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The aim of this quality improvement project is to improve identification and management of mood disorder in patients over 65 years admitted to Royal Surrey County Hospital (RSCH) with hip fractures by introducing a standardised assessment tool to guide appropriate interventions.
The signs of depression in the elderly can be subtle and often go unnoticed. The multidisciplinary team (MDT) at RSCH observed that low mood could negatively impact on a patient's recovery, affecting pain thresholds and leading to poor engagement with rehabilitation. Proactive identification and management of mood disorder is an important part of Comprehensive Geriatric Assessment but not routinely performed in patients with hip fracture admitted to RSCH.
Notes and discharge summaries of patients with hip fracture admitted over a four-month period were retrospectively reviewed to establish if patients were screened for low mood. A mood screening tool was chosen and implemented prospectively over a four-month period. Occupational therapists and junior doctors completed a Cornell Score for all patinets. Those identified with depression or probable depression were issued verbal advice, an information leaflet and follow-up arranged.
Ninety-eight patients were included in the retrospective cohort. No patients were formally identified as having depression or probable depression, and there was no indication that mood was considered or assessed at any point during admission. During the four-month prospective period, 90 patients were admitted to RSCH with hip fracture and 86 patients (96%) were screened for low mood. Four patients were excluded due to a terminal prognosis. Of the patients screened, 9% had major depression and 16% probable depression. Feedback from our occupational therapists and doctors was positive, with the tool being relatively easy to use in patients with or without cognitive impairment. Much of the assessment could be incorporated into their initial assessment or in gaining collateral history from next of kin. Anecdotally, considering patients psychological well-being had a positive impact on inpatient therapy sessions guided the MDT in supporting the patient appropriately.
Implementation of a standardised and validated mood screening tool enabled us to identify that a quarter (25%) of the patients admitted following a hip fracture had, or probably had depression. This allowed us to intervene with simple measures such as verbal advice and an information leaflet and consider pharmacological intervention where appropriate.
To develop an international template to support patient submissions in Health Technology Assessments (HTAs). This was to be based on the experience and feedback from the implementation and use of the Scottish Medicines Consortium's (SMC) Summary Information for Patient Groups (SIP).
To gather feedback on the SMC experience, web-based surveys were conducted with pharmaceutical companies and patient groups familiar with the SMC SIP. Semistructured interviews with representatives from HTA bodies were undertaken, along with patient group discussions with those less familiar with the SIP, to explore issues around the approach. These qualitative data informed the development of an international SIP template.
Survey data indicated that 82 percent (18 of 22 respondents) of pharmaceutical company representatives felt that the SIP was worthwhile; 88 percent (15/17) of patient group respondents found the SIP helpful. Both groups highlighted the need for additional support and guidance around plain language summaries. Further suggestions included provision of a glossary of terms and cost-effectiveness information. Patient group interviews supported the survey findings and led to the development of a new template. HTA bodies raised potential challenges around buy-in, timing, and bias connected to the SIP approach.
The international SIP template is another approach to support deliberative processes in HTA. Although challenges remain around writing summaries for lay audiences, along with feasibility considerations for HTA bodies, the SIP approach should support more meaningful patient involvement in HTAs.
Research suggests that the metacognitive model is applicable to clinical child populations. However, few measures related to the model are available for younger age groups. A key concept of the model is the cognitive attentional syndrome (CAS), which encompasses the individual’s worry and rumination, maladaptive coping strategies, and metacognitive beliefs. While the CAS has been successfully measured in adults, this has not yet been attempted in children.
The aim of this study was to adapt a measure of the CAS for use with children and investigate the measure’s associations with anxiety, worry, depression and metacognitions.
Our study included 127 children with anxiety disorders aged 7–13 years. The adult measure of CAS was adapted for use with children and administered at pre- and post-treatment. We examined the correlations between variables and the ability of the CAS measure to explain variance in anxious symptomatology, as well as the measure’s sensitivity to treatment change.
The adapted measure, CAS-1C, displayed strong associations with overall anxiety, depression, worry and metacognitions. The CAS-1C explained an additional small amount of variance in anxiety and worry symptoms after accounting for metacognitions, which may be due to the measure also assessing thinking styles and coping strategies. Furthermore, the measure displayed sensitivity to treatment change.
The child measure of the CAS is a brief tool for collecting information on metacognitive beliefs and strategies that maintain psychopathology according to the metacognitive model, and it can be used to monitor treatment changes in these components.
The Interdisciplinary Network for Dementia Using Current Technology, INDUCT, is a Marie Sklodowska Curie funded International Training Network that aims to develop a multi-disciplinary, inter-sectorial educational research framework for Europe to improve technology and care for people with dementia, and to provide the evidence to show how technology can improve the lives of people with dementia. Within INDUCT (2016-2020) 15 Early Stage Researchers worked on projects in the areas of Technology to support every day life; technology to promote meaningful activities; and health care technology.
Three transversal objectives were adopted by INDUCT: 1) To determine the practical, cognitive and social factors needed to make technology more useable for people with dementia; 2) To evaluate the effectiveness of specific contemporary technology; and 3) To trace facilitators and barriers for implementation of technology in dementia care.
The main recommendations resulting from the research projects are integrated in a web-based digital Best Practice Guidance on Human Interaction with Technology in Dementia which will be presented at the congress. The recommendations are meant to be helpful for different target groups, i.e. people with dementia, their formal and informal carers, policy makers, designers and researchers, who can easily select the for them relevant recommendations in the Best Practice Guidance by means of a selection tool. The main aim of the Best Practice Guidance is to improve the development, usage and implementation of technology for people with dementia in the three mentioned technology areas.
This Best Practice Guidance is the result of the intensive collaborative partnership of INDUCT with academic and non-academic partners as well as the involvement of representatives of the different target groups throughout the INDUCT project.
Acknowledgements: The research presented was carried out within the Marie Sklodowska Curie International Training Network (ITN) action, H2020-MSCA-ITN-2015, grant agreement number 676265.
The inclusion of students with autism spectrum disorder (ASD) is increasing, but there have been no longitudinal studies of included students in Australia. Interview data reported in this study concern primary school children with ASD enrolled in mainstream classes in South Australia and New South Wales, Australia. In order to examine perceived facilitators and barriers to inclusion, parents, teachers, and principals were asked to comment on the facilitators and barriers to inclusion relevant to each child. Data are reported about 60 students, comprising a total of 305 parent interviews, 208 teacher interviews, and 227 principal interviews collected at 6-monthly intervals over 3.5 years. The most commonly mentioned facilitator was teacher practices. The most commonly mentioned barrier was intrinsic student factors. Other factors not directly controllable by school staff, such as resource limitations, were also commonly identified by principals and teachers. Parents were more likely to mention school- or teacher-related barriers. Many of the current findings were consistent with previous studies but some differences were noted, including limited reporting of sensory issues and bullying as barriers. There was little change in the pattern of facilitators and barriers identified by respondents over time. A number of implications for practice and directions for future research are discussed.
To evaluate the effect of cosmetic surgery and the stability of body dysmorphic disorder (BDD) diagnosis in patients with a minimal defect in appearance, with and without BDD, 5 years after their request for plastic surgery.
Subjects and methods
Thirty patients requesting cosmetic surgery with minimal defect in appearance, of whom 12 had BDD and 18 did not, were re-evaluated 5 years later by telephone interview regarding their cosmetic surgery interventions, satisfaction with the intervention, BDD diagnosis, handicap, and psychiatric comorbidity.
Of the 30 patients, we were able to re-evaluate 24 subjects (80%), 10 with BDD and 14 non-BDD. Seven BDD subjects had undergone cosmetic surgery vs 8 non-BDD. Patient satisfaction with the intervention was high in both groups. Nevertheless at follow-up, 6 of the 7 operated BDD patients still had a BDD diagnosis and exhibited higher levels of handicap and psychiatric comorbidity compared to their non-BDD counterparts. Moreover, 3 non-BDD patients had developed a BDD at follow-up.
This prospective study confirms that cosmetic surgery is not efficient on BDD despite declared patient satisfaction. Cosmetic surgery had no significant effects on BDD diagnosis, handicap or psychiatric comorbidity in BDD patients at 5-year follow-up. Furthermore, BDD appeared at follow-up in some initially non-BDD diagnosed subjects. Patients' declared satisfaction with surgery may contribute to explain why some plastic surgeons may not fully adhere to the contraindication of cosmetic surgery in BDD.
This chapter will review the evidence of early oasis development in Western Egypt and Eastern Libya, broadly following the course of the ‘route of the oases’, running west from the Nile to Siwa, then onwards to Awjila and al-Jufra in Libya, where it met the major north-south route from the Mediterranean to Garamantian Fazzan and beyond to Chad. The evidence presented for pre-Islamic oasis development is particularly strong in this part of the Sahara; indeed the origins of agriculture at some of the Egyptian oases went back to the third millennium BC and the route as a whole seems to have been well-developed by the fifth century BC.
We suggest that the ultimate origins of oasis agriculture in the Western Desert are to be sought in the Nile Valley and the Fayum, with a package of plants and irrigation techniques first developed there, then adopted in the oasis depressions of the Western Desert – notably Kharga, Dakhla, Farfara, Bahariya and Siwa (Fig. 3.1).
Decisions on the use of nature reflect the values and rights of individuals, communities and society at large. The values of nature are expressed through cultural norms, rules and legislation, and they can be elicited using a wide range of tools, including those of economics. None of the approaches to elicit peoples’ values are neutral. Unequal power relations influence valuation and decision-making and are at the core of most environmental conflicts. As actors in sustainability thinking, environmental scientists and practitioners are becoming more aware of their own posture, normative stance, responsibility and relative power in society. Based on a transdisciplinary workshop, our perspective paper provides a normative basis for this new community of scientists and practitioners engaged in the plural valuation of nature.
Nutrition strongly impacts the incidence and progression of chronic kidney disease (CKD). Recently, reduced rank regression (RRR) has emerged as a method that identifies dietary patterns in an exploratory way while using prior knowledge to select a set of response variables. The aim of this study was to identify a specific dietary pattern associated with renal function using RRR, and to evaluate its association with CKD incidence. We included 78,350 participants from the LifeLines population-based cohort in the Northern Netherlands. All participants were free of CKD (defined as eGFRCKD-EPI < 60 mL/min/1.73 m2) at baseline and completed a second visit four years later. Dietary intake was ascertained with a 110-item food frequency questionnaire. The dietary pattern, stratified by sex, was constructed cross-sectionally by RRR, with eGFR as a response variable. Multivariable logistic regression was used to study the association between dietary patterns score and CKD incidence or an eGFR decline of ≥ 20%, adjusted for potential confounders. Among women, the eGFR-associated dietary pattern was characterized by high intake of eggs, low-fat and high-fat cheese, and legumes and low consumption of sweetened dairy drinks, desserts, cake and cookies, sweet sandwich toppings, white meat, and commercially prepared dishes. The male dietary pattern was characterized by high consumption of high-fat and low-fat cheese, bread, full-fat milk, fruits, vegetables, beer, and low consumption of white and red meat. After a mean follow-up of 3.9 years, 7,612 participants experienced a > 20% eGFR decline and 2,072 participants developed CKD. The eGFR-based diet was associated with a lower risk of eGFR decline (OR 4th vs 1st quartile, women: 0.84 [95% CI 0.76–0.92]; men: 0.74 [0.65–0.84] and of incident CKD (women: 0.60 [0.50–0.73] ; men: 0.52 [0.41–0.66]). The results provide support for potential diet interventions to prevent renal function decline and CKD. RRR may be a useful tool to identify dietary patterns that affect renal function loss and CKD development.
Gut bacteria from the genus Prevotella are found in high abundance in faeces of non-industrialised communities but low abundance in industrialised, Westernised communities. Prevotella copri is one of the principal Prevotella species within the human gut. As it has been associated with developmental health and disease states, we sought to (i) develop a real-time polymerase chain reaction (PCR) to rapidly determine P. copri abundance and (ii) investigate its abundance in a large group of Australian pregnant mothers.
The Barwon Infant Study is a pre-birth cohort study (n = 1074). Faecal samples were collected from mothers at 36 weeks gestation. Primers with a probe specific to the V3 region of P. copri 16S rRNA gene were designed and optimised for real-time PCR. Universal 16S rRNA gene primers amplified pan-bacterial DNA in parallel. Relative abundance of P. copri was calculated using a 2-ΔCt method.
Relative abundance of P. copri by PCR was observed in 165/605 (27.3%) women. The distribution was distinctly bimodal, defining women with substantial (n = 115/165, 69.7%) versus very low P. copri expression (n = 50/165, 30.3%). In addition, abundance of P. copri by PCR correlated with 16S rRNA gene MiSeq sequencing data (r2 = 0.67, P < 0.0001, n = 61).
We have developed a rapid and cost-effective technique for identifying the relative abundance of P. copri using real-time PCR. The expression of P. copri was evident in only a quarter of the mothers, and either at substantial or very low levels. PCR detection of P. copri may facilitate assessment of this species in large, longitudinal studies across multiple populations and in various clinical settings.
The rocky shores of the north-east Atlantic have been long studied. Our focus is from Gibraltar to Norway plus the Azores and Iceland. Phylogeographic processes shape biogeographic patterns of biodiversity. Long-term and broadscale studies have shown the responses of biota to past climate fluctuations and more recent anthropogenic climate change. Inter- and intra-specific species interactions along sharp local environmental gradients shape distributions and community structure and hence ecosystem functioning. Shifts in domination by fucoids in shelter to barnacles/mussels in exposure are mediated by grazing by patellid limpets. Further south fucoids become increasingly rare, with species disappearing or restricted to estuarine refuges, caused by greater desiccation and grazing pressure. Mesoscale processes influence bottom-up nutrient forcing and larval supply, hence affecting species abundance and distribution, and can be proximate factors setting range edges (e.g., the English Channel, the Iberian Peninsula). Impacts of invasive non-native species are reviewed. Knowledge gaps such as the work on rockpools and host–parasite dynamics are also outlined.
To evaluate the feasibility and acceptability of the Takeaway Masterclass, a three-hour training session delivered to staff of independent takeaway food outlets that promoted healthy cooking practices and menu options.
A mixed-methods study design. All participating food outlets provided progress feedback at 6 weeks post-intervention. Baseline and 6-week post-intervention observational and self-reported data were collected in half of participating takeaway food outlets.
North East England.
Independent takeaway food outlet owners and managers.
Staff from eighteen (10 % of invited) takeaway food outlets attended the training; attendance did not appear to be associated with the level of deprivation of food outlet location. Changes made by staff that required minimal effort or cost to the business were the most likely to be implemented and sustained. Less popular changes included using products that are difficult (or expensive) to source from suppliers, or changes perceived to be unpopular with customers.
The Takeaway Masterclass appears to be a feasible and acceptable intervention for improving cooking practices and menu options in takeaway food outlets for those who attended the training. Further work is required to increase participation and retention and explore effectiveness, paying particular attention to minimising adverse inequality effects.
The deep subsurface of other planetary bodies is of special interest for robotic and human exploration. The subsurface provides access to planetary interior processes, thus yielding insights into planetary formation and evolution. On Mars, the subsurface might harbour the most habitable conditions. In the context of human exploration, the subsurface can provide refugia for habitation from extreme surface conditions. We describe the fifth Mine Analogue Research (MINAR 5) programme at 1 km depth in the Boulby Mine, UK in collaboration with Spaceward Bound NASA and the Kalam Centre, India, to test instruments and methods for the robotic and human exploration of deep environments on the Moon and Mars. The geological context in Permian evaporites provides an analogue to evaporitic materials on other planetary bodies such as Mars. A wide range of sample acquisition instruments (NASA drills, Small Planetary Impulse Tool (SPLIT) robotic hammer, universal sampling bags), analytical instruments (Raman spectroscopy, Close-Up Imager, Minion DNA sequencing technology, methane stable isotope analysis, biomolecule and metabolic life detection instruments) and environmental monitoring equipment (passive air particle sampler, particle detectors and environmental monitoring equipment) was deployed in an integrated campaign. Investigations included studying the geochemical signatures of chloride and sulphate evaporitic minerals, testing methods for life detection and planetary protection around human-tended operations, and investigations on the radiation environment of the deep subsurface. The MINAR analogue activity occurs in an active mine, showing how the development of space exploration technology can be used to contribute to addressing immediate Earth-based challenges. During the campaign, in collaboration with European Space Agency (ESA), MINAR was used for astronaut familiarization with future exploration tools and techniques. The campaign was used to develop primary and secondary school and primary to secondary transition curriculum materials on-site during the campaign which was focused on a classroom extra vehicular activity simulation.
Introduction: We have undertaken four online surveys of Stop Smoking Service (SSS) practitioners in England, between 2011 and 2016, in order to enhance our understanding of e-cigarettes: a fast moving new phenomenon. It is important to understand whether e-cigarettes can ameliorate or exacerbate health inequalities given that smoking is one of the most serious causes of excessive mortality and morbidity among disadvantaged groups globally.
Aims: To update findings of previous surveys and examine socioeconomic status differences in e-cigarette use and efficacy.
Methods: Analysis was undertaken of electronic surveys, particularly, the most recent 2016 survey (n = 514) and 2015/16 SSS client routine monitoring data.
Results: SSS practitioners were becoming more positive about e-cigarettes: 42% agreed that e-cigarettes were a good thing compared with 15% in 2011. Reported use of e-cigarettes among SSS clients was low (about 3%) despite higher quit rates (63% of clients reported being quit at four week follow-up, compared with 51% overall). Where socioeconomic differences in e-cigarettes’ efficacy for quitting were identified, affluent and working smokers were advantaged.
Conclusions: Low use of e-cigarettes by clients and practitioner opinions suggest that further education of SSS staff is needed if they are to adopt the current service recommendations about e-cigarettes.
Chagas disease is a public health problem, affecting about 7 million people worldwide. Benznidazole (BZN) is the main treatment option, but it has limited effectiveness and can cause severe adverse effects. Drug delivery through nanoparticles has attracted the interest of the scientific community aiming to improve therapeutic options. The aim of this study was to evaluate the cytotoxicity of benznidazole-loaded calcium carbonate nanoparticles (BZN@CaCO3) on Trypanosoma cruzi strain Y. It was observed that BZN@CaCO3 was able to reduce the viability of epimastigote, trypomastigote and amastigote forms of T. cruzi with greater potency when compared with BZN. The amount of BZN necessary to obtain the same effect was up to 25 times smaller when loaded with CaCO3 nanoparticles. Also, it was observed that BZN@CaCO3 enhanced the selectivity index. Furthermore, the cell-death mechanism induced by both BZN and BZN@CaCO3 was evaluated, indicating that both substances caused necrosis and changed mitochondrial membrane potential.
Introduction: Telephone quitlines are an easily accessible and effective means for delivering cessation services including nicotine replacement therapy (NRT). Varenicline (VAR) may show superior quit rates to NRT, but has not been routinely evaluated in the context of quitlines.
Aims: To assess the feasibility of distributing VAR through a quitline, and preliminarily compare cessation rates between participants receiving VAR and NRT.
Methods: Participants were recruited through the New York State Smokers’ Quitline. Those randomised to VAR (n = 200) were instructed to obtain a prescription from their primary care physician (PCP) to be filled by mail through the research pharmacy. Those randomised to NRT (n = 100) were mailed NRT using an existing protocol. Outcome measures were number of submitted prescriptions and dispensed medication kits, and self-reported 7-day point prevalence abstinence at follow-up.
Results: The research pharmacy filled 100% of prescriptions through the quitline. However, only 27% of the VAR Arm submitted a prescription. An intent-to-treat analysis revealed that those receiving NRT were more likely to be abstinent at follow-up than the VAR Arm (OR, 2.42; 95% CI, 1.27–4.60; p < 0.01). The per-protocol analysis, which only included those in the VAR Arm who submitted a prescription, showed no difference in quit rates.
Conclusions: The present protocol resulted in successful delivery of VAR through the quitline, but a sizable proportion of the VAR Arm did not submit a prescription. Self-reported barriers included being unable to obtain a prescription from a PCP. Future studies should explore alternative methods for delivering VAR through quitlines.
The numerous new excavations and archaeozoological analyses of Pre-Pottery Neolithic (PPN) sites in the Levant during the last 15 years shed new light on the domestication and early husbandry of animals. This chapter provides a synthetic update of the dates and locations of the early domestication of dog, cat, pig, sheep, goat and cattle, and of their utilisation by PPN societies. It also briefly discusses patterns and processes, with special attention to the commensalism and controlled hunting. Based on the data presented, the authors discuss different mechanisms and possible reasons behind early animal domestications in the Levant, as well as the role of animal domestication in the Neolithic transition.
The composition of grass/clover silage varies depending on time of harvest time. In particular silage from late regrowths is expected to contain lower fibre and higher linolenic acid concentrations compared to spring growth, thereby autumn silage is expected to increase linolenic acid content of milk fat. Rapeseed supplementation is expected to increase milk production and to increase all C18 fatty acids in milk fat. An interaction between rapeseed and silage type is expected, as hydrogenation of unsaturated fatty acids in rapeseed is expected to be less when low fibre silage is fed. Thirty-six Jersey cows were used in a 4 × 4 Latin square design, for 4 periods of 3 weeks and with a 2 × 2 factorial arrangement of treatments: spring grass/clover silage from primary growth or autumn grass/clover silage which was an equal mixture of 3rd regrowth and 4th regrowth, with or without rapeseed supplementation. Dry matter intake and milk production was higher for autumn than for spring silage. Rapeseed supplementation did not affect dry matter intake, but increased milk production. The concentrations of C18 : 1cis9, C18 : 2n6 and β-carotene and C18 : 3n3 in milk were increased whereas the concentrations of C16 : 0, riboflavin and α-tocopherol were decreased with autumn silage. The majority of C18 FAs in milk and α-tocopherol concentration increased with rapeseed whereas C11 : 0 to C16 : 0 FA were reduced. Autumn silage reduced biohydrogenation of C18 : 2n6, whereas rapeseed increased biohydrogenation of C18 : 2n6 and reduced biohydrogenation of C18 : 3n3. Apparent recovery of C18 : 2n6 was reduced with rapeseed. Minor interaction effects of silage type and rapeseed addition were observed for some milk fatty acids. Feeding silage from late regrowth increased linolenic acid concentration in milk fat. Rapeseed inclusion increased milk production, and increased C18 : 0 as well as C18 : 1 fatty acids, but not C18 : 2 and C18 : 3 in milk fat. Interactions between silage type and rapeseed supplementation were minimal.
Recent zooarchaeological analyses of game exploitation in the Epipalaeolithic of the Southern Levant identify a decline in large game in the Natufian, with corresponding increase in small prey, interpreted as hunting pressure driven by population expansion. To date, studies focus on the Mediterranean zone. This paper adopts similar approaches to examine Epipalaeolithic to Neolithic faunal data from 16 sites in the steppic Jordanian Azraq Basin. Results here reveal very different trends. Large game, mainly equids, fluctuate throughout the Epipalaeolithic, due to climatic conditions and available water/vegetation. Cattle thrive in the Azraq oasis, showing no decline in the Late Epipalaeolithic. Gazelle exploitation is predominant and sustainable throughout the Epipalaeolithic, even at Kharaneh IV and Wadi Jilat 6 ‘megasites’. However, PPNB assemblages from the limestone steppe show intensive game exploitation resulting from longer-stay settlement. The focused gazelle-hunting camp at Dhuweila in the basalt desert also shows pressure from indiscriminate culling impacting herd demography, interpreted as providing meat for onwards exchange. Human impacts on steppe fauna appear both local and in many cases short-term, unlike the large-game suppression reported from west of the Rift Valley. Resource pressures and game over-kill, whether population-driven or otherwise, are not currently apparent east of the Jordan River.