1 at Galiano Reef and 137 mm year−1 at Fraser Reef, but sediments eroded so that there was no net gain or loss over time. Sponges recovered within 1 year from small-scale damage that mimicked bites by fish or nudibranchs; however sponges did not recover from crushing of a large area (1.5 × 2 m2) even 3 years later. These observations and experiments show that while recruitment and growth of sponge reefs is more dynamic than previously thought, the reefs are not resilient in the face of larger-scale disturbances such as might be inflicted by trawling.
Many studies use radiocarbon dates on estuarine shell material to build age-depth models of sediment accumulation in estuaries in California, USA. Marine 14C ages are typically older than dates from contemporaneous terrestrial carbon and local offsets (ΔR) from the global average marine offset need to be calculated to ensure the accuracy of calibrated dates. We used accelerator mass spectrometry (AMS) 14C dating on 40 pre-1950 salt marsh snail and clam shells previously collected from four California estuaries. The average ΔR and standard deviation of 217 ± 129 14C yr is consistent with previous calculations using mixed estuarine and marine samples, although the standard deviation and resulting age uncertainty was higher for our estuarine calculations than previous studies. There was a slight but significant difference (p = 0.024) in ΔR between epifaunal snails (ΔR = 171 ± 154 14C yr) and infaunal clams (ΔR = 263 ± 77 14C yr), as well as between samples from individual estuaries. However, a closer examination of the data shows that even for the same species, at the same estuary, ΔR can vary as much as ∼500 14C yr. In some cases, the bulk of this variation occurs between samples collected by different collectors at different times, potentially indicating time dependence in carbon sources and ΔR variation. These variations could also be attributed to differences in collection location within a single estuary and resulting spatial differences in carbon sources. Intertidal specimens located in the high marsh may have lower ΔR than fully marine counterparts because of increased terrestrial 14C input. The large variations in ΔR here highlight the need for conservative chronological interpretations, as well as the assumption of wide uncertainties, when dating samples from estuarine sources.
In North America, terrestrial records of biodiversity and climate change that span Marine Oxygen Isotope Stage (MIS) 5 are rare. Where found, they provide insight into how the coupling of the ocean–atmosphere system is manifested in biotic and environmental records and how the biosphere responds to climate change. In 2010–2011, construction at Ziegler Reservoir near Snowmass Village, Colorado (USA) revealed a nearly continuous, lacustrine/wetland sedimentary sequence that preserved evidence of past plant communities between ~140 and 55 ka, including all of MIS 5. At an elevation of 2705 m, the Ziegler Reservoir fossil site also contained thousands of well-preserved bones of late Pleistocene megafauna, including mastodons, mammoths, ground sloths, horses, camels, deer, bison, black bear, coyotes, and bighorn sheep. In addition, the site contained more than 26,000 bones from at least 30 species of small animals including salamanders, otters, muskrats, minks, rabbits, beavers, frogs, lizards, snakes, fish, and birds. The combination of macro- and micro-vertebrates, invertebrates, terrestrial and aquatic plant macrofossils, a detailed pollen record, and a robust, directly dated stratigraphic framework shows that high-elevation ecosystems in the Rocky Mountains of Colorado are climatically sensitive and varied dramatically throughout MIS 5.
The present study aimed to model obesity trends and future obesity-related disease for nine countries in the Middle East; in addition, to explore how hypothetical reductions in population obesity levels could ameliorate anticipated disease burdens.
A regression analysis of cross-sectional data v. BMI showed age- and sex-specific BMI trends, which fed into a micro simulation with a million Monte Carlo trials for each country. We also examined two alternative scenarios where population BMI was reduced by 1 % and 5 %.
Statistical modelling of obesity trends was carried out in nine Middle East countries (Bahrain, Egypt, Iran, Jordan, Kuwait, Lebanon, Oman, Saudi Arabia and Turkey).
BMI data along with disease incidence, mortality and survival data from national and sub-national data sets were used for the modelling process.
High rates of overweight and obesity increased in both men and women in most countries. The burden of incident type 2 diabetes, CHD and stroke would be moderated with even small reductions in obesity levels.
Obesity is a growing problem in the Middle East which requires government action on the primary prevention of obesity. The present results are important for policy makers to know the effectiveness of obesity interventions on future disease burden.