936 IMPROVING DELIRIUM SCREENING IN OLDER ADULTS AT THE ROYAL UNITED HOSPITAL, BATH

Introduction

Delirium affects up to 20% of older patients within hospital and is associated with increases in mortality, length of stay, institutionalisation and accelerated cognitive decline in patients with dementia. 30% of cases are preventable. NICE therefore advocates for delirium screening on admission in the elderly and those with cognitive impairment. We aimed to determine the compliance of the RUH Bath with delirium screening. National guidelines advocate for the use of a CAM, 4AT and/or SQiD. The RUH internal policy accepts a full AMT10, AMT4 plus an assessment of alertness, 4AT or a comment from a Consultant geriatrician about the presence of delirium.

Method

Notes of 60 patients on geriatric wards were inspected for compliance with screening in the first 24 hours of the patient’s admission. Following this, we implemented education sessions for junior doctors, changed the hospital admission proformas and re-wrote the hospital guidelines for delirium to re-emphasise the need for screening. We re-screened the notes 6 months after these changes and then again at 18 months to look for longstanding change.

Results

Initially, only 25% of patients were screened according to national standards and 63% met the hospital criteria. At 6 months 52% met the national standard and 82% met the hospital policy. At 18 months 41% the national standard and 87% met the hospital standard. There was also an increase in the proportion of patients being screened for delirium via multiple different method.

Conclusion

There has been significant, long-term improvement in delirium screening at the RUH Bath. This is particularly remarkable for the hospital standard where, despite no further intervention, the figures were maintained over 18 months. Despite a slight degradation in those meeting the national standard, the proportion was still higher than pre-intervention.

Improving delirium screening in older adults at the Royal United Hospital, Bath

Aims/Background

Delirium affects around 20% of older inpatients, increasing mortality and length of stay. Around 30% of cases are preventable. The authors sought to determine compliance of the admissions to the Older People's Unit of the Royal University Hospital Bath with the national and internal guidelines for delirium screening and improve its use on admission.

Methods

A total of 60 patients' notes were inspected for compliance. Subsequently, the authors implemented teaching, changed the admission proforma and re-wrote the hospital guidelines for delirium. The notes were rescreened at 6 and 18 months.

Results

Initially, 25% of notes met the national standards and 63% met the hospital criteria. At 6 months this was 52% and 82% respectively, and at 18 months it was 41% and 87% respectively. The proportion of patients screened via multiple methods also increased.

Conclusions

There was a sustained improvement in compliance with the national and hospital standards for delirium screening. There was some degradation in the national standard but the proportion of patients meeting the National Institute for Health and Care Excellence standard was still higher than pre-intervention.

Development of a structured process for fair allocation of critical care resources in the setting of insufficient capacity: a discussion paper

Early in the COVID-19 pandemic there was widespread concern that healthcare systems would be overwhelmed, and specifically, that there would be insufficient critical care capacity in terms of beds, ventilators or staff to care for patients. In the UK, this was avoided by a threefold approach involving widespread, rapid expansion of critical care capacity, reduction of healthcare demand from non-COVID-19 sources by temporarily pausing much of normal healthcare delivery, and by governmental and societal responses that reduced demand through national lockdown. Despite high-level documents designed to help manage limited critical care capacity, none provided sufficient operational direction to enable use at the bedside in situations requiring triage. We present and describe the development of a structured process for fair allocation of critical care resources in the setting of insufficient capacity. The document combines a wide variety of factors known to impact on outcome from critical illness, integrated with broad-based clinical judgement to enable structured, explicit, transparent decision-making founded on robust ethical principles. It aims to improve communication and allocate resources fairly, while avoiding triage decisions based on a single disease, comorbidity, patient age or degree of frailty. It is designed to support and document decision-making. The document has not been needed to date, nor adopted as hospital policy. However, as the pandemic evolves, the resumption of necessary non-COVID-19 healthcare and economic activity mean capacity issues and the potential need for triage may yet return. The document is presented as a starting point for stakeholder feedback and discussion.

Localizing syntactic predictions using recurrent neural network grammars

Brain activity in numerous perisylvian brain regions is modulated by the expectedness of linguistic stimuli. We leverage recent advances in computational parsing models to test what representations guide the processes reflected by this activity. Recurrent Neural Network Grammars (RNNGs) are generative models of (tree, string) pairs that use neural networks to drive derivational choices. Parsing with them yields a variety of incremental complexity metrics that we evaluate against a publicly available fMRI data-set recorded while participants simply listen to an audiobook story. Surprisal, which captures a word's un-expectedness, correlates with a wide range of temporal and frontal regions when it is calculated based on word-sequence information using a top-performing LSTM neural network language model. The explicit encoding of hierarchy afforded by the RNNG additionally captures activity in left posterior temporal areas. A separate metric tracking the number of derivational steps taken between words correlates with activity in the left temporal lobe and inferior frontal gyrus. This pattern of results narrows down the kinds of linguistic representations at play during predictive processing across the brain's language network.

Erratum: "A microfluidic chip based model for the study of full thickness human intestinal tissue using dual flow" [Biomicrofluidics , 064101 (2016)]

[This corrects the article DOI: 10.1063/1.4964813.].

Approaches to education provision for mobile pastoralists

Experiences of mobile pastoralists often attest to a wide range of contradictions about the presumed advantages of formal education. While effort to 'reach' pastoralists has intensified under the global Education for All movement, there remain considerable difficulties in finding ways to make formal education relate to pastoralist livelihoods and complement endogenous knowledge. This paper examines how these dynamics play out across models of formal and non-formal education service provision, and identifies innovations that offer promising ways forward: Alternative Basic Education, Open and Distance Learning, and Pastoralist Field Schools.

162 DEVELOPMENT AND EVALUATION OF AN ORAL CONTRACEPTIVE BAIT FOR FERAL PIGS

Feral pigs (Sus scrofa) are an invasive species widely distributed throughout North and South America, as well as Australia. Feral pigs frequently destroy farm fields, causing $1.5 billion in damage annually in the United States alone. These pigs are known carriers of over 30 diseases, thereby posing a threat to livestock and public health. Current control methods are ineffective due to high fecundity rates. An orally consumed contraceptive bait may be effective, but currently none exists for pigs. In rats, an orally consumed contraceptive that affects both male and females has shown considerable promise. This bait contains 2 active ingredients: triptolide, a diterpenoid diepoxide isolated from the Chinese medicinal plant Tripterygium wildfordii, and 4-vinylcyclohexene diepoxide (VCD), an industrial chemical. Triptolide prevents ovarian follicle maturation and disrupts spermatogenesis; VCD acts in the female to cause premature ovarian failure and, in one report, disrupt male mouse spermatogenesis. There are no studies reported for these active ingredients on boar spermatogenesis. A proprietary pig bait has been developed containing these 2 ingredients and was fed to commercial (com.) and Sinclair (sin.) boars (com. n = 3, sin. n = 3) for 15 consecutive days to evaluate changes in reproductive parameters. Boars were given 250 g of bait twice daily that contained 0.25 mg of triptolide and 1.55 mM of VCD. Ejaculates were collected from boars before, during, and after the treatment period (Day 0, 7, 15, 30, 37, 45, and 60) and were evaluated for possible impacts on fertility. Ejaculates were able to be collected from 4 of 6 boars (com. n = 2, sin. n = 2). Previous studies indicate triptolide acts during the differentiation phase of spermatogenesis, suggesting a delayed onset of perturbation allowing for comparison of semen collected early in the study (Day 0, 7, and 15) to post-treatment samples. Progressive motility (PM) was rated on a 1 to 5 scale. Plasma testosterone and testes volume were also monitored at these time points. Statistical analysis was performed using Kruskal–Wallis test. No significant differences were found in plasma testosterone, testes volume, or sperm concentration. No significant differences in viability, morphology, or PM were found at Day 0, 7, or 15. However, differences (P < 0.05) were observed in semen parameters at Day 37 and 45 in comparison to D0, 7, and 15. The percentage of sperm with normal morphology at treatment Day 37 (3.3%) and 45 (3.3%) was lower than at Day 0, 7, and 15 (72.3%, P < 0.05). Differences (P < 0.05) were also found in viability at Day 37 (13.3%) and 45 (8%) in comparison to Day 0, 7, and 15 (71.6%). Differences were also found in PM at Day 37 (0.33) and 45 (1) in comparison to Day 0, 7, and 15 (4.8). These results suggest an impact on spermatogenesis, specifically spermiogenesis, suggesting a decrease in fertility due to lower quality of spermatozoa. Further studies are needed to evaluate the bait’s impact on feral pig reproduction.

A microfluidic chip based model for the study of full thickness human intestinal tissue using dual flow

The study of inflammatory bowel disease, including Ulcerative Colitis and Crohn's Disease, has relied largely upon the use of animal or cell culture models; neither of which can represent all aspects of the human pathophysiology. Presented herein is a dual flow microfluidic device which holds full thickness human intestinal tissue in a known orientation. The luminal and serosal sides are independently perfused ex vivo with nutrients with simultaneous waste removal for up to 72 h. The microfluidic device maintains the viability and integrity of the tissue as demonstrated through Haematoxylin & Eosin staining, immunohistochemistry and release of lactate dehydrogenase. In addition, the inflammatory state remains in the tissue after perfusion on the device as determined by measuring calprotectin levels. It is anticipated that this human model will be extremely useful for studying the biology and testing novel interventions in diseased tissue.

A Framework for Restaurant Information Technology

Some three decades after computers first automated restaurants' backoffice systems and two decades after point-of-sale systems made their appearance, information technology (IT) has finally become sufficiently sophisticated that it can be an integrated tool for management decision making and control of restaurant operations. Not coincidentally, restaurant chains themselves have finally grown large enough to support the heavy investment that IT can require. Rather than upgrade systems piecemeal, however, restaurant operators and managers would do well to gauge IT investments against a framework that takes into account all aspects of the restaurant's operation, including revenue-management and guestsatisfaction functions. Such a framework is presented in this article, with consideration given to the following aspects of restaurant management: production systems (including demand forecasting), scheduling (both in the kitchen and dining room), process control (including managing meal duration and kitchen production), and enterprise-resource planning (extended back-office functions).

Cross-Lingual Bridges with Models of Lexical Borrowing

Linguistic borrowing is the phenomenon of transferring linguistic constructions (lexical, phonological, morphological, and syntactic) from a “donor” language to a “recipient” language as a result of contacts between communities speaking different languages. Borrowed words are found in all languages, and—in contrast to cognate relationships—borrowing relationships may exist across unrelated languages (for example, about 40% of Swahili’s vocabulary is borrowed from the unrelated language Arabic). In this work, we develop a model of morpho-phonological transformations across languages. Its features are based on universal constraints from Optimality Theory (OT), and we show that compared to several standard—but linguistically more naïve—baselines, our OT-inspired model obtains good performance at predicting donor forms from borrowed forms with only a few dozen training examples, making this a cost-effective strategy for sharing lexical information across languages. We demonstrate applications of the lexical borrowing model in machine translation, using resource-rich donor language to obtain translations of out-of-vocabulary loanwords in a lower resource language. Our framework obtains substantial improvements (up to 1.6 BLEU) over standard baselines.

Costs and quality of life associated with acute upper gastrointestinal bleeding in the UK: cohort analysis of patients in a cluster randomised trial

OBJECTIVES

Data on costs associated with acute upper gastrointestinal bleeding (AUGIB) are scarce. We provide estimates of UK healthcare costs, indirect costs and health-related quality of life (HRQoL) for patients presenting to hospital with AUGIB.

SETTING

Six UK university hospitals with >20 AUGIB admissions per month, >400 adult beds, 24 h endoscopy, and on-site access to intensive care and surgery.

PARTICIPANTS

936 patients aged ≥18 years, admitted with AUGIB, and enrolled between August 2012 and March 2013 in the TRIGGER trial of AUGIB comparing restrictive versus liberal red blood cell (RBC) transfusion thresholds.

PRIMARY AND SECONDARY OUTCOME MEASURES

Healthcare resource use during hospitalisation and postdischarge up to 28  days, unpaid informal care, time away from paid employment and HRQoL using the EuroQol EQ-5D at 28  days were measured prospectively. National unit costs were used to value resource use. Initial in-hospital treatment costs were upscaled to a UK level.

RESULTS

Mean initial in-hospital costs were £2458 (SE=£216) per patient. Inpatient bed days, endoscopy and RBC transfusions were key cost drivers. Postdischarge healthcare costs were £391 (£44) per patient. One-third of patients received unpaid informal care and the quarter in paid employment required time away from work. Mean HRQoL for survivors was 0.74. Annual initial inhospital treatment cost for all AUGIB cases in the UK was estimated to be £155.5 million, with exploratory analyses of the incremental costs of treating hospitalised patients developing AUGIB generating figures of between £143 million and £168 million.

CONCLUSIONS

AUGIB is a large burden for UK hospitals with inpatient stay, endoscopy and RBC transfusions as the main cost drivers. It is anticipated that this work will enable quantification of the impact of cost reduction strategies in AUGIB and will inform economic analyses of novel or existing interventions for AUGIB.

TRIAL REGISTRATION NUMBER

ISRCTN85757829 and NCT02105532.

The APOL1 genotype of African American kidney transplant recipients does not impact 5-year allograft survival

Apolipoprotein L-1 (APOL1) gene variants are associated with end-stage renal disease in African Americans (AAs). Here we investigate the impact of recipient APOL1 gene distributions on kidney allograft outcomes. We conducted a retrospective analysis of 119 AA kidney transplant recipients, and found that 58 (48.7%) carried two APOL1 kidney disease risk variants. Contrary to the association seen in native kidney disease, there is no difference in allograft survival at 5-year posttransplant for recipients with high-risk APOL1 genotypes. Thus, we were able to conclude that APOL1 genotypes do not increase risk of allograft loss after kidney transplantations, and carrying 2 APOL1 risk alleles should not be an impediment to transplantation.

Improving recruitment of older people to research through good practice

There is widespread evidence both of the exclusion of older people from clinical research, and of under-recruitment to clinical trials. This review and opinion piece provides practical advice to assist researchers both to adopt realistic, achievable recruitment rates and to increase the number of older people taking part in research. It analyses 14 consecutive recently published trials, providing the number needed to be screened to recruit one older participant (around 3:1), numbers excluded (up to 49%), drop out rates (5-37%) and whether the planned power was achieved. The value of planning and logistics are outlined, and approaches to optimising recruitment in hospital, primary care and care home settings are discussed, together with the challenges of involving older adults with mental incapacity and those from minority groups in research. The increasingly important task of engaging older members of the public and older patients in research is also discussed. Increasing the participation of older people in research will improve the generalisability of research findings and inform best practice in the clinical management of the growing older population.

Rehabilitation of older patients: day hospital compared with rehabilitation at home. Clinical outcomes

OBJECTIVES

to test the hypothesis that older people and their informal carers are not disadvantaged by home-based rehabilitation (HBR) relative to day hospital rehabilitation (DHR).

DESIGN

pragmatic randomised controlled trial.

SETTING

four geriatric day hospitals and four home rehabilitation teams in England.

PARTICIPANTS

eighty-nine patients referred for multidisciplinary rehabilitation. The target sample size was 460.

INTERVENTION

multidisciplinary rehabilitation either in the home or in the day hospital.

MEASUREMENTS

the primary outcome measure was the Nottingham extended activities of daily living scale (NEADL). Secondary outcome measures included EQ-5D, hospital anxiety and depression scale, therapy outcome measures, hospital admissions and the General Health Questionnaire for carers.

RESULTS

at the primary end point of 6 months NEADL scores were not significantly in favour of HBR cf. DHR; mean difference -2.139 (95% confidence interval -6.87 to 2.59, P = 0.37). A post hoc analysis suggested non-inferiority for HBR for NEADL but there was considerable statistical uncertainty.

CONCLUSION

taken together the statistical analyses and lack of power of the trial outcomes do not provide sufficient evidence to conclude that patients in receipt of HBR are disadvantaged compared with those receiving DHR.