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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.
Early assessment, diagnosis and management for people living with dementia is essential, both for the patient and their carers. We recognised delays in established local pathways when patients had unplanned acute hospital admissions preventing them from attending memory diagnostic appointments. The Psychiatric Liaison Team (PLT) Memory Pathway was introduced as we had the skills and expertise to resume the process and to find new undetected patients.
Our aim was to determine how well the newly implemented PLT Memory Pathway follows the standards outlined in the National Institute of Health & Care Excellence (NICE) Clinical Guideline 97 (CG97): Assessment, management and support for people living with dementia and their carers.
A retrospective analysis of all PLT referrals from July 2018 to February 2020 (20 months) was performed to identify patients on the community memory pathway and those with possible undetected cognitive impairment. Data were collected from electronic patient records which included demographics, primary and collateral history, cognitive testing and imaging, dementia type among others. Results were analysed using Microsoft Excel.
41 patients were included (59% female). 80% of patients were referred for memory problems or confusion. 63% had previous referrals to a memory service and was on the community memory pathway at the time of the referral. 34% were on anticholinergic medication but in only 14% were this documented as reviewed. 100 % were offered and had head imaging. A finding worthy of note was the absence of any from the ethnic minority background. 63% of patients were given a memory diagnosis and 34% had anti-dementia medication started. Patients’ families were made aware of the diagnosis in 83% of cases, due to the absence of next of kin details in the patient record. Primary Care was made aware in 100% of cases; post-diagnostic support was 100%.
The PLT is well placed to bridge the service gap between the acute care trust and established community memory services when dealing with patients with dementia. A dedicated Memory Pathway has helped to close this gap and adherence to NICE CG97 standards was good, but there is room for improvement. A particular focus will be on improving documentation of anticholinergic medication review and exploration for the absence of ethnic minority patients. Aiming to achieve 100% family involvement is also recommended.
This study has been submitted to the Royal College of Psychiatrists' Faculty of Old Age Annual Conference 2021.
Recently the NHS has expanded the provision of liaison mental health services (LMHS) to ensure that every acute hospital with an emergency department in England has a liaison psychiatry service. Little work has been undertaken to explore first-hand experiences of these services. The aim of this study was to capture service users’ experiences of LMHS in both emergency departments and acute inpatient wards in the UK, with a view to adapt services to better meet the needs of its users.
This cross-sectional internet survey was initially advertised from May-July 2017 using the social media platform Facebook. Due to a paucity of male respondents, it was re-run from November 2017-February 2018, specifically targeting this demographic group. 184 people responded to the survey, of which 147 were service users and 37 were service users’ accompanying partners, friends or family members. The survey featured a structured questionnaire divided into three categories: the profile of the respondent, perceived professionalism of LMHS, and overall opinion of the service. Space was available for free-text comments in each section. Descriptive analysis of quantitative data was undertaken with R statistical software V.3.2.2. Qualitative data from free-text comments were transcribed and interpreted independently by three researchers using framework analysis; familiarisation with the data was followed by identification of a thematic framework, indexing, charting, mapping and interpretation.
Opinions of the service were mixed but predominantly negative. 31% of service users and 27% of their loved ones found their overall contact with LMHS useful. Features most frequently identified as important were the provision of a 24/7 service, assessment by a variety of healthcare professionals and national standardisation of services. Respondents indicated that the least important feature was the provision of a separate service for older people. They also expressed that a desirable LMHS would include faster assessments following referral from the parent team, clearer communication about next steps and greater knowledge of local services and third sector organisations.
Our survey identified mixed responses, however service users and their loved ones perceived LMHS more frequently as negative than positive. This may be attributed to the recent governmental drive to assess, treat and discharge 95% of all patients seen in emergency departments within four hours of initial attendance. Additionally, dissatisfied service users are more likely to volunteer their opinions. The evaluation and adaptation of LMHS should be prioritised to enhance their inherent therapeutic value and improve engagement with treatment and future psychiatric care.
Target Product Profiles (TPPs) outline the characteristics that new health technologies require to address an unmet clinical need. To date, published TPPs for medical tests have focused on infectious diseases, mostly in the context of low- and middle-income countries. Recently, there have been calls for a broader use of TPPs as a mechanism to ensure that diagnostic innovation is aligned with clinical needs, yet the methodology underpinning TPP development remains suboptimal. Here, we propose that early economic evaluation (EEE) should be integrated within the TPP methodology to create a more rigorous framework for the development of “fit-for-purpose” tests. We discuss the potential benefits that EEE could bring to the core activities underpinning TPP development—scoping, drafting, consensus building, and updating—and argue that using EEE to help inform TPPs provides a more objective, evidence-based, and transparent approach to defining test specifications.
The effect of minor orthopaedic day surgery (MiODS) on patient’s mood.
A prospective population-based cohort study of 148 consecutive patients with age above 18 and less than 65, an American Society of Anaesthesiology (ASA) score of 1, and the requirement of general anaesthesia (GA) were included. The Medical Outcomes Study – Short Form 36 (SF-36), Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI) were used pre- and post-operatively.
The mean physical component score of SF-36 before surgery was 45.3 (SD = ±10.1) and 8 weeks following surgery was 44.9 (SD = ±11.04) [n = 148, p = 0.51, 95% CI = (−1.03 to 1.52)]. For the measurement of the changes in mood using BDI, BAI and SF-36, latent construct modelling was employed to increase validity. The covariance between mood pre- and post-operatively (cov = 69.44) corresponded to a correlation coefficient, r = 0.88 indicating that patients suffering a greater number of mood symptoms before surgery continue to have a greater number of symptoms following surgery. When the latent mood constructs were permitted to have different means the model fitted well with χ2 (df = 1) = 0.86 for which p = 0.77, thus the null hypothesis that MiODS has no effect on patient mood was rejected.
MiODS affects patient mood which deteriorates at 8 weeks post-operatively regardless of the pre-operative patient mood state. More importantly patients suffering a greater number of mood symptoms before MiODS continue to have a greater number of symptoms following surgery.
Increasing fluorination of organosilyl nitrile solvents improves ionic conductivities of lithium salt electrolytes, resulting from higher values of salt dissociation. Ionic conductivities at 298 K range from 1.5 to 3.2 mS/cm for LiPF6 salt concentrations at 0.6 or 0.7 M. The authors also report on solvent blend electrolytes where the fluoroorganosilyl (FOS) nitrile solvent is mixed with ethylene carbonate and diethyl carbonate. Ionic conductivities of the FOS solvent/carbonate blend electrolytes increase achieving ionic conductivities at 298 K of 5.5–6.3 mS/cm and salt dissociation values ranging from 0.42 to 0.45. Salt dissociation generally decreases with increasing temperature.
The authors report on 7Li, 19F, and 1H pulsed field gradient NMR measurements of 26 organosilyl nitrile solvent-based electrolytes of either lithium bis(trifluorosulfonyl)imide (LiTFSI) or lithium hexafluorophosphate. Lithium transport numbers (as high as 0.50) were measured and are highest in the LiTFSI electrolytes. The authors also report on solvent blend electrolytes of fluoroorganosilyl (FOS) nitrile solvent mixed with ethylene carbonate (EC) and diethyl carbonate. Solvent diffusion measurements on an electrolyte with 6% FOS suggest both the FOS and EC solvate the lithium cation. By comparing lithium transport and transference numbers, the authors find less ion pairing in FOS nitrile carbonate blend electrolytes and difluoroorganosilyl nitrile electrolytes.
The longevity of Cassini’s exploration of Saturn’s atmosphere (a third of a Saturnian year) means that we have been able to track the seasonal evolution of atmospheric temperatures, chemistry and cloud opacity over almost every season, from solstice to solstice and from perihelion to aphelion. Cassini has built upon the decades-long ground-based record to observe seasonal shifts in atmospheric temperature, finding a thermal response that lags behind the seasonal insolation with a lag time that increases with depth into the atmosphere, in agreement with radiative climate models. Seasonal hemispheric contrasts are perturbed at smaller scales by atmospheric circulation, such as belt/zone dynamics, the equatorial oscillations and the polar vortices. Temperature asymmetries are largest in the middle stratosphere and become insignificant near the radiative-convective boundary. Cassini has also measured southern-summertime asymmetries in atmospheric composition, including ammonia (the key species forming the topmost clouds), phosphine and para-hydrogen (both disequilibrium species) in the upper troposphere; and hydrocarbons deriving from the UV photolysis of methane in the stratosphere (principally ethane and acetylene). These chemical asymmetries are now altering in subtle ways due to (i) the changing chemical efficiencies with temperature and insolation and (ii) vertical motions associated with large-scale overturning in response to the seasonal temperature contrasts. Similarly, hemispheric contrasts in tropospheric aerosol opacity and coloration that were identified during the earliest phases of Cassini’s exploration have now reversed, suggesting an intricate link between the clouds and the temperatures. Finally, comparisons of observations between Voyager and Cassini (both observing in early northern spring, one Saturn year apart) show tantalizing suggestions of non-seasonal variability. Disentangling the competing effects of radiative balance, chemistry and dynamics in shaping the seasonal evolution of Saturn’s temperatures, clouds and composition remains the key challenge for the next generation of observations and numerical simulations.
This chapter reviews the state of our knowledge about Saturn’s polar atmosphere that has been revealed through Earth- and space-based observation as well as theoretical and numerical modeling. In particular, the Cassini mission to Saturn, which has been in orbit around the ringed planet since 2004, has revolutionized our understanding of the planet. The current review updates a previous review by Del Genio et al. (2009), written after Cassini’s primary mission phase that ended in 2008, by focusing on the north polar region of Saturn and comparing it to the southern high latitudes. Two prominent features in the northern high latitudes are the northern hexagon and the north polar vortex; we extensively review observational and theoretical investigations to date of both features. We also review the seasonal evolution of the polar regions using the observational data accumulated during the Cassini mission since 2004 (shortly after the northern winter solstice in 2002), through the equinox in 2009, and approaching the next solstice in 2017. We conclude the current review by listing unanswered questions and describing the observations of the polar regions planned for the Grand Finale phase of the Cassini mission between 2016 and 2017.
An estimated 293,300 healthcare-associated cases of Clostridium difficile infection (CDI) occur annually in the United States. To date, research has focused on developing risk prediction models for CDI that work well across institutions. However, this one-size-fits-all approach ignores important hospital-specific factors. We focus on a generalizable method for building facility-specific models. We demonstrate the applicability of the approach using electronic health records (EHR) from the University of Michigan Hospitals (UM) and the Massachusetts General Hospital (MGH).
We utilized EHR data from 191,014 adult admissions to UM and 65,718 adult admissions to MGH. We extracted patient demographics, admission details, patient history, and daily hospitalization details, resulting in 4,836 features from patients at UM and 1,837 from patients at MGH. We used L2 regularized logistic regression to learn the models, and we measured the discriminative performance of the models on held-out data from each hospital.
Using the UM and MGH test data, the models achieved area under the receiver operating characteristic curve (AUROC) values of 0.82 (95% confidence interval [CI], 0.80–0.84) and 0.75 ( 95% CI, 0.73–0.78), respectively. Some predictive factors were shared between the 2 models, but many of the top predictive factors differed between facilities.
A data-driven approach to building models for estimating daily patient risk for CDI was used to build institution-specific models at 2 large hospitals with different patient populations and EHR systems. In contrast to traditional approaches that focus on developing models that apply across hospitals, our generalizable approach yields risk-stratification models tailored to an institution. These hospital-specific models allow for earlier and more accurate identification of high-risk patients and better targeting of infection prevention strategies.
Introduction: Higher levels of anxiety and depression have been found to be associated with greater difficulty in stopping smoking. This raises the question as to whether mood disturbance may be associated with exposure to, and use of, quitting support.
Aims: This study examined whether General Practitioner (GP) advice and/or offer of support, or stop-smoking service use differed between smokers reporting or not reporting depression/anxiety.
Methods: Data came from the Smoking Toolkit Study. Participants were 1,162 English adults who reported currently smoking or having stopped within the past 12 months, aged 40+ years, surveyed between April and September 2012. Anxiety/depression was assessed by the mood disturbance item of the EuroQol five dimensions questionnaire (EQ-5D). This was compared to recall of GP quit advice and/or support, and stop-smoking aid use adjusting for age, gender, and social grade.
Results/Findings: Smokers reporting depression/anxiety were more likely to recall being offered advice and support to stop smoking by their GP (OR = 1.50, 95% C.I. = 1.05–2.13). However, there were no significant differences in use of stop-smoking aids during the past year.
Conclusions: Smokers reporting depression/anxiety are more likely to be offered stop-smoking support by their GPs, but this does not appear to translate into stop-smoking aid use, despite high motivation to quit. Given higher nicotine dependence in this group, mental health specific support may need to be offered, and more needs to be done to make this offer of aid attractive.
Bacterial cultures exposed to iron-doped apatite nanoparticles (IDANPs) prior to the introduction of antagonistic viruses experience up to 2.3 times the bacterial destruction observed in control cultures. Maximum antibacterial activity of these bacteria-specific viruses, or phage, occurs after bacterial cultures have been exposed to IDANPs for 1 hr prior to phage introduction, demonstrating that IDANP-assisted phage therapy would not be straight forward, but would instead require controlled time release of IDANPs and phage. These findings motivated the design of an electrospun nanofiber mesh treatment delivery system that allows burst release of IDANPs, followed by slow, consistent release of phage for treatment of topical bacterial infections. IDANPs resemble hydroxyapatite, a biocompatible mineral analogous to the inorganic constituent of mammalian bone, which has been approved by the Food and Drug Administration for many biomedical purposes. The composite nanofiber mesh was designed for IDANP-assisted phage therapy treatment of topical wounds and consists of a superficial, rapid release layer of polyethylene oxide (PEO) fibers doped with IDANPs, followed by inner, coaxial polycaprolactone / polyethylene glycol (PCL/PEG) blended polymer fiber layer for slower phage delivery. Our investigations have established that IDANP-doped PEO fibers are effective vehicles for dissemination of IDANPs for bacterial exposure and resultant increased bacterial death by phage. In this work, slower delivery of the phage behind IDANPs was accomplished using coaxial, electrospun fibers composed of PCL/PEG polymer blend.
Russian-olive is a nitrogen-fixing tree invading riparian corridors in western North America. The premise of revegetation after weed removal is that revegetation is required to return native species to a removal site and that revegetation improves site resistance to invasion or reinvasion via competitive exclusion. Therefore, we expected that revegetation would reduce invasive species cover and increase native species cover compared with non-revegetated controls. Native understory species diversity increased with time since removal. We recorded 18.2 native species in 2012, and 28.2 native species in 2016. Out of 22 planted species, 2 did not establish. Diversity in revegetated plots did not differ from unplanted controls, likely because species spread quickly across plot boundaries. Native perennial grass, seeded species, and annual bromes increased over time, while nonnative forbs and native forbs decreased over time. Only invasive perennial grass cover responded to the revegetation treatment with cover much higher in controls compared with revegetated plots (25.7% vs. 7.7%); this was likely a response to a preplanting herbicide treatment. All categories of species diversity except invasive species diversity increased over time. Only 4% of Russian-olive stumps resprouted in the first year of removal, less than 1% resprouted 2 yr after removal. There was no Russian-olive emergence from seed in the removal year, and seed emergence varied exponentially among following years. Seeded native species did not have trouble establishing once adequate spring moisture occurred in the second growing season after Russian-olive removal, indicating that removal did not present substantial obstacles to successful revegetation. Follow-up control of Russian-olive is critical after initial treatment.
Introduction: There is wide variation in the success rates of practitioners employed to help smokers to stop, even once a range of potential confounding factors has been taken into account.
Aim: This paper examined whether personality characteristics of practitioners might play a role success rates.
Methods: Data from 1,958 stop-smoking treatment episodes in two stop-smoking services (SSS) involving 19 stop-smoking practitioners were used in the analysis. The outcome measure was clients’ biochemically verified quit status 4 weeks after the target quit date. The five dimensions of personality, as assessed by the Ten-Item Personality Inventory, were included as predictor variables: openness, conscientiousness, agreeableness, extraversion, and neuroticism. A range of client and other practitioner characteristics were used as covariates. A sensitivity analysis was conducted to determine if managers' ratings of practitioner personality were also associated with clients’ quit status.
Results: Multi-level random intercept models indicated that clients of practitioners with a higher extraversion score had greater odds of being abstinent at four weeks (self-assessed: OR = 1.10, 95% CI = 1.01–1.19; manager-assessed: OR = 1.32, 95% CI = 1.21–1.44).
Conclusions: More extraverted stop smoking practitioners appear to have greater success in advising their clients to quit smoking. Findings need to be confirmed in larger practitioner populations, other SSS, and in different smoking cessation contexts. If confirmed, specific training may be needed to assist more introverted stop smoking practitioners.
Background: Status epilepticus (SE) is a frequent admission diagnosis to paediatric intensive care units (PICUs) and is associated with variable outcomes. We have audited our experience of patients presenting in SE at a Canadian PICU to determine unfavorable outcome variables. Methods: Charts of patients <18 years of age presenting in SE to a tertiary care PICU over a 10-year period were audited. Data were analyzed at three care-points: transport, the emergency department (ED) and the PICU. Patient outcome before PICU discharge was categorized as “favorable” for return to pre-status functioning level or “unfavorable” for new deficit/death. Student’s t-test and the Kruskal-Wallis test were used for analysis of normal and skewed continuous variables, respectively, and either Chi-square test or Fisher’s exact test for categorical variables. Results: 189 patients (54% males) were identified with a median age of 1.9 years. Idiopathic SE had the highest incidence; infectious/vascular etiologies were associated with more unfavorable outcomes. Progression to refractory SE in the ED had a higher incidence of death (p<0.05). Patients with an unfavorable outcome had a higher incidence of apnea during transport (p=0.01), longer hospital stays (p<0.05), need for therapeutic coma (p=0.01), longer duration of therapeutic coma (p<0.05), need for mechanical ventilation (p<0.05), and recurrent or refractory seizures during inpatient stay (p<0.05). Multivariate analysis of unfavorable outcomes of patients in SE presenting to the PICU included renal failure, cerebral edema, apnea during transport, refractory seizures, and recurrent seizures. Conclusions: Refractory seizures in children presenting with SE are associated with worsened outcomes in the PICU.
Depression is a particular problem in older people and it is important to know how it affects and is affected by smoking cessation.
To identify reciprocal, longitudinal relationships between smoking cessation and depression among older smokers.
Across four waves, covering six years (2002–2008), changes in smoking status and depression, measured using the 8-item Centre for Epidemiologic Studies Depression Scale, were assessed among recent ex-smokers and smokers (n = 2375) in the English Longitudinal Study of Ageing.
In latent growth curve analysis, smoking at baseline predicted depression caseness longitudinally and vice versa. When both processes were modelled concurrently, depression predicted continued smoking longitudinally (B(β) = 0.21 (0.27); 95% CI = 0.08–0.35) but not the other way round. This was the case irrespective of mental health history and adjusting for a range of covariates.
In older smokers, depression appears to act as an important barrier to quitting, although quitting has no long-term impact on depression.