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The COVID-19 pandemic precipitated widespread change across health and social care in England and Wales. A series of lockdowns and UK Government guidance designed to reduce the spread of COVID-19 which emphasised social distancing and increased use of personal protective equipment led to changes such as increased use of remote consultation technologies and the closure of services deemed non-essential. This included many services for people with dementia and their families, such as day centres and dementia cafes.
To explore the changes made to services during the pandemic and the impact of these changes on the delivery of good post-diagnostic dementia support.
Professionals who had previously been recruited to the ongoing PriDem qualitative study were approached for follow up interview. Eighteen interviews with a total of 21 professionals working in health, social care and the third sector were conducted using telephone or video conferencing.
Interviews were audio recorded, transcribed and checked prior to thematic analysis.
Key themes emerging from preliminary analysis of the data include: uncertainty about the future and the need to adapt quickly to shifting guidance; changing job roles and ways of working; the emotional and physical impact of the pandemic on staff working with people with dementia and their families; and the impact of changes made (e.g. increased PPE, remote working) on the ability to deliver post-diagnostic support. However, there were also some unintended positive outcomes of the changes. These included the ability to include family members living at a distance in remote consultations, allowing for more robust history-taking, as well as the uptake of technology to facilitate cross-sector and multidisciplinary working between professionals.
Delivering post-diagnostic dementia support during COVID-19 was challenging and forced dementia services to make adaptations. Participants expected that some of these changes would be incorporated into post-pandemic work, for example increased use of technology for multidisciplinary team meetings or blended approaches to patient-facing services involving both virtual and face to face work as appropriate. However, most participants agreed that it was not appropriate nor desirable to provide fully remote post-diagnostic support on a full time basis.
The aim of this study is to systematically investigate the demographic and disease predictors of cognitive and behavioural phenotype in the largest cohort of children with NF1 published to date. Based on previously published research, we examine the potential role of demographic predictors such as age, sex, SES, parental NF1 status as well as the neurological complications such as epilepsy and brain tumours in NF1 associated cognitive/ behavioural impairments.
In this cross-sectional study design, participant data were drawn from two large databases which included (i) A clinical database of all patients with NF1 seen in a clinical psychological service from 2010 to 2019 and (ii) A research dataset from two previously published studies (2,8). The complex National NF1 service based within Manchester regional genetic services is set up for individuals with complex NF1 (https://www.mangen.co.uk/healthcare-professionals/clinical-genomic-services/nf1/) in the North of the UK. Children were referred to the psychological services by NF1 clinicians if psychological assessment was warranted based on parental reports. In order to reduce clinic referral bias, the clinical sample was supplemented by including participants that were seen solely for the purposes of research studies within our centre.
Relative to population norms, 90% of the NF1 sample demonstrated significantly lower scores in at least one cognitive or behavioral domain. Family history of NF1 and lower SES were independently associated with poorer cognitive, behavioral and academic outcomes. Neurological problems such as epilepsy and hydrocephalus were associated with lower IQ and academic skills.
Cognitive and behavioural phenotypes commonly emerge via a complex interplay between genes and environmental factors, and this is true also of a monogenic condition such as NF1. Early interventions and remedial education may be targeted to risk groups such those with familial NF1, families with lower SES and those with associated neurological comorbidities.
The objective of this scoping review was to examine the research question: In the adults with or without cardiometabolic risk, what is the availability of literature examining interventions to improve or maintain nutrition and physical activity-related outcomes? Sub-topics included: (1) behaviour counseling or coaching from a dietitian/nutritionist or exercise practitioner, (2) mobile applications to improve nutrition and physical activity and (3) nutritional ergogenic aids.
The current study is a scoping review. A literature search of the Medline Complete, CINAHL Complete, Cochrane Database of Systematic Reviews and other databases was conducted to identify articles published in the English language from January 2005 until May 2020. Data were synthesised using bubble charts and heat maps.
Out-patient, community and workplace.
Adults with or without cardiometabolic risk factors living in economically developed countries.
Searches resulted in 19 474 unique articles and 170 articles were included in this scoping review, including one guideline, thirty systematic reviews (SR), 134 randomised controlled trials and five non-randomised trials. Mobile applications (n 37) as well as ergogenic aids (n 87) have been addressed in several recent studies, including SR. While primary research has examined the effect of individual-level nutrition and physical activity counseling or coaching from a dietitian/nutritionist and/or exercise practitioner (n 48), interventions provided by these practitioners have not been recently synthesised in SR.
SR of behaviour counseling or coaching provided by a dietitian/nutritionist and/or exercise practitioner are needed and can inform practice for practitioners working with individuals who are healthy or have cardiometabolic risk.
To identify a posteriori dietary patterns among women planning pregnancy and assess the reproducibility of these patterns in a subsample using two dietary assessment methods.
A semi-quantitative FFQ was administered to women enrolled in the Singapore PREconception Study of long-Term maternal and child Outcomes study. Dietary patterns from the FFQ were identified using exploratory factor analysis (EFA). In a subsample of women (n 289), 3-d food diaries (3DFD) were also completed and analysed. Reproducibility of the identified patterns was assessed using confirmatory factor analysis (CFA) in the subsample, and goodness of fit of the CFA models was examined using several fit indices. Subsequently, EFA was conducted in the subsample and dietary patterns of the FFQ and the 3DFD were compared.
1007 women planning pregnancy (18–45 years).
Three dietary patterns were identified from the FFQ: the ‘Fish, Poultry/Meat and Noodles’ pattern was characterised by higher intakes of fish, poultry/meat and noodles in soup; ‘Fast Food and Sweetened Beverages’ pattern was characterised by higher intakes of fast food, sweetened beverages and fried snacks; ‘Bread, Legumes and Dairy’ pattern was characterised by higher intakes of buns/ethnic breads, nuts/legumes and dairy products. The comparative fit indices from the CFA models were 0·79 and 0·34 for the FFQ and 3DFD of the subsample, respectively. In the subsample, three similar patterns were identified in the FFQ while only two for the 3DFD.
Dietary patterns from the FFQ are reproducible within this cohort, providing a basis for future investigations on diet and health outcomes.
Ensuring equitable access to health care is a widely agreed-upon goal in medicine, yet access to care is a multidimensional concept that is difficult to measure. Although frameworks exist to evaluate access to care generally, the concept of “access to genomic medicine” is largely unexplored and a clear framework for studying and addressing major dimensions is lacking.
Comprised of seven clinical genomic research projects, the Clinical Sequencing Evidence-Generating Research consortium (CSER) presented opportunities to examine access to genomic medicine across diverse contexts. CSER emphasized engaging historically underrepresented and/or underserved populations. We used descriptive analysis of CSER participant survey data and qualitative case studies to explore anticipated and encountered access barriers and interventions to address them.
CSER’s enrolled population was largely lower income and racially and ethnically diverse, with many Spanish-preferring individuals. In surveys, less than a fifth (18.7%) of participants reported experiencing barriers to care. However, CSER project case studies revealed a more nuanced picture that highlighted the blurred boundary between access to genomic research and clinical care. Drawing on insights from CSER, we build on an existing framework to characterize the concept and dimensions of access to genomic medicine along with associated measures and improvement strategies.
Our findings support adopting a broad conceptualization of access to care encompassing multiple dimensions, using mixed methods to study access issues, and investing in innovative improvement strategies. This conceptualization may inform clinical translation of other cutting-edge technologies and contribute to the promotion of equitable, effective, and efficient access to genomic medicine.
Background: Shared Healthcare Intervention to Eliminate Life-threatening Dissemination of MDROs in Orange County, California (SHIELD OC) was a CDC-funded regional decolonization intervention from April 2017 through July 2019 involving 38 hospitals, nursing homes (NHs), and long-term acute-care hospitals (LTACHs) to reduce MDROs. Decolonization in NH and LTACHs consisted of universal antiseptic bathing with chlorhexidine (CHG) for routine bathing and showering plus nasal iodophor decolonization (Monday through Friday, twice daily every other week). Hospitals used universal CHG in ICUs and provided daily CHG and nasal iodophor to patients in contact precautions. We sought to evaluate whether decolonization reduced hospitalization and associated healthcare costs due to infections among residents of NHs participating in SHIELD compared to nonparticipating NHs. Methods: Medicaid insurer data covering NH residents in Orange County were used to calculate hospitalization rates due to a primary diagnosis of infection (counts per member quarter), hospital bed days/member-quarter, and expenditures/member quarter from the fourth quarter of 2015 to the second quarter of 2019. We used a time-series design and a segmented regression analysis to evaluate changes attributable to the SHIELD OC intervention among participating and nonparticipating NHs. Results: Across the SHIELD OC intervention period, intervention NHs experienced a 44% decrease in hospitalization rates, a 43% decrease in hospital bed days, and a 53% decrease in Medicaid expenditures when comparing the last quarter of the intervention to the baseline period (Fig. 1). These data translated to a significant downward slope, with a reduction of 4% per quarter in hospital admissions due to infection (P < .001), a reduction of 7% per quarter in hospitalization days due to infection (P < .001), and a reduction of 9% per quarter in Medicaid expenditures (P = .019) per NH resident. Conclusions: The universal CHG bathing and nasal decolonization intervention adopted by NHs in the SHIELD OC collaborative resulted in large, meaningful reductions in hospitalization events, hospitalization days, and healthcare expenditures among Medicaid-insured NH residents. The findings led CalOptima, the Medicaid provider in Orange County, California, to launch an NH incentive program that provides dedicated training and covers the cost of CHG and nasal iodophor for OC NHs that enroll.
Disclosures: Gabrielle M. Gussin, University of California, Irvine, Stryker (Sage Products): Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Clorox: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Medline: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes. Xttrium: Conducting studies in which contributed antiseptic product is provided to participating hospitals and nursing homes.
Local governments have integral roles in contributing to public health. One recent focus has been on how local governments can impact community nutrition by engaging food service outlets to improve their food offer. The Healthier Catering Commitment (HCC) is an initiative where London local governments support takeaways and restaurants to meet centrally defined nutrition criteria on their food options. Using the case of HCC, the current study aims to provide (1) practical learnings of how local governments could facilitate and overcome barriers associated with implementing healthy food service initiatives in general, and (2) specific recommendations for enhancements for HCC.
Key informant, semi-structured interviews were conducted with local government staff involved in HCC, exploring barriers and facilitators to HCC implementation in food businesses. A thematic analysis approach was used, with results presented according to a logic pathway of ideal implementation in order to provide practical, focused insights.
Facilitators to implementation included flexible approaches, shared resourcing and strategically engaging businesses with practical demonstrations. Barriers were limited resources, businesses fearing negative customer responses and low uptake in disadvantaged areas. Key suggestions to enhance implementation and impact included offering additional incentives, increasing HCC awareness and encouraging recruited businesses to make healthy changes beyond initiative requirements.
In order to facilitate the implementation of healthy food initiatives in food outlets, local governments would benefit from involving their environmental health team, employing community-tailored approaches and focusing on supporting businesses in disadvantaged areas.
To examine factors that influence decision-making, preferences, and plans related to advance care planning (ACP) and end-of-life care among persons with dementia and their caregivers, and examine how these may differ by race.
13 geographically dispersed Alzheimer’s Disease Centers across the United States.
431 racially diverse caregivers of persons with dementia.
Survey on “Care Planning for Individuals with Dementia.”
The respondents were knowledgeable about dementia and hospice care, indicated the person with dementia would want comfort care at the end stage of illness, and reported high levels of both legal ACP (e.g., living will; 87%) and informal ACP discussions (79%) for the person with dementia. However, notable racial differences were present. Relative to white persons with dementia, African American persons with dementia were reported to have a lower preference for comfort care (81% vs. 58%) and lower rates of completion of legal ACP (89% vs. 73%). Racial differences in ACP and care preferences were also reflected in geographic differences. Additionally, African American study partners had a lower level of knowledge about dementia and reported a greater influence of religious/spiritual beliefs on the desired types of medical treatments. Notably, all respondents indicated that more information about the stages of dementia and end-of-life health care options would be helpful.
Educational programs may be useful in reducing racial differences in attitudes towards ACP. These programs could focus on the clinical course of dementia and issues related to end-of-life care, including the importance of ACP.
Making data broadly accessible is essential to creating a medical information commons (MIC). Transparency about data-sharing practices can cultivate trust among prospective and existing MIC participants. We present an analysis of 34 initiatives sharing DNA-derived data based on public information. We describe data-sharing practices captured, including practices related to consent, privacy and security, data access, oversight, and participant engagement. Our results reveal that data-sharing initiatives have some distance to go in achieving transparency.
The US Agency for Healthcare Research and Quality (AHRQ) Evidence-based Practice Center (EPC) program sponsors the development of systematic reviews to inform clinical policy and practice. The EPC program sought to better understand how health systems identify and use this evidence.
Representatives from eleven EPCs, the EPC Scientific Resource Center, and AHRQ developed a semi-structured interview script to query a diverse group of nine Key Informants (KIs) involved in health system quality, safety and process improvement about how they identify and use evidence. Interviews were transcribed and qualitatively summarized into key themes.
All KIs reported that their organizations have either centralized quality, safety, and process improvement functions within their system, or they have partnerships with other organizations to conduct this work. There was variation in how evidence was identified, with larger health systems having medical librarians and central bureaus to gather and disseminate information and smaller systems having local chief medical officers or individual clinicians do this work. KIs generally prefer guidelines, especially those with treatment algorithms, because they are actionable. They like systematic reviews because they efficiently condense study results and reconcile conflicting data. They prefer information from systematic reviews to be presented as short digestible summaries with the full report available on demand. KIs preferred systematic reviews from reputable entities and those without commercial bias. Some of the challenges KIs reported include how to resolve conflicting evidence, the generalizability of evidence to local needs, determining whether the evidence is up-to-date, and the length of time required to generate reviews. The topics of greatest interest included predictive analytics, high-value care, advance care planning, and care coordination. To increase awareness of AHRQ EPC reviews, KIs suggest alerting people at multiple levels in a health-system when new evidence reports are available and making reports easier to find in common search engines.
Systematic reviews are valued by health system leaders. To be most useful they should be easy to locate and available in different formats targeted to the needs of different audiences.
To explore influences on diet in a group of community-dwelling older adults in the UK.
Data were collected through focus group discussions with older people; discussions were audio-recorded, transcribed verbatim and transcripts analysed thematically.
Participants were sampled purposively from the Hertfordshire Cohort Study, focusing on those whose diets had been assessed at two time points: 1998–2001 and 2011.
Ninety-two adults participated (47 % women; 74–83 years) and eleven focus groups were held. A number of age-related factors were identified that were linked to food choices, including lifelong food experiences, retirement, bereavement and medical conditions, as well as environmental factors (such as transport). There appeared to be variability in how individuals responded to these influences, indicating that other underlying factors may mediate the effects of age-related factors on diet. Discussions about ‘keeping going’, being motivated to ‘not give up’, not wanting to be perceived as ‘old’, as well as examples of resilience and coping strategies, suggest the importance of mediating psychological factors. In addition, discussion about social activities and isolation, community spirit and loneliness, indicated the importance of social engagement as an influence on diet.
Interventions to promote healthier diets in older age should take account of underlying psychological and social factors that influence diet, which may mediate the effects of age-related factors.
To develop an automated method for ventilator-associated condition (VAC) surveillance and to compare its accuracy and efficiency with manual VAC surveillance
The intensive care units (ICUs) of 4 hospitals
This study was conducted at Detroit Medical Center, a tertiary care center in metropolitan Detroit. A total of 128 ICU beds in 4 acute care hospitals were included during the study period from August to October 2013. The automated VAC algorithm was implemented and utilized for 1 month by all study hospitals. Simultaneous manual VAC surveillance was conducted by 2 infection preventionists and 1 infection control fellow who were blinded to each another’s findings and to the automated VAC algorithm results. The VACs identified by the 2 surveillance processes were compared.
During the study period, 110 patients from all the included hospitals were mechanically ventilated and were evaluated for VAC for a total of 992 mechanical ventilation days. The automated VAC algorithm identified 39 VACs with sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 100%. In comparison, the combined efforts of the IPs and the infection control fellow detected 58.9% of VACs, with 59% sensitivity, 99% specificity, 91% PPV, and 92% NPV. Moreover, the automated VAC algorithm was extremely efficient, requiring only 1 minute to detect VACs over a 1-month period, compared to 60.7 minutes using manual surveillance.
The automated VAC algorithm is efficient and accurate and is ready to be used routinely for VAC surveillance. Furthermore, its implementation can optimize the sensitivity and specificity of VAC identification.
Infect. Control Hosp. Epidemiol. 2015;36(9):999–1003
Augmented reality (AR) is defined by Wikipedia (2014) as ‘a live direct or indirect view of a physical, real-world environment whose elements are augmented (or supplemented) by computer-generated sensory input such as sound, video, graphics or GPS data’.
The use of AR in the worlds of entertainment and commerce has increased rapidly in the last few years, bringing to life objects, printed matter and even locations by enriching what we see around us with additional digital resources. In effect, the use of AR creates a virtual layer on top of our actual situation to enhance our experience through the addition of rich media.
Several brands are using AR to add these virtual layers to physical objects, notably the UK retailers Tesco and Marks & Spencer, who have included AR in their customer magazines to offer readers the opportunity to view videos of recipes being turned into meals, simply by holding their smartphone or tablet over a particular image. More recently, we have started to see educational institutions exploring the possibilities that AR offers not only for public engagement and marketing, but also for enhancing teaching and the student learning experience.
During the 2012–13 academic year at the University of Bath, the library and the e-learning teams worked collaboratively with the students’ union, the Public Engagement department and others to experiment with AR in a university setting, using agile development techniques to create applications for its use and to engage the university community with this emerging technology. The collaborative partnerships within this project team quickly established a group dynamic of co-operation rather than competition. In particular, the direct involvement of the ‘student voice’ coming from the students’ union added to the project's credibility at the highest levels within the university and was especially helpful in generating ideas and priorities.
The project had little financial resource on which to call and it was therefore important for us to draw on the expertise and enthusiasm of the collaborators and on their networks and knowledge. We built on previous experience of being an early adopter of QR codes (Robinson, 2010). We also used commercial contacts in the city of Bath (Bath University, 2014) who were already experimenting with AR, and drew upon the expertise of colleagues at MIMAS in Manchester (MIMAS, 2014), including their AR Project Manager Matt Ramirez.
To test the hypothesis that maternal psychological profiles relate to children’s quality of diet.
Cross-sectional study. Mothers provided information on their health-related psychological factors and aspects of their child’s mealtime environment. Children’s diet quality was assessed using an FFQ from which weekly intakes of foods and a diet Z-score were calculated. A high score described children with a better quality diet. Cluster analysis was performed to assess grouping of mothers based on psychological factors. Mealtime characteristics, describing how often children ate while sitting at a table or in front of the television, their frequency of takeaway food consumption, maternal covert control and food security, and children’s quality of diet were examined, according to mothers’ cluster membership.
Mother–child pairs (n 324) in the Southampton Initiative for Health. Children were aged 2–5 years.
Two main clusters were identified. Mothers in cluster 1 had significantly higher scores for all psychological factors than mothers in cluster 2 (all P<0·001). Clusters were termed ‘more resilient’ and ‘less resilient’, respectively. Children of mothers in the less resilient cluster ate meals sitting at a table less often (P=0·03) and watched more television (P=0·01). These children had significantly poorer-quality diets (β=−0·61, 95 % CI −0·82, −0·40, P≤0·001). This association was attenuated, but remained significant after controlling for confounding factors that included maternal education and home/mealtime characteristics (P=0·006).
The study suggests that mothers should be offered psychological support as part of interventions to improve children’s quality of diet.