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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.
Strong associations between neural tube defects (NTDs) and monozygotic (MZ) twinning have long been noted, and it has been suggested that NTD cases who do not present as MZ twins may be the survivors of MZ twinning events. We have recently shown that MZ twins carry a strong, distinctive DNA methylation signature and have developed an algorithm based on genomewide DNA methylation array data that distinguishes MZ twins from dizygotic twins and other relatives at well above chance level. We have applied this algorithm to published methylation data from five fetal tissues (placental chorionic villi, kidney, spinal cord, brain and muscle) collected from spina bifida cases (n = 22), anencephalic cases (n = 15) and controls (n = 19). We see no difference in signature between cases and controls, providing no support for a common etiological role of MZ twinning in NTDs. The strong associations therefore continue to await elucidation.
The first demonstration of laser action in ruby was made in 1960 by T. H. Maiman of Hughes Research Laboratories, USA. Many laboratories worldwide began the search for lasers using different materials, operating at different wavelengths. In the UK, academia, industry and the central laboratories took up the challenge from the earliest days to develop these systems for a broad range of applications. This historical review looks at the contribution the UK has made to the advancement of the technology, the development of systems and components and their exploitation over the last 60 years.
As the contemporary version of the crisis brought on by the financial crash of 2008 reaches its second decade, the cinema of Ken Loach presents something of a conundrum for the politically radical spectator. Since his return to frequent feature film production as the Cold War began to end in 1990, his work has predominantly been focused in two areas: the everyday struggle for existence in the contemporary world: for example, Riff-Raff (1991), Ladybird, Ladybird (1994), Sweet Sixteen (2001), It's a Free World (2007) and I, Daniel Blake (2016); and the historical, revolutionary struggles of working people against capitalism and imperialism, such as Land and Freedom (1995), Carla's Song (1996) and The Wind that Shakes the Barley (2006). There have also been documentaries made for television, notably The Flickering Flame (1996) and Spirit of ‘45 (2013).
In this chapter, the defeatism of the British left since the 1980s and the positions taken by its reformist wing following that period, one in which Francis Fukuyama (1992) pronounced ‘the end of history’, will be posited as a seam running through Loach's contemporary cinema. A binary is set up by Loach’s films during this period: a Gramscian War of Manoeuvre is represented in the revolutionary time of the historical films, but in the contemporary period texts, there is no complementary War of Position, which is the form that the struggle takes in order to fight the hegemony of bourgeois culture; instead, we have a working class that is atomised and ground down, with any victories presented being on an individual level. Moreover, as the neoliberal model has lurched further into crisis since 2008, and as social movements attempting to combat neoliberalism have risen since the Seattle World Trade Organization protests of 1999, no change in Loach's cinema can be discerned. In order to ascertain why this might be, Alain Badiou's work on the constitution of the subject will be used to suggest that what is missing from Loach's worldview is faith in what Badiou calls ‘the Idea of Communism’, which he situates as one ‘related to the destiny of generic humanity’ (2009a: 79).
Optimal stroke care requires access to resources such as neuroimaging, acute revascularization, rehabilitation, and stroke prevention services, which may not be available in rural areas. We aimed to determine geographic access to stroke care for residents of rural communities in the province of Ontario, Canada.
We used the Ontario Road Network File database linked with the 2016 Ontario Acute Stroke Care Resource Inventory to estimate the proportion of people in rural communities, defined as those with a population size <10,000, who were within 30, 60, and 240 minutes of travel time by car from stroke care services, including brain imaging, thrombolysis treatment centers, stroke units, stroke prevention clinics, inpatient rehabilitation facilities, and endovascular treatment centers.
Of the 1,496,262 people residing in rural communities, the majority resided within 60 minutes of driving time to a center with computed tomography (85%), thrombolysis (81%), a stroke unit (68%), a stroke prevention clinic (74%), or inpatient rehabilitation (77.0%), but a much lower proportion (32%) were within 60 minutes of driving time to a center capable of providing endovascular thrombectomy (EVT).
Most rural Ontario residents have appropriate geographic access to stroke services, with the exception of EVT. This information may be useful for jurisdictions seeking to optimize the regional organization of stroke care services.
Item 9 of the Patient Health Questionnaire-9 (PHQ-9) queries about thoughts of death and self-harm, but not suicidality. Although it is sometimes used to assess suicide risk, most positive responses are not associated with suicidality. The PHQ-8, which omits Item 9, is thus increasingly used in research. We assessed equivalency of total score correlations and the diagnostic accuracy to detect major depression of the PHQ-8 and PHQ-9.
We conducted an individual patient data meta-analysis. We fit bivariate random-effects models to assess diagnostic accuracy.
16 742 participants (2097 major depression cases) from 54 studies were included. The correlation between PHQ-8 and PHQ-9 scores was 0.996 (95% confidence interval 0.996 to 0.996). The standard cutoff score of 10 for the PHQ-9 maximized sensitivity + specificity for the PHQ-8 among studies that used a semi-structured diagnostic interview reference standard (N = 27). At cutoff 10, the PHQ-8 was less sensitive by 0.02 (−0.06 to 0.00) and more specific by 0.01 (0.00 to 0.01) among those studies (N = 27), with similar results for studies that used other types of interviews (N = 27). For all 54 primary studies combined, across all cutoffs, the PHQ-8 was less sensitive than the PHQ-9 by 0.00 to 0.05 (0.03 at cutoff 10), and specificity was within 0.01 for all cutoffs (0.00 to 0.01).
PHQ-8 and PHQ-9 total scores were similar. Sensitivity may be minimally reduced with the PHQ-8, but specificity is similar.
Surgical site infections (SSIs) following colorectal surgery (CRS) are among the most common healthcare-associated infections (HAIs). Reduction in colorectal SSI rates is an important goal for surgical quality improvement.
To examine rates of SSI in patients with and without cancer and to identify potential predictors of SSI risk following CRS
American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) data files for 2011–2013 from a sample of 12 National Comprehensive Cancer Network (NCCN) member institutions were combined. Pooled SSI rates for colorectal procedures were calculated and risk was evaluated. The independent importance of potential risk factors was assessed using logistic regression.
Of 22 invited NCCN centers, 11 participated (50%). Colorectal procedures were selected by principal procedure current procedural technology (CPT) code. Cancer was defined by International Classification of Disease, Ninth Revision, Clinical Modification (ICD-9-CM) codes.
The primary outcome of interest was 30-day SSI rate.
A total of 652 SSIs (11.06%) were reported among 5,893 CRSs. Risk of SSI was similar for patients with and without cancer. Among CRS patients with underlying cancer, disseminated cancer (SSI rate, 17.5%; odds ratio [OR], 1.66; 95% confidence interval [CI], 1.23–2.26; P=.001), ASA score ≥3 (OR, 1.41; 95% CI, 1.09–1.83; P=.001), chronic obstructive pulmonary disease (COPD; OR, 1.6; 95% CI, 1.06–2.53; P=.02), and longer duration of procedure were associated with development of SSI.
Patients with disseminated cancer are at a higher risk for developing SSI. ASA score >3, COPD, and longer duration of surgery predict SSI risk. Disseminated cancer should be further evaluated by the Centers for Disease Control and Prevention (CDC) in generating risk-adjusted outcomes.
Sexual dimorphism is common in many extant animals, but it is difficult to demonstrate in fossil species. Working with material from the Late Cretaceous of the U.S. Coastal Plain, we herein analyze sexual dimorphism in ostracodes from the superfamily Cytheroidea, a group whose extant members have males that are relatively more elongate than females. We digitized outlines of more than 6000 individual ostracode valves or carapaces, extracted size (area) and shape (length-to-height ratio) information, and used finite mixture models to assess hypotheses of sexual dimorphism. Male and female clusters can be discerned in nearly all populations with sufficient data, resulting in estimates of size and shape dimorphism for 142 populations across 106 species; an additional nine samples are interpreted to consist only of females. Dimorphism patterns varied across taxa, especially for body size: males range from 30% larger to 20% smaller than females. Magnitudes of sexual dimorphism are generally stable within species across time and space; we can demonstrate substantial evolutionary changes in dimorphism in only one species, Haplocytheridea renfroensis. Several lines of evidence indicate that patterns of sexual dimorphism in these ostracodes reflect male investment in reproduction, suggesting that this study system has the potential to capture variation in sexual selection through the fossil record.
This work provides new insights into human responses to and perceptions of sea-level rise at a time when the landscapes of north-west Europe were radically changing. These issues are investigated through a case study focused on the Channel Islands. We report on the excavation of two sites, Canal du Squez in Jersey and Lihou (GU582) in Guernsey, and the study of museum collections across the Channel Islands. We argue that people were drawn to this area as a result of the dynamic environmental processes occurring and the opportunities these created. The evidence suggests that the area was a particular focus during the Middle Mesolithic, when Guernsey and Alderney were already islands and while Jersey was a peninsula of northern France. Insularisation does not appear to have created a barrier to occupation during either the Middle or Final Mesolithic, indicating the appearance of lifeways increasingly focused on maritime voyaging and marine resources from the second half of the 9th millennium BC onwards.
Few studies have investigated developmental strengths and weaknesses within the cognitive profile of children and adolescents with fragile X syndrome (FXS), a single-gene cause of inherited intellectual impairment. With a prospective longitudinal design and using normalized raw scores (Z scores) to circumvent floor effects, we measured cognitive functioning of 184 children and adolescents with FXS (ages 6 to 16) using the Wechsler Scale of Intelligence for Children on one to three occasions for each participant. Participants with FXS received lower raw scores relative to the Wechsler Scale of Intelligence for Children normative sample across the developmental period. Verbal comprehension, perceptual organization, and processing speed Z scores were marked by a widening gap from the normative sample, while freedom from distractibility Z scores showed a narrowing gap. Key findings include a relative strength for verbal skills in comparison with visuospatial–constructive skills arising in adolescence and a discrepancy between working memory (weakness) and processing speed (strength) in childhood that diminishes in adolescence. Results suggest that the cognitive profile associated with FXS develops dynamically from childhood to adolescence. Findings are discussed within the context of aberrant brain morphology in childhood and maturation in adolescence. We argue that assessing disorder-specific cognitive developmental profiles will benefit future disorder-specific treatment research.
Two broad aims drive weed science research: improved management and improved
understanding of weed biology and ecology. In recent years, agricultural
weed research addressing these two aims has effectively split into separate
subdisciplines despite repeated calls for greater integration. Although some
excellent work is being done, agricultural weed research has developed a
very high level of repetitiveness, a preponderance of purely descriptive
studies, and has failed to clearly articulate novel hypotheses linked to
established bodies of ecological and evolutionary theory. In contrast,
invasive plant research attracts a diverse cadre of nonweed scientists using
invasions to explore broader and more integrated biological questions
grounded in theory. We propose that although studies focused on weed
management remain vitally important, agricultural weed research would
benefit from deeper theoretical justification, a broader vision, and
increased collaboration across diverse disciplines. To initiate change in
this direction, we call for more emphasis on interdisciplinary training for
weed scientists, and for focused workshops and working groups to develop
specific areas of research and promote interactions among weed scientists
and with the wider scientific community.
Interventions that prevent healthcare-associated infection should lead to fewer deaths and shorter hospital stays. Cleaning hands (with soap or alcohol) is an effective way to prevent the transmission of organisms, but rates of compliance with hand hygiene are sometimes disappointingly low. The National Hand Hygiene Initiative in Australia aimed to improve hand hygiene compliance among healthcare workers, with the goal of reducing rates of healthcare-associated infection.
We examined whether the introduction of the National Hand Hygiene Initiative was associated with a change in infection rates. Monthly infection rates for healthcare-associated Staphylococcus aureus bloodstream infections were examined in 38 Australian hospitals across 6 states. We used Poisson regression and examined 12 possible patterns of change, with the best fitting pattern chosen using the Akaike information criterion. Monthly bed-days were included to control for increased hospital use over time.
The National Hand Hygiene Initiative was associated with a reduction in infection rates in 4 of the 6 states studied. Two states showed an immediate reduction in rates of 17% and 28%, 2 states showed a linear decrease in rates of 8% and 11% per year, and 2 showed no change in infection rates.
The intervention was associated with reduced infection rates in most states. The failure in 2 states may have been because those states already had effective initiatives before the national initiative’s introduction or because infection rates were already low and could not be further reduced.
Bushmeat trade is a threat to biodiversity in Africa. Information about the bushmeat value chain can inform conservation policies, yet such knowledge is lacking for most of East Africa. We examine the structure and organization of bushmeat markets in three villages in the Kilombero Valley of Tanzania, where illegal hunting is widespread. We base our analysis on 1,855 observations of trade during 1 year (2008–2009) and questionnaire interviews with 325 individuals involved in the trade in 2011. Our results reveal that the trade is large-scale both in volume (1,100 animals, equivalent to 370,000 kg meat per year) and local turnover (USD 210,000 per year) and that several threatened species are hunted. There are no patron–client relationships and hunters, traders and retailers, which are the main actors involved, conduct only basic product upgrading (drying and making packages). The value chain is characterized by governance problems, including widespread rent-seeking and violent enforcement. Although hunting is open-access, lack of access to firearms constitutes an entry barrier, curbing supply and enabling actors to realize supernormal profits. Decentralization of management rights and responsibilities to communities, supplemented by improved firearms control, appears the most realistic option for regulating the trade and preventing further declines of wildlife.