Homicidal ideation in family carers of people with dementia

OBJECTIVE

Family carers of people with dementia have higher than average rates of suicidal ideation, but there has been no research on homicidal ideation in this population. The aim of this study was to explore thoughts of homicide in family carers of people with dementia.

METHOD

A descriptive qualitative approach was taken. Twenty-one Australian carers (7 men, 14 women) participated in individual, in-depth interviews and the transcripts were analysed thematically.

RESULTS

Seven themes were identified in the data - active thoughts of homicide; understanding homicidal thoughts in others; passive thoughts of death; euthanasia; homicidal thoughts in other caregiving situations; abuse; and disclosing thoughts of harm. Two of the 21 participants had actively contemplated the homicide of their care recipient, four expressed a passive desire for the care recipient's death, and four reported physically or verbally abusing the care recipient. Only one carer had previously disclosed these experiences.

CONCLUSION

Homicidal ideation is a real and significant phenomenon among family carers of people with dementia. Service providers and health professionals are encouraged to identify and support carers contemplating homicide, but to do so in a way that recognises the broader social context of carer burden.

Recreational physical activity in natural environments and implications for health: A population based cross-sectional study in England

BACKGROUND

Building on evidence that natural environments (e.g. parks, woodlands, beaches) are key locations for physical activity, we estimated the total annual amount of adult recreational physical activity in England's natural environments, and assessed implications for population health.

METHODS

A cross-sectional analysis of six waves (2009/10-2014/5) of the nationally representative, Monitor of Engagement with the Natural Environment survey (n=280,790). The survey uses a weekly quota sample, and population weights, to estimate nature visit frequency across England, and provides details on a single, randomly selected visit (n=112,422), including: a) duration; b) activity; and c) environment type.

RESULTS

Approximately 8.23 million (95% CIs: 7.93, 8.54) adults (19.5% of the population) made at least one 'active visit' (i.e. ≥30min, ≥3 METs) to natural environments in the previous week, resulting in 1.23 billion (1.14, 1.32) 'active visits' annually. An estimated 3.20 million (3.05, 3.35) of these also reported meeting recommended physical activity guidelines (i.e. ≥5×30min a week) fully, or in part, through such visits. Active visits by this group were associated with an estimated 109,164 (101,736, 116,592) Quality Adjusted Life Years (QALYs) annually. Assuming the social value of a QALY to be £20,000, the annual value of these visits was approximately £2.18 billion (£2.03, £2.33). Results for walking were replicated using WHO's Health Economic Assessment Tool.

CONCLUSIONS

Natural environments provide the context for a large proportion of England's recreational physical activity and highlight the need to protect and manage such environments for health purposes.

Recreational physical activity in natural environments and implications for health: A population based cross-sectional study in England

BACKGROUND

Building on evidence that natural environments (e.g. parks, woodlands, beaches) are key locations for physical activity, we estimated the total annual amount of adult recreational physical activity in England's natural environments, and assessed implications for population health.

METHODS

A cross-sectional analysis of six waves (2009/10-2014/5) of the nationally representative, Monitor of Engagement with the Natural Environment survey (n=280,790). The survey uses a weekly quota sample, and population weights, to estimate nature visit frequency across England, and provides details on a single, randomly selected visit (n=112,422), including: a) duration; b) activity; and c) environment type.

RESULTS

Approximately 8.23 million (95% CIs: 7.93, 8.54) adults (19.5% of the population) made at least one 'active visit' (i.e. ≥30min, ≥3 METs) to natural environments in the previous week, resulting in 1.23 billion (1.14, 1.32) 'active visits' annually. An estimated 3.20 million (3.05, 3.35) of these also reported meeting recommended physical activity guidelines (i.e. ≥5×30min a week) fully, or in part, through such visits. Active visits by this group were associated with an estimated 109,164 (101,736, 116,592) Quality Adjusted Life Years (QALYs) annually. Assuming the social value of a QALY to be £20,000, the annual value of these visits was approximately £2.18 billion (£2.03, £2.33). Results for walking were replicated using WHO's Health Economic Assessment Tool.

CONCLUSIONS

Natural environments provide the context for a large proportion of England's recreational physical activity and highlight the need to protect and manage such environments for health purposes.

Readmission rates and financial penalties after ear, nose and throat surgery: how can we improve?

INTRODUCTION

Since April 2011, all patient readmissions within 30 days have resulted in a financial penalty to the hospital trust, and therefore the responsible department. These costs may be substantial and potentially preventable.

METHODS

A service evaluation of readmissions within 30 days of discharge, over a 12-month period (January-December 2012), was performed in the ear, nose and throat department of a district general hospital, and findings were used as a basis to suggest areas for potential quality improvement.

AIMS

To determine the number of readmissions, causes of readmission and resulting costs, and to explore how these readmissions may be prevented.

RESULTS

The departmental 30-day readmission rate over the study period was 3.12% (81/2606). The commonest causes of readmission (33.3%) were complications following tonsillectomy (27/81) such as pain, infection or bleeding. Over a third of these patients (30/81) were readmitted for less than 24 hours, with the average length of stay being less than 2.5 days. Financial implications: In 2011 the trust had 7526 emergency readmissions which were eligible for penalty within the 30-day time frame. This resulted in a loss of income of more than £60 000 to the ear, nose and throat department.

CONCLUSIONS

Optimizing postoperative care and improving patient understanding of common complications may reduce readmission rates, thus limiting the financial burden on the trust. These areas could serve as a basis for future quality improvement projects.

Negotiating Care in the Special Care Nursery: Parents' and Nurses' Perceptions of Nurse-Parent Communication

OBJECTIVE

Nursing staff are an important source of support for parents of a hospitalized preterm infant. This study aimed to describe parents' and nurses' perceptions of communicating with each other in the context of the special care nursery.

METHOD

A qualitative descriptive design was employed. Thirty two parents with a newborn admitted to one of two special care nurseries in Queensland, Australia participated, and 12 nurses participated in semi-structured interviews. Thematic analysis was used to analyze the interviews.

RESULTS

Nurses and parents focused on similar topics, but their perceptions differed. Provision of information and enabling parenting were central to effective communication, supported by an appropriate interpersonal style by nurses. Parents described difficulties accessing or engaging nurses. Managing enforcement of policies was a specific area of difficulty for both parents and nurses.

CONCLUSION

The findings indicated a tension between providing family-centered care that is individualized and based on family needs and roles, and adhering to systemic nursery policies.

NIH response criteria measures are associated with important parameters of disease severity in patients with chronic GVHD

Lack of standardized criteria measuring therapeutic response remains an obstacle to the development of better treatments for chronic GVHD (cGVHD). This cross-sectional prospective study examined the concurrent and predictive validity of 18 clinician-reported ('Form A') and 8 patient-reported ('Form B') response measures proposed by NIH criteria. Concurrent parameters of interest were NIH global score, cGVHD activity, Lee symptom score and SF36 PCS. Patient cohort included 193 adults with moderate-to-severe cGVHD. Measures associated with the highest number of outcomes were lung function score (LFS), 2-min walk, grip strength, 4-point health-care provider (HCP) and patient global scores, 11-point clinician- and patient-reported global symptom severity scores, and Karnofsky performance score (KPS). Measures associated with survival in univariate analyses led to a Cox model containing skin erythema, LFS, KPS, eosinophil count and interval from cGVHD diagnosis to enrollment as jointly associated with survival. In conclusion, 4-point HCP and patient global scores and 11-point clinician- and patient-reported global symptom severity scores are associated with the majority of concurrent outcomes. Skin erythema is a potentially reversible sign of cGVHD that is associated with survival. These results define a subset of measures that should be prioritized for evaluation in future studies.

Integrating health and environmental impact analysis

Scientific investigations have progressively refined our understanding of the influence of the environment on human health, and the many adverse impacts that human activities exert on the environment, from the local to the planetary level. Nonetheless, throughout the modern public health era, health has been pursued as though our lives and lifestyles are disconnected from ecosystems and their component organisms. The inadequacy of the societal and public health response to obesity, health inequities, and especially global environmental and climate change now calls for an ecological approach which addresses human activity in all its social, economic and cultural complexity. The new approach must be integral to, and interactive, with the natural environment. We see the continuing failure to truly integrate human health and environmental impact analysis as deeply damaging, and we propose a new conceptual model, the ecosystems-enriched Drivers, Pressures, State, Exposure, Effects, Actions or 'eDPSEEA' model, to address this shortcoming. The model recognizes convergence between the concept of ecosystems services which provides a human health and well-being slant to the value of ecosystems while equally emphasizing the health of the environment, and the growing calls for 'ecological public health' as a response to global environmental concerns now suffusing the discourse in public health. More revolution than evolution, ecological public health will demand new perspectives regarding the interconnections among society, the economy, the environment and our health and well-being. Success must be built on collaborations between the disparate scientific communities of the environmental sciences and public health as well as interactions with social scientists, economists and the legal profession. It will require outreach to political and other stakeholders including a currently largely disengaged general public. The need for an effective and robust science-policy interface has never been more pressing. Conceptual models can facilitate this by providing theoretical frameworks and supporting stakeholder engagement process simplifications for inherently complex situations involving environment and human health and well-being. They can be tools to think with, to engage, to communicate and to help navigate in a sea of complexity. We believe models such as eDPSEEA can help frame many of the issues which have become the challenges of the new public health era and can provide the essential platforms necessary for progress.

The view from the road: the contribution of on-road glance-monitoring technologies to understanding driver behavior

Using glance-monitoring technologies for on-road studies is an excellent way to investigate driver behaviors in an ecologically valid setting. Recent advances in glance-monitoring technologies have made it possible to conduct on-road studies of drivers' glance behavior that heretofore were simply not possible. Yet it is not always easy to determine which glance-monitoring technology to use for a particular application. Here, we first identify the generic capabilities of the various glance-monitoring technologies. We then describe how particular glance-monitoring technologies have been used in the field to (a) identify the skill deficiencies of novice and older drivers, (b) evaluate the effectiveness of training programs that are designed to reduce deficits in these skills, and (c) address interface issues both inside (e.g., collision warning systems) and outside (e.g., yield markings) the vehicle. The limitations and advantages of on-road eye-tracking and the associated glance-monitoring technologies are identified throughout. A comparison, where possible, is made between the results of on-road eye-tracking studies of drivers' behaviors and the results of those studies conducted in the laboratory. Overall, the use of appropriate on-road glance-monitoring technologies has greatly enhanced our theoretical understanding of why drivers behave the way they do, and this knowledge has paved the way for significant improvements in road user safety.

Oral chronic graft-vs.-host disease characterization using the NIH scale

Chronic graft-vs.-host disease (cGVHD) is a complication of allogeneic hematopoietic stem cell transplantation (alloHSCT). Oral cGVHD is manifested by mucosal, salivary, and/or sclerotic changes that have been linked to pain and poor quality of life. Our aim was to describe the demographic, clinical, and laboratory markers of oral cGVHD in alloHSCT patients (N = 187) enrolled in a cGVHD cross-sectional study at the NIH (#NCT00331968). We propose a meaningful and reproducible measure of disease defined by a cut-off point reflecting clinical minimally detectable change (0-2 = no oral cGVHD, 3-15 = oral cGVHD) on the 15-point NIH cGVHD clinician assessment scale. Forty-four patients had oral cGVHD. Oral cGVHD was associated with a quiescent or de novo type of cGVHD onset (p = 0.05), higher cGVHD severity (p = 0.033), lower albumin (p = 0.0008), higher total complement (p = 0.012), greater bother from foods or oral ulcers and greater mouth pain, and sensitivity (p < 0.0001). Multivariable logistic regression modeling with albumin, mouth pain, and total complement was 74.3% predictive of oral cGVHD and 80.2% predictive of non-oral cGVHD. We propose the use of >2 points on the NIH scale as a reproducible definition of clinically significant oral cGVHD, which may be useful in clinical settings or as eligibility criterion or as an endpoint in clinical trials.