Determining when a hospital admission of an older person can be avoided in a subacute setting: a systematic review and concept analysis

OBJECTIVE

To conduct a systematic review of the evidence for when a hospital admission for an older person can be avoided in subacute settings. We examined the definition of admission avoidance and the evidence for the factors that are required to avoid admission to hospital in this setting.

METHODS

Using defined PICOD criteria, we conducted searches in three databases (Medline, Embase and Cinahl) from January 2006 to February 2018. References were screened by title and abstract followed by full paper screening by two reviewers. Additional studies were searched from the grey literature, experts in the field and forward and backward referencing. Data were narratively described, and concept analysis was used to investigate the definition of admission avoidance.

RESULTS

A total of 17 studies were considered eligible for review; eight provided a definition of admission avoidance and 10 described admission avoidance criteria. We identified three factors which play a key role in admission avoidance in the subacute setting: (1) ambulatory care sensitive conditions and common medical scenarios for the older person, which included respiratory infections or pneumonia, urinary tract infections and catheter care, dehydration and associated symptoms, falls and behavioural management, and managing ongoing chronic conditions; (2) criteria/tools, referring to interventions that have used clinical expertise in conjunction with a range of general and geriatric triage tools; in condition-specific interventions, the decision whether to admit or not was based on level of risk determined by defined clinical tools; and (3) personnel and resources, referring to the need for experts to make the initial decision to avoid an admission. Supervision by nurses or physicians was still needed at subacute level, requiring resources such as short-stay beds, intravenous antibiotic treatment or fluids for rehydration and rapid access to laboratory tests.

CONCLUSION

The review identified a set of criteria for ambulatory care sensitive conditions and common medical scenarios for the older person that can be treated in the subacute setting with appropriate tools and resources. This information can help commissioners and care providers to take on these important elements and deliver them in a locally designed way.

Imaging biomarkers of posttraumatic epileptogenesis

Traumatic brain injury (TBI) affects 2.5 million people annually within the United States alone, with over 300 000 severe injuries resulting in emergency room visits and hospital admissions. Severe TBI can result in long-term disability. Posttraumatic epilepsy (PTE) is one of the most debilitating consequences of TBI, with an estimated incidence that ranges from 2% to 50% based on severity of injury. Conducting studies of PTE poses many challenges, because many subjects with TBI never develop epilepsy, and it can be more than 10 years after TBI before seizures begin. One of the unmet needs in the study of PTE is an accurate biomarker of epileptogenesis, or a panel of biomarkers, which could provide early insights into which TBI patients are most susceptible to PTE, providing an opportunity for prophylactic anticonvulsant therapy and enabling more efficient large-scale PTE studies. Several recent reviews have provided a comprehensive overview of this subject (Neurobiol Dis, 123, 2019, 3; Neurotherapeutics, 11, 2014, 231). In this review, we describe acute and chronic imaging methods that detect biomarkers for PTE and potential mechanisms of epileptogenesis. We also describe shortcomings in current acquisition methods, analysis, and interpretation that limit ongoing investigations that may be mitigated with advancements in imaging techniques and analysis.

The maternal immune activation model uncovers a role for the Arx gene in GABAergic dysfunction in schizophrenia

A hallmark feature of schizophrenia is altered high frequency neural oscillations, including reduced auditory-evoked gamma oscillatory power, which is underpinned by parvalbumin (PV) interneuron dysfunction. Maternal immune activation (MIA) in rodents models an environmental risk factor for schizophrenia and recapitulates these PV interneuron changes. This study sought to link reduced PV expression in the MIA model with alterations to auditory-evoked gamma oscillations and transcript expression. We further aligned transcriptional findings from the animal model with human genome sequencing data. We show that MIA, induced by the viral mimetic, poly-I:C in C57Bl/6 mice, caused in adult offspring reduced auditory-evoked gamma and theta oscillatory power paralleled by reduced PV protein levels. We then showed the Arx gene, critical to healthy neurodevelopment of PV interneurons, is reduced in the forebrain of MIA exposed mice. Finally, in a whole-genome sequenced patient cohort, we identified a novel missense mutation of ARX in a patient with schizophrenia and in the Psychiatric Genomics Consortium 2 cohort, a nominal association of proximal ARX SNPs with the disorder. This suggests MIA, as a risk factor for schizophrenia, may be influencing Arx expression to induce the GABAergic dysfunction seen in schizophrenia and that the ARX gene may play a role in the prenatal origins of schizophrenia pathophysiology.

2 The incidence of undiagnosed coeliac disease in patients presenting with stress fracture to a tertiary referral centre

Aim

Stress fracture aetiology is often multifactorial and laboratory blood tests (LBT) can unmask underlying metabolic bone risk factors and disorders. Coeliac disease (CD) is associated with low bone mineral density and an increased risk of fractures.1 In addition, there are rare reports of occult CD presenting with stress fractures.2 Anti-tissue transglutaminase antibody (TTG) testing has a high sensitivity and specificity for CD and is used as a screening test.3 This report examines the incidence of undiagnosed CD in patients presenting with stress fractures to a Sport and Exercise Medicine (SEM) clinic.

Methods

A retrospective analysis of 100 consecutive patients with radiologically proven stress fractures presenting to a single tertiary NHS SEM clinic was performed. Age, gender, fracture site, co-morbidities, TTG result and subsequent investigations were examined. Records were reviewed to confirm LBT, including TTG, had been performed at the time of diagnosis.

Results

Seventy patients (70%) were female and mean age was 37 years (range 18–69). Metatarsal (35%) and tibial (21%) fractures were most common. TTG was performed in 85 patients. Two patients were excluded due to pre-existing CD. Five patients (5/83 (6%), mean age 38 years (28–57), 80% female) had a positive TTG; three of whom had CD confirmed by endoscopic biopsy and two are awaiting investigation. Four patients with a positive TTG underwent dual energy X-ray absorptiometry, with osteopenia (T-Score between −1.0 and −2.5) found in 75% of cases, although only one had a Z-score less than -2.0.

Conclusion

In this cohort, the incidence of undiagnosed CD was between 3.6% to 6%, with a prevalence between 5% to 7%, approximately 5-fold higher than UK population estimates. We recommend that TTG screening should be performed in all patients presenting with stress fractures to identify underlying CD. Further work is required to confirm this association and elucidate potential underlying mechanisms.

References

Heikkilä K, Pearce J, Mäki M, et al. Celiac disease and bone fractures: a systematic review and meta-analysis. J Clin Endocrinol Metab 2015;100(1):25–34.

Gilbody J, Trevett M. Coeliac disease presenting with bilateral fibular stress fractures. Foot Ankle Surg 2009;15:96–100.

3. Downey L, Houten R, Murch S, Longson D, Group GD. Recognition, assessment, and management of coeliac disease: summary of updated NICE guidance. BMJ 2015;351:h4513.

Occupational stress in Remotely Piloted Aircraft System operators

BACKGROUND

Although there is currently little research data to support the contention, concerns have been raised about possible traumatic stressors inherent to Remotely Piloted Aircraft System (RPAS) operator roles. Factors such as exposure to visually traumatic events compounded by long working hours and blurred boundaries between military and civilian life have been cited as potential stressors. Robust research into the well-being of RPAS operators is scarce and mostly samples US personnel.

AIMS

To provide mental health and well-being data relating to UK RPAS operators.

METHODS

UK RPAS operators completed mental health questionnaires to assess levels of post-traumatic stress disorder (PTSD), anxiety and depression symptoms, alcohol use and occupational functioning. Respondents were also asked about work patterns.

RESULTS

Forty-one per cent of the sample reported potentially hazardous alcohol use. Ten per cent met psychiatric symptom criteria for moderate or severe anxiety, and 20% for moderate depressive symptoms. While there were no cases of probable PTSD, 30% of the sample reported sub-clinical PTSD symptoms likely to impair occupational functioning. Overall, 70% of the sample reported that psychological symptoms significantly impaired their functioning.

CONCLUSIONS

Compared to UK military sub-groups, RPAS operators were not at increased risk of mental health problems. However, a high proportion of the sample reported significant functional impairment, which has not been explored in other comparable studies. The most frequently highlighted work-related stressors were timing of RPAS work and operator shift patterns.

BSACI guideline for the diagnosis and management of allergic and non-allergic rhinitis (Revised Edition 2017; First edition 2007)

This is an updated guideline for the diagnosis and management of allergic and non-allergic rhinitis, first published in 2007. It was produced by the Standards of Care Committee of the British Society of Allergy and Clinical Immunology, using accredited methods. Allergic rhinitis is common and affects 10-15% of children and 26% of adults in the UK, it affects quality of life, school and work attendance, and is a risk factor for development of asthma. Allergic rhinitis is diagnosed by history and examination, supported by specific allergy tests. Topical nasal corticosteroids are the treatment of choice for moderate to severe disease. Combination therapy with intranasal corticosteroid plus intranasal antihistamine is more effective than either alone and provides second line treatment for those with rhinitis poorly controlled on monotherapy. Immunotherapy is highly effective when the specific allergen is the responsible driver for the symptoms. Treatment of rhinitis is associated with benefits for asthma. Non-allergic rhinitis also is a risk factor for the development of asthma and may be eosinophilic and steroid-responsive or neurogenic and non- inflammatory. Non-allergic rhinitis may be a presenting complaint for systemic disorders such as granulomatous or eosinophilic polyangiitis, and sarcoidoisis. Infective rhinitis can be caused by viruses, and less commonly by bacteria, fungi and protozoa.

U.S. prevalence of endocrine therapy-naïve locally advanced or metastatic breast cancer

Background

Variations in treatment choice, or late stage at first diagnosis, mean that, despite guideline recommendations, not all patients with hormone receptor (hr)-positive locally advanced or metastatic breast cancer (la/mbca) will have received endocrine therapy before disease progression. In the present study, we aimed to estimate the proportion of women with postmenopausal hr-positive la/mbca in the United States who are endocrine therapy-naïve.

Methods

Women in the Optum Electronic Health Record (ehr) database with a breast cancer (bca) diagnosis (January 2008-March 2015) were included. Patient and malignancy characteristics were identified using structured data fields and natural-language processing of free-text clinical notes. The proportion of women with postmenopausal hr-positive, human epidermal growth factor 2 (her2)-negative (or unknown) la/mbca who had not received prior endocrine therapy was determined. Results were extrapolated to the entire U.S. population using the U.S. National Cancer Institute's Surveillance, Epidemiology, and End Results database. Results are presented descriptively.

Results

In the ehr database, 11,831 women with bca had discernible information on postmenopausal status, hr status, and disease stage. Of those women, 1923 (16.3%) had postmenopausal hr-positive, her2-negative (or unknown) la/mbca, and 70.7% of those 1923 patients (n = 1360) had not received prior endocrine therapy, accounting for 11.5% of the overall population. Extrapolating those estimates nationally suggests an annual incidence of 14,784 cases, and a 5-year limited duration prevalence of 50,638 cases.

Conclusions

A substantial proportion of women with postmenopausal hr-positive la/mbca in the United States could be endocrine therapy-naïve.

Harmonization of pipeline for detection of HFOs in a rat model of post-traumatic epilepsy in preclinical multicenter study on post-traumatic epileptogenesis

Studies of chronic epilepsy show pathological high frequency oscillations (HFOs) are associated with brain areas capable of generating epileptic seizures. Only a few of these studies have focused on HFOs during the development of epilepsy, but results suggest pathological HFOs could be a biomarker of epileptogenesis. The Epilepsy Bioinformatics Study for Antiepileptogenic Therapy" (EpiBioS4Rx) is a multi-center project designed to identify biomarkers of epileptogenesis after a traumatic brain injury (TBI) and evaluate treatments that could modify or prevent the development of post-traumatic epilepsy. One goal of the EpiBioS4Rx project is to assess whether HFOs could be a biomarker of post-traumatic epileptogenesis. The current study describes the work towards this goal, including the development of common surgical procedures and EEG protocols, an interim analysis of the EEG for HFOs, and identifying issues that need to be addressed for a robust biomarker analysis. At three participating sites - University of Eastern Finland (UEF), Monash University in Melbourne (Melbourne) and University of California, Los Angeles (UCLA) - TBI was induced in adult male Sprague-Dawley rats by lateral fluid-percussion injury. After injury and in sham-operated controls, rats were implanted with screw and microwire electrodes positioned in neocortex and hippocampus to record EEG. A separate group of rats had serial magnetic resonance imaging after injury and then implanted with electrodes at 6 months. Recordings 28 days post-injury were available from UEF and UCLA, but not Melbourne due to technical issues with their EEG files. Analysis of recordings from 4 rats - UEF and UCLA each had one TBI and one sham-operated control - showed EEG contained evidence of HFOs. Computer-automated algorithms detected a total of 1,819 putative HFOs and of these only 40 events (2%) were detected by all three sites. Manual review of all events verified 130 events as HFO and the remainder as false positives. Review of the 40 events detected by all three sites was associated with 88% agreement. This initial report from the EpiBioS4Rx Consortium demonstrates the standardization of EEG electrode placements, recording protocol and long-term EEG monitoring, and differences in detection algorithm HFO results between sites. Additional work on detection strategy, detection algorithm performance, and training in HFO review will be performed to establish a robust, preclinical evaluation of HFOs as a biomarker of post-traumatic epileptogenesis.

Process evaluation of a cluster-randomised controlled trial of multi-component weight management programme in adults with intellectual disabilities and obesity

BACKGROUND

Providing effective weight management to adults with intellectual disabilities is necessary to challenge the high rates of obesity. The aim of this process evaluation was to explore the feasibility of conducting a full-scale clinical trial of the TAKE 5 multi-component weight management programme.

METHODS

The study was a 12-month pilot cluster-randomised controlled trial. Adults with intellectual disabilities and obesity were randomised to either TAKE 5, which included an energy deficit diet (EDD) or Waist Winners Too, based on health education principles. A mixed-methods process evaluation was conducted focussing on the reach, recruitment, fidelity, implementation, dose (delivered/received) and context.

RESULTS

The study successfully recruited adults with intellectual disabilities. Both weight management programmes were delivered with high fidelity and implemented as intended. Only one weight management programme, TAKE 5, demonstrated potential efficacy in reducing body weight and body composition. The effectiveness was largely attributed to the EDD and social support from carers.

CONCLUSIONS

The extensive process evaluation illustrated that a full-scale trial of a multi-component programme including an EDD is feasible and an acceptable approach to weight management for adults with intellectual disabilities and obesity.

Safety and Efficacy of Bupivacaine HCl Collagen-Matrix Implant (INL-001) in Open Inguinal Hernia Repair: Results from Two Randomized Controlled Trials

INTRODUCTION

Surgical site infiltration with bupivacaine results in short-lived analgesia. The MATRIX-1 and MATRIX-2 studies examined the efficacy and safety of the bioresorbable bupivacaine HCl collagen-matrix implant (INL-001) for postsurgical pain after open inguinal hernia repair. INL-001, designed to provide early and extended delivery of bupivacaine, provides prolonged duration of perioperative analgesia.

METHODS

In two phase 3 double-blind studies [MATRIX-1 (ClinicalTrials.gov identifier, NCT02523599) and MATRIX-2 (ClinicalTrials.gov identifier, NCT02525133)], patients undergoing open tension-free mesh inguinal hernia repair were randomized to receive 300-mg bupivacaine (three INL-001 100-mg bupivacaine HCl collagen-matrix implants) (MATRIX-1 n = 204; MATRIX-2 n = 213) or three placebo collagen-matrix implants (MATRIX-1 n = 101; MATRIX-2 n = 106) during surgery. Postsurgical medication included scheduled acetaminophen and as-needed opioids.

RESULTS

Patients who received INL-001 in both studies reported statistically significantly lower pain intensity (P ≤ 0.004; primary end point) and opioid analgesic use (P < 0.0001) through 24-h post-surgery versus those who received a placebo collagen-matrix. Patients who received INL-001 reported lower pain intensity through 72 h (P = 0.0441) for the two pooled studies. In both studies, more of the patients (28-42%) who received INL-001 used no opioid medication 0-24, 0-48, and 0-72 h post-surgery versus those who received a placebo collagen-matrix (12-22%). Among patients who needed opioid medication, patients receiving INL-001 used fewer opioids than those who received a placebo collagen-matrix through 24 h in both studies (P < 0.0001) and through 48 h in MATRIX-2 (P = 0.0003). Most adverse events were mild or moderate, without evidence of bupivacaine toxicity or deleterious effects on wound healing.

CONCLUSION

These findings indicate that INL-001 results in post-inguinal hernia repair analgesia that is temporally aligned with the period of maximal postsurgical pain and may reduce the need for opioids while offering a favorable safety profile.

TRIAL REGISTRATION

ClinicalTrials.gov identifiers, NCT02523599; NCT02525133.

FUNDING

Innocoll Pharmaceuticals. Plain language summary available for this article.

Campaigns to reduce mental illness stigma in Europe: a scoping review

Background: Evidence has emerged in recent decades about effective and ineffective methods to reduce mental illness related stigma and discrimination. As more European countries start national anti-stigma campaigns, there is potentially more to learn from their experiences, but also a risk that, with such rapid developments, lessons may be missed.

Aim: This scoping review aims to identify and discuss European stigma reduction campaigns conducted to date.

Methods: We searched electronic databases, hand-searched reference lists of identified articles and contacted stigma experts to enquire about ongoing initiatives.

Results: We identified anti-stigma campaigns in 21 European countries and regions. We found considerable variation in their content, delivery formats, duration and target groups.

Conclusions: Although anti-stigma campaigns have been implemented in many European countries, the level of attention paid to sharing lessons learned is variable. It is vital that campaigns are evaluated, to maximise their potential impact both on the target population, and that the findings are disseminated widely to allow international learning.

The effect of high-flow nasal oxygen on hospital length of stay in cardiac surgical patients at high risk for respiratory complications: a randomised controlled trial

There has been increased interest in the prophylactic and therapeutic use of high‐flow nasal oxygen in patients with, or at risk of, non‐hypercapnic respiratory failure. There are no randomised trials examining the efficacy of high‐flow nasal oxygen in high‐risk cardiac surgical patients. We sought to determine whether routine administration of high‐flow nasal oxygen, compared with standard oxygen therapy, leads to reduced hospital length of stay after cardiac surgery in patients with pre‐existing respiratory disease at high risk for postoperative pulmonary complications. Adult patients with pre‐existing respiratory disease undergoing elective cardiac surgery were randomly allocated to receive high‐flow nasal oxygen (n = 51) or standard oxygen therapy (n = 49). The primary outcome was hospital length of stay and all analyses were carried out on an intention‐to‐treat basis. Median (IQR [range]) hospital length of stay was 7 (6–9 [4–30]) days in the high‐flow nasal oxygen group and 9 (7–16 [4–120]) days in the standard oxygen group (p=0.012). Geometric mean hospital length of stay was 29% lower in the high‐flow nasal group (95%CI 11–44%, p = 0.004). High‐flow nasal oxygen was also associated with fewer intensive care unit re‐admissions (1/49 vs. 7/45; p = 0.026). When compared with standard care, prophylactic postoperative high‐flow nasal oxygen reduced hospital length of stay and intensive care unit re‐admission. This is the first randomised controlled trial examining the effect of prophylactic high‐flow nasal oxygen use on patient‐centred outcomes in cardiac surgical patients at high risk for postoperative respiratory complications.

Perceived effect of deployment on families of UK military personnel

Background

In the UK, little is known about the perceived effects of deployment, on military families, from military personnel in theatre.

Aims

To investigate military personnel's perceptions of the impact of deployment on intimate relationships and children.

Methods

Deployed service personnel who were in a relationship, and who had children, completed a survey while deployed on combat operations. Data were taken from four mental health surveys carried out in Iraq in 2009 and Afghanistan in 2010, 2011 and 2014.

Results

Among 4265 participants, after adjusting for military and social-demographic covariates, perceiving that deployment had a negative impact on intimate relationships and children was associated with psychological distress, and traumatic stress symptoms. Military personnel who reported being in danger of being injured or killed during deployment, were more likely to report a perceived negative effect of deployment on their intimate relationships. Reservists were less likely to report a perceived negative impact of deployment on their children compared with regulars. Military personnel who themselves planned to separate from their partner were more likely to report psychological distress, and stressors at home. Perceived insufficient support from the Ministry of Defence was associated with poor mental health, and holding a junior rank.

Conclusions

Deployed UK military personnel with symptoms of psychological distress, who experienced stressors at home, were especially likely to perceive that their family were inadequately supported by the military. Those planning to separate from their partner were at increased risk of suffering with mental health problems while deployed.

Lyman-α source for laser cooling antihydrogen

We present a Lyman-α laser developed for cooling trapped antihydrogen. The system is based on a pulsed Ti:sapphire laser operating at 729 nm that is frequency doubled using an LBO crystal and then frequency tripled in a Kr/Ar gas cell. After frequency conversion, this system produces up to 5.7 μW of average power at the Lyman-α wavelength. This laser is part of the ATRAP experiment at the antiproton decelerator in CERN.

Experiences and career intentions of combat-deployed UK military personnel

Background

Most studies of the psychological impact of military deployment focus on the negative and traumatic aspects. Less is known about the full range of deployment experiences nor how these may impact on career intentions.

Aims

To examine subjective operational experiences and career intentions in deployed UK military personnel using data gathered toward the end of an operational deployment.

Methods

Data were gathered during deployment in Iraq and Afghanistan. A self-report survey collected data on sociodemographic, operational and military factors. Respondents provided their strength of agreement or disagreement with six potentially positive deployment experiences and their endorsement or rejection of six possible career intentions. Two mental health measures assessed symptoms of common mental disorder and post-traumatic stress disorder.

Results

Responses were 681 in Iran 2009 (100% response rate); 1421 in Afghanistan in 2010 (100%), 1362 in 2011 (96%) and 860 in 2015 (91%). Five of the potentially positive outcomes were endorsed by >50% of the sample: confidence about remaining healthy after returning home, pride in accomplishments, increased confidence in abilities, improved unit cohesion and experiencing a positive life effect. Ninety per cent of respondents planned to continue in service after returning home. Fewer positive deployment experiences, poorer mental health, lesser unit cohesion and more negative impressions of leadership were significantly associated with intention to leave service.

Conclusions

Contrary to the popular belief that UK military personnel deployed to Iraq or Afghanistan experience negative outcomes, this paper shows that deployment can be a positive experience for a substantial majority of deployed personnel.